HospitalInspections.org

Based on observations, the facility failed to maintain the 2-hour fire resistance of fire barrier walls and doors in a building which has a common wall with a nonconforming building. This deficiency could affect a very limited number of patients, staff, and visitors.

Finds include:

In accordance with Chapter 19.1.1.4.1-3, of Life Safety Code 101,
(1) additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)
(2) communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)
(3) doors in barriers required by 19.1.1.4.1 shall normally be kept closed.
Exception: Doors shall be permitted to be held open if they meet the requirements of 19.2.2.2.6.

1. The set of double doors between the hospital and the service hallway leading to the laundry were exercised at 2:30 p.m. on 10/22/13. The fire doors failed to latch when exercised on two attempts.

2. The fire wall in the service hallway was observed at 2:50 p.m. on 10/22/13. There were two heating water supply pipes, above the chart auditors door, penetrating the wall and left unsealed.

3. There was an open conduit in the fire wall north of the Hospital Birthing Center, above the smoke alarm numbered N4L2D04.

Based on observations, the facility did not maintain the fire resistive rating of ceiling and floor assemblies. The deficiencies could affect a very limited number of patients, staff, and visitors.

Findings include:

In accordance with Section 18.1.6.3 of NFPA 101, Life Safety Code; all interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.

1. The basement was observed at 3:10 p.m. on 10/21/13. In the mechanical room, holes had been cut into the ceiling of this room to pour new support posts for the upper additions to be added. The holes were cut in the wrong place and later filled in with wood construction and the floor above repoured with concrete. The plywood floor pieces and wood supports had not been removed after the floor was cured above. No untreated raw wood supports can be utilized in a building which is rated for building type II (111) protected non-combustible construction.

2. The sprinkler riser room on first floor of the Surgical Services Addition was observed at 1:37 p.m. on 10/22/13. There were two penetrations in the ceiling of this room where the riser continued through the floor above.

Based on observations, the facility failed to maintain the fire and smoke resistance rating of wall and ceiling assemblies. This deficiency could affect more than a very limited number of patients, staff, and visitors.

Findings include:

The building is of Type II (111) non-combustible construction with three floors which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 Standards per Table 19.1.6.1 Construction Type Limitations.

1. On 10/21/13 at 3:16 p.m. during a tour of the basement, a ceiling tile in the northwest corner of the ceiling of the women's bathroom, next to the housekeeping restroom, had a corner broken off.

2. On 10/21/13 at 3:55 p.m., during a tour of the basement, an electrical box was observed under the desk in the print shop. A 1/4 inch by 4 inch opening on the left side was observed next to the cover plate.

3. On 10/22/13 at 9:25 a.m. during a tour of the Barn (pump room) in the OB department, an observation of tiles with 1/2 inch spaces between.



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4. On 10/22/13 at 2:00 p.m., a penetration was observed by the west entrance between Neonatal Intensive Care Unit (NICU) and the employee break room.

5. There was a four inch by eight inch piece of gypsum board removed with two cables, red and gray, penetrating through a hole in the gypsum board on the other side of the wall, which was also unsealed.

Based on observations, the facility failed to ensure interior finishes were in compliance with necessary fire ratings. This deficiency could affect a very limited number of patients, staff and visitors.

Findings include:

According to Section 38.3.3.2, interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in exits and in enclosed corridors furnishing access to exits.

The south exit of the building was left with exposed untreated wood around the door frame. Wood does not hold a class A or class B fire rating unless treated with a fire retardant.

Based on observations, the facility failed to maintain corridor walls to resist the passage of smoke. This deficiency could affect a very limited number of patients, staff and visitors.

Findings include:

In accordance with Sections 18.3.6.1, and 18.3.6.2., of NFPA 101, 2000 Edition; corridors are separated from use areas by walls constructed with at least ½ hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke.

1. At 9:15 a.m. on 10/23/13, the wall above the anesthesia supply door was observed. Two deficiencies were noted:
a.) There was a large group of approximately 20 IT wires running through an open four inch by four inch cut-out through the gypsum board in the smoke barrier.
b.) There was also a sealed conduit running throught he same barrier, but the opening in the conduit, through which the wires ran through, was not sealed.

2. The network communications room on 2nd floor of the Surgical Tower was observed at 10:30 a.m. on 10/22/13. Three sprinkler pipes which extended through the corridor wall were not sealed to maintain the integrity of the corridor wall to limit the transfer of smoke.

3. The electrical room in the south east corner of the second floor surgical tower was observed at 11:00 a.m. on 10/22/13. There were five penetrations in the corridor wall which were not properly sealed to limit the transfer of smoke.






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Based on observation, the facility failed to maintain an elevator enclosure of at least one hour in a building which is three stories in height or less and is fully sprinkled. The deficiency could affect a very limited number of patients, staff, and visitors.

Findings included:

In accordance with Section 18.3.1.1 of NFPA 101, Life Safety Code; stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinklered buildings up to three stories in height.)

1. The elevator enclosure doors to the elevator in the basement of the surgical services addition were exercised at 3:05 p.m. on 10/21/13. The doors failed to latch on three attempts.

2. The basement mechanical room was observed at 3:30 p.m. on 10/21/13. There was an unsealed 1-1/4 conduit through the ceiling of this room.

Based on observation, the facility did not ensure vertical openings between floors were sealed and/or enclosed by fire resistive construction of at least 1/2-hour rating. This deficiency had the potential to affect more than a limited number of patients, staff, and visitors.

Findings include:

In accordance with Section 39.3.1.1 of NFPA 101, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1/2-hour resistance rating, in existing buildings.

On 10/23/13 at 2:15 p.m., the smoke control door to block access to the elevator when the fire alarm is activated, failed to latch when exercised by the surveyor.

Based on observation, the facility failed to maintain the rating of smoke barrier construction due to penetrations. This deficiency could affect more than a very limited amount of patients, staff, and visitors.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. At 4:42 p.m. on 10/21/13, a two inch penetration was observed in the gypsum wallboard along the floor between the west switch gear area and central sterile.



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2. At 2:05 p.m. on 10/22/13, the smoke barrier above the double doors in front of the soiled utility room in the Obstetrics (OB) Department was observed. There were two wires penetrating the smoke wall, a large yellow wire and a small gray wire. The gypsum board was partially cut and damaged below the wires, but not removed. The hole around the wires was not sealed.

3. At 2:15 p.m. on 10/22/13, the wall above the medication dispensing system in the OB department was examined. A hole approximately four by four inches was found cut in the gypsum board and not sealed. The insulation material was removed exposing a dark, hard surface. It was undetermined what this surface was.

4. At 5:00 p.m. on 10/22/13, the wall above the double doors outside the old plant operations office, in the employee hallway to the E.R. was observed. The was a two inch round copper pipe penetrating the smoke barrier directly above the doors in the corridor. The hole around the pipe was unsealed.

5. At 5:10 p.m. on 10/22/13, the wall above the double doors between the old OR and the ER was observed. There was a one inch metal conduit above the door penetrating the wall, the hole was unsealed.

6. At 7:50 a.m. on 10/23/13, the wall above the double doors in the "Green Mile" corridor was observed. The was a two inch copper pipe, and two larger water pipes penetrating the smoke barrier. The insulation around the water pipes was retracted to reveal the penetrations were not sealed. The hole around the copper pipe was not sealed as well.

Based on observations, the facility failed to maintain the fire resistance rating of smoke barriers. The deficiencies could affect a very limited number of patients, staff and visitors in two smoke compartments.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. At 8:15 a.m. on 10/23/13, the wall above the double doors in the east hall of the northeast corner of the surgical tower was observed. There was a sleeve conduit running through the wall containing Information Technology wires. The hole through which the conduit ran was sealed around the conduit, but the open area of the conduit was not sealed around the wires.

2. At 9:20 a.m. on 10/23/13, the wall above the "Red Line" doors next to the second floor elevators in the southeast corner was observed. The wall was found to have an open penetration around an electrical conduit, just above the elevator in the angular portion of the wall.

Based on observation, the facility failed to maintain smoke barrier doors for complete closure. The deficiency could affect more than a very limited amount of patients, staff, visitors, on one of five smoke compartments on this floor.

Findings include:

In accordance with NFPA 101 and Section 8.3.4.1, doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Further Annex A.8.3.4.1states that the clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies, 1999 Edition.

The set of smoke doors between Radiology and the Catheterization Lab were exercised at 11:20 a.m. on 10/22/13. The set of smoke doors failed to come together to form a smoke tight seal.

Based on observation, the facility failed to maintain the one-hour rated construction of hazardous areas in accordance with 8.4.1.2 and/or 18.3.2.1. The deficiency could affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with Section 8.4.1.2 of NFPA 101, which states: In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4.

In accordance with Section 8.2.3.2.4.2 of NFPA 101, which states: Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts and similar building service equipment that pass through fire barriers shall be protected as follows:

1. The basement large storeroom in the Health Information Technology (HIT) department was observed at 3:02 p.m. on 10/21/13. There were two conduits through the wall of this room which were not properly sealed for a hazardous area.

2. The 3-hour rated door between the hot lab and the office storage area was exercised at 3:40 p.m. on 10/21/13. The door failed to latch when exercised on three different tries.

3. The large west storeroom in basement Radiation was observed at 3:59 p.m. on 10/21/13 The following deficiencies were noted:
a.) the west wall had a two inch conduit which was not properly sealed,
b.) the south wall had three penetrations above the door which were not sealed, and
c.) the east wall had one penetration of an unsealed conduit.

4. The east/west wall in the shelled construction space between Central Sterile and the empty shell space was observed at 5:00 p.m. on 10/21/13. The open shell space was being utilized to store copiers which had been removed from all over the campus. There was other equipment also being stored in the unoccupied shell space, but for the most part it was copiers. There were 45 penetrations in the east/west wall which made up the separation.

5. The second floor door to the soiled utility room for Endoscopy was exercised at 8:01 a.m. on 10/22/13. The door to this hazardous area failed to latch when exercised three different times.

Based on observations, the facility failed to assure that doors protecting hazardous areas had self-closing mechanisms or that the doors integrity was being maintained to prevent the passage of smoke. These deficiencies have the potential to affect more than a very limited number of patients, staff, visitors, and one of five smoke compartments on the lower level.

The findings include:

In accordance with Section 19.3.2.1, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

1. The old lab in the basement was being used as a storeroom, and was much greater than 50 square feet in area. The east wall of the room was observed at 3:56 p.m. on 10/21/13. The wall was noted to have two open conduits into the unsprinklered crawl space and also had two wooden doors which served as access to the crawl space which were not self-closing and tight to the passage of smoke.


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2. On 10/21/13 at 3:40 p.m., a 1/2 inch copper pipe was observed to penetrate the north wall of the electrical room in the basement to the new tower addition. The penetration did not have a fire stop material to seal the penetration.

3. On 10/22/13 at 8:51 a.m., a patient room was utilized as storage during the construction of the infusion area on 1st floor. The room contained four beds, one incubator, one crib, eight chairs and numerous other furniture items. The corridor door did not have a self closure.

Based observation, the facility failed to ensure the fire door to an exit stairway was kept closed. This deficiency could affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 101 and Section 39.3.1.1, any vertical opening shall be enclosed or protected in accordance with 8.2.5. Further, in accordance with Section 8.2.5.1, every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation. Openings shall be protected as appropriate for the fire resistance rating of the barrier as required in Section 8.2.5.2 of the LSC.

At 2:17 p.m. on 10/23/13, upon entering the facility, the main door to the facility was observed to be propped open using a wedge of wood.

Based on observation, the facility failed to maintain their emergency lighting and ensure functionality of such. This deficiency could affect all patients, staff, and visitors.

Findings include:

In accordance with NFPA 101 and Section 38.2.9.1, emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 300 or more total occupants.

Section 7.9.3 of NFPA 101 states that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Section 4.6.12.2 of NFPA 101 states that existing life safety features obvious to the public, if not required by the code, shall be either maintained or removed.

At 1:35 p.m. on 10/23/13, observations and testing of emergency lighting was done in the facility. Six emergency light fixtures throughout the facility were found to be non-functioning.

Based on observation, the facility failed to maintain their emergency lighting and ensure functionality of such. This deficiency could affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 101 and Section 38.2.9.1, emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 300 or more total occupants.

Section 7.9.3 of NFPA 101 states that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Section 4.6.12.2 of NFPA 101 states that existing life safety features obvious to the public, if not required by the code, shall be either maintained or removed.

At 11:00 on 10/24/13, a test was conducted on the emergency light at the north entrance, it was found to be non-functional.

Based on observations, the facility failed to maintain all fire suppression systems in accordance with the standards of NFPA 72, 1999 Edition. This deficiency had potential to affect all patients, staff and visitors in the building.

Findings include

In accordance with NFPA 101 and Section 39.3.4.1, a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Secondly, in accordance with NFPA 101 and Section 9.6.1.4, a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72.

Finally, in accordance with NFPA 101 Chapter 4 and Section 4.6.12.2 of NFPA 101, existing life safety features obvious to the public, if not required by the code, shall be either maintained or removed.

On 10/23/13 at 2:30 p.m., the FACP was observed to have a sticker stating the breaker that cut off the power to this panel 2N2L was #32. In the mechanical room panel 2N2L, the breaker marked for the FACP was #33 and was not marked in red.

Based on observations made the facility failed to maintain components of the fire alarm system, being thermal or smoke detection devices, in fully operational condition. This deficiency could affect a very limited number of patients, staff and visitors.

The findings include:

On 10/22/13 at 1:40 p.m., the smoke detector in the temporary construction area located in the vault was observed to have blue tape covering it.

Based on observation, record review and staff interview, the facility failed to maintain all smoke detection equipment installed to activate the alarm system. This deficiency could affect more than a very limited number of staff in a limited area within the facility.

Findings include:

In accordance with Section 9.6.2.8 of NFPA 101, which states: where a complete smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in a occupiable areas, common areas, and work spaces in those environments suitable for proper smoke detector operation.

1. The control room and data center in the basement of the Surgical Services Tower were observed at 4:15 p.m. on 10/21/13. The smoke detectors had been removed from the area, as Information Technology (IT) was being moved to this new area of the tower and they did not want to set off the alarm system. No contractors or IT personnel were working in this area at the time.

In accordance with NFPA 72 and Section 6-4.2.1; public fire alarm reporting systems as defined in this chapter, shall, in their entirety, be subject to a complete operational acceptance test upon completion of system installation. This test(s) shall be made in accordance with the requirements of the authority having jurisdiction. However, in no case shall the operational functions tested be less than those stipulated in Chapter 7. Acceptance tests shall also be performed on any alarm reporting devices as identified in this chapter that are added subsequent to the installation of the initial system.

In accordance with NFPA 72, 7-1.6.1 Initial Acceptance Testing, all new systems shall be inspected and tested in accordance with the requirements of Chapter 7.

In accordance with NFPA 72, 7-1.6.2.1 Reacceptance Testing, reacceptance testing shall be performed after any of the following:

(1) Added or deleted system components
(2) Any modification, repair, or adjustment to system hardware or wiring
(3) Any change to site-specific software.
All components, circuits, systems operations, or site-specific software functions known to be affected by the change or identified by a means that indicates the system operational changes shall be 100 percent tested. In addition, 10 percent of initiating devices that are not directly affected by the change, up to a maximum of 50 devices, also shall be tested, and correct system operation shall be verified. A revised record of completion in accordance with 1-6.2.1 shall be prepared to reflect any changes.

2. The fire alarm service records were reviewed at 11:30 a.m. on 10/21/13. The record of completion indicated the following:
a. Testing of elevator recall and AHU devices will be done at a later date.
b. Audibles and annunciators will be tested at a later date.
c. Provide visual notification in room 299M that the notifier is working.
d. Verify visual notification kiosk S/S Room 235-P.
e. Verify smoke detection in PACU, room 295 between the header.

An interview included a statement that the facility environmental safety officer could not confirm that these items had been corrected since the Inspection Report of 1/30/13.

Based on observation and staff interview, the facility failed to ensure complete sprinkler coverage. This deficiency has the potential to affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 101 and Section 18.3.5.1, where required by 18.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.6. There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999 Edition), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility.

1. The CT dressing rooms #1 and #2 were observed at 1:10 p.m. on 10/22/13. There were no sprinkler heads in the dressing rooms nor the alcove just outside the dressing area.
In accordance with NFPA 13 and Section 5-13.3.2; in noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.
Exception: Sprinklers shall be installed beneath landings or stairways where the area beneath is used for storage.

2. The second floor stair tower in Surgical Services West was observed at 10:00 a.m. on 10/23/13. There were no sprinkler heads installed in the stair tower.

In accordance with NFPA 13 and Section 5-13.6.1, sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

3. The twin elevators in the Surgical Tower with State ID#'s of 000021 and 000022 were observed at 7:30 a.m. on 10/22/13. There was no sprinkler protection in the pit areas for either elevator.

Based on surveyor observations, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 13, 1999 Edition. The deficiency could affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 13 and Section 3-2.7.2; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further the in Annex A-3-2.7.2 the guidance is that the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

Sprinklers shall be free of corrosion, foreign material, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall) per section 2-2.1.1 of NFPA 25, 1998 Edition.

1. The employee break room for Radiology had an escutcheon ring missing as observed at 3:00 p.m. on 10/21/13.

2. The supply rooms of the Emergency Department had lint buildup on the sprinkler heads as observed at 1:30 p.m. on 10/22/13.

3. An escutcheon ring was missing on the west end of a large room on the Emergency Department, as observed at 1:35 p.m. on 10/22/13.

Based on observation, the facility did not maintain the fire sprinkler system as required by NFPA 25, 1998 Edition. These deficiencies have the potential to affect more than a very limited amount of patients, staff and visitors.

Findings include:

In accordance with NFPA 25 and Section 2-2.1.1, sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

1. The men's restroom in the basement next to the housekeeping break room was observed on 10/21/13 at 3:16 p.m. The room sprinkler head lacked an escutcheon ring.

2. The men's restroom in the basement in the environmental hallway was observed on 10/21/13 at 4:27 p.m. The escutcheon ring was not flush with the ceiling.

3. On 10/22/13 at 9:16 a.m., the sprinkler in the NICU supervisors office was observed. The sprinkler head was above and behind the drop down light fixtures preventing a proper spray pattern.

4. On 10/22/13 at 9:25 a.m., the sprinkler head in the Barn (pump room) in the OB department was observed to be missing the escutcheon ring.

5. On 10/22/13 at 10:08 a.m., an observation of the soiled utility room of the Medical Surgical Unit on 1st floor revealed plastic hanging from the sprinkler head.

6. On 10/22/13 at 1:08 p.m., a penetration was observed in the ceiling above the electrical room in the old OR hallway.


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7. Dietary was observed at 8:00 a.m. on 10/23/13. There were three heads which had corrosion, and another two heads with excessive lint buildup.

Based on observations, the facility failed to ensure that the portable fire extinguishers were maintained and located in accordance with the standards of NFPA 10. This deficiency had the potential to affect more than a very limited number of residents, staff and visitors in the facility.

Findings include:

In accordance with NFPA 10, 1998 Edition, section 4-3.2 Procedures; periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility

Additionally, in accordance with 1-6.7 and 1-6.10 of NFPA 10, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 Inches) above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet (42 inches) above the floor.

1. On 10/21/13 at 4:32 p.m. during a tour of the materials management department, a fire extinguisher was observed mounted on a pillar. The fire extinguisher was at a height of approximately six feet (72 inches) off the floor.

2. On 10/22/13 at 9:13 a.m. during a tour of the OB department, a fire extinguisher was observed mounted on a wall in a closet. A wheelchair and a piece of medical equipment were observed parked directly in front of the fire extinguisher blocking access to the extinguisher.

3. On 10/23/13 at 11:25 a.m. during a tour of the medical gases room, a fire extinguisher was observed to be mounted at approximately six feet four inches (76 inches) off the floor.

Based on observation, the facility failed to maintain the exit corridors free of all obstructions and failed to prevent the exit corridors from being used for storage purposes. The deficiency could affect a very limited number of patients, staff, and visitors who may use the smoke compartment as a required exit.

Findings include:

The first floor elevator lobby area between the Emergency Department (ED) and the vestibule was being utilized to store construction materials and containers as observed at 4:40 p.m. on 10/21/13. The vestibule is designated as an exit way from ED and no combustible materials shall be stored in any required means of egress.

Based on observations and staff interview, the facility failed to store oxygen in accordance with the standards of NFPA 99. This deficiency had potential to affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 99, 1999 Edition, and Section 8-3.1.11.2, storage for nonflammable gases less than 3000 ft 3 (85m3); subsection (h) requires that cylinder or container restraint shall meet 4-3.5.2.1(b)27. Further, Section 4-3.5.2.1(b)27 states that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

On 10/23/13 at 7:45 a.m., two carbon dioxide tanks in the Microbiology department of the Laboratory were not properly secured.

Based on record review, the facility failed to install zone valves in the surgery holding areas, in compliance with NFPA 99, Chapter 4. The deficiency could affect many or all patients and staff within the smoke compartment.

Findings include:

In accordance with NFPA 99, 1999 Edition, and Section 4-3.1.2.3 Gas Shutoff Valves,
shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(d) Zone Valve. Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet (see Figure 4-3.1.2). This valve shall be readily operable from a standing position in the corridor on the same floor it serves. Each lateral branch line serving patient rooms shall be provided with a shutoff valve that controls the flow of medical gas to the patient rooms. Zone valves shall be so arranged that shutting off the supply of medical gas to one zone will not affect the supply of medical gas to the rest of the system. A pressure gauge shall be provided downstream of each zone valve.

The med-gas verification report dated 1/30/13 was reviewed by the survey team at 1:30 p.m. on 10/21/13. The contractor who verified the medical gas system identified an areas of concern on their report. The report indicated the following: "The surgery "Holding" areas zone valve is in the room designated as Holding. The authority having jurisdiction will need to determine if the partitions between bays constitutes enough of a barrier to isolate the valve from the outlet/inlets in case of an emergency of fire."

The curtain partitions between bays in the holding area for surgery were not enough of a barrier to satisfy the requirements of 4-3.1.2.3 (d) NFPA 99, zone valve shut off. An intervening wall must be installed between the valve and the outlet.

Based on interview, the facility failed to provide a main supply shut off valve where the main line first enters the building or downstream of the source valve and outside the source room. This deficiency could affect many of the patients, staff, and visitors.

Findings include:

In accordance with NFPA 99 4-3.1.2.3 (b), the main supply line valve shall be located downstream of the source valve and outside the source room, enclosure, or where the main valve first enters the building. This valve shall be identified.

The medical gases which did not have shut off valves inside the building were: Nitrogen, Nitrous Oxide, and Carbon Dioxide.

Based on observations, the facility failed to assure that smoke dampers closed upon activation of the fire alarm system. The deficiency could affect more than a very limited number of patients, staff and visitors.

The findings include:

If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of Heating, Ventilation, and Air Conditioning (HVAC) systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity, including relays that cause the dampers to close and open upon activation and reset of the fire alarm system per section 3-9.5.2 of NFPA 72, 1999 Edition.

On 10/24/13 at 8:15 a.m., the fire alarm was tested in the OB Department. Smoke damper #68 failed to close with the activation of the fire alarm. At 9:00 a.m., the damper was retested and again failed to close.

Based on observations the facility failed to store oxygen in accordance with the standards of NFPA 99. This deficiency had potential to affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 99, 1999 Edition and Section 8-3.1.11.2, storage for nonflammable gases less than 3000 ft 3 (85 m3); subsection (h) requires that cylinder or container restraint shall meet 4-3.5.2.1(b)27. Further, Section 4-3.5.2.1(b)27 states that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

On 10/23/13 at 7:53 a.m., Kalispell Gastroenterology was toured. An observation of two oxygen tanks revealed they were not secured in place. A chain was hanging from the wall beside the oxygen tanks.

Based on observation and interview, the facility failed to properly secure a tank of liquid nitrogen to resist being knocked over or spilled. This deficiency could affect a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 99 Standards for Health Care Facilities, 1999 Edition, and Section 13-3.8 Gas Equipment Requirements-Patient; gas equipment shall conform to the patient equipment requirements in Chapter 8.

In accordance with sections 8-3.1.11.2(h) and 4-3.5.2.1 (b27) of NFPA 99, freestanding cylinders or containers of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

At 10:50 on 10/24/13, the liquid nitrogen tank was observed, outside the patient room it was normally stored in. The office manager said it was not secured to the wall with a chain.

Based on observations and interviews, the facility failed to properly secure a tank of liquid nitrogen to a wall with a chain, to resist being knocked over or spilled. This deficiency could affect a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 99 Standards for Health Care Facilities, 1999 Edition, and Section 13-3.8 Gas Equipment Requirements-Patient; gas equipment shall conform to the patient equipment requirements in Chapter 8.

In accordance with sections 8-3.1.11.2(h) and 4-3.5.2.1 (b27) of NFPA 99, freestanding cylinders or containers of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

On 10/23/13 at 10:50 a.m., the liquid nitrogen tank was observed, in the examination room in which it is stored, it was not secured to the wall with any device. The three oxygen tanks in the room next to the liquid nitrogen were secured using a Bungee cord.

Based on observation, a medical gas panel was not appropriately marked reflecting changes to room usage. This deficiency has the potential to affect a very limited amount of patients, staff, and visitors.

Findings include:

The medical gas panel #43 was examined at 11:05 a.m. on 10/22/13. The panel now serves respiratory therapy and no longer serves the old ultrasound area, the medical gas identification panel was labeled for both locations instead of just the respiratory area.

Based on observations, the facility failed to post a non-smoking or no smoking sign at a location where nitrous oxide was being stored. This deficiency has the potential to affect more than a very limited amount of patients, staff, and visitors.

Findings include:

In accordance with Section 19.3.2.4 of NFPA 101 and Section 8-3.1.11.3 of NFPA 99, a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

On 10/23/13 at 11:25 a.m., the storage building for Medical Gas lacked proper signage per NFPA 99 and Section 8-3.1.11.3.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition. The deficiencies may affect a very limited number of staff in two of eight smoke compartments on first floor.

Findings included:

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

1. The electrical room outside of Endoscopy was observed at 8:00 a.m. on 10/22/13. Two ladders in storage were blocking access to the electrical panels in this room.

In accordance with NFPA 70 and Article 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(3)(c) Covers. 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. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.
2. The housekeeping closet on Computed Tomography (CT) was observed at 11:25 a.m. on 10/22/2013. An electrical box cover was missing on the back wall of this room.

Based on observations, the facility failed to maintain requirements of NFPA 70, 1999 Edition and electrical requirements set forth by CMS. This deficiency could have an affect on patients, staff, and visitors in the building.

Findings include:

In accordance with 240-4 of the NFPA 70 (1999 Edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 Edition) and interpretations from CMS, extension cords or multiple adaptors used in health care shall be protected against over-current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS). One means is by providing power taps or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. The limited use of circuit breaker protected power taps is acceptable, provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power tap. These items must be directly connected to an appropriate receptacle.

Finally, in accordance with NFPA 70 and Article 370-25, in completed installations, each box shall have a cover, faceplate, or fixture canopy.

1. On 10/21/13 at 4:25 p.m., the South wall of the new education area in the basement was observed. An outlet cover was missing from an electrical outlet.

2. On 10/22/13 at 8:51 a.m., the Infusion Outpatient area was observed. Two power taps in the patient check in area were not secured or flat on the floor.

3. On 10/22/13 at 12:55 p.m., the Pharmacy department was observed. A power tap in the receiving area was not secured and dangling with multiple cords plugged into it.

4. On 10/22/13 at 1:05 p.m., the Pharmacy department was observed. A freezer was plugged in a power tap.

5. On 10/22/13 at 1:47 p.m., the Admitting Office was observed. A refrigerator was plugged into a power tap.

6. On 10/22/13 at 2:19 p.m., Medical Records was observed. Three power taps were dangling from the wall. The power taps were not secured and were supported by their electrical cords.

Based on observations, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). This deficiency could affect more than a very limited number of patients and staff.

Findings include:

In accordance with 240-4 of the NFPA 70 (1999 Edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 Edition) and interpretations from CMS, extension cords or multiple adaptors used in health care shall be protected against over-current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS). One means is by providing power taps or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. The limited use of circuit breaker protected power taps is acceptable, provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

1. At 2:05 p.m. on 10/23/13, a refrigerator in the infusion office was observed to be plugged into a power tap.

2. On 10/23/13, at the nurses station, another refrigerator was observed to be plugged into a power tap.

Based on observations, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition. This deficiency could affect a very limited amount of patients, staff, and visitors.

Findings include:

In accordance with NFPA 101 and Section 38.5.1 Utilities, utilities shall comply with the provisions of Section 9.1. Further in accordance with 9.1.2 Electric, electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

In accordance with NFPA 70 and Article 110-22 Identification of Disconnecting Means;
each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

During a building tour on 10/24/13 between 10:30 a.m. and 11:00 a.m. in breaker panels throughout the facility, numerous spare breakers were found to be in the "on" position. It was unknown if there was power being supplied to rooms, lights, or equipment, or if the panel was labeled improperly.

Based on observation, the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over an ignition source. This deficiency could affect a very limited number of patients, staff, and visitors in one of eight smoke compartments.

Finding include:

In accordance with CMS interpretations (Ref: S&C-05-33) issued on June 9, 2005, ABHR dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Sate Survey Agency (SA) enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.

The supply room in the Emergency Department of the Surgical Services Tower was observed at 1:30 p.m. on 10/22/13. An ABHR was installed directly over an electrical source in the room.

Based on observation, the facility failed to ensure alcohol based hand rub dispensers were not installed over an ignition source. The deficiency had the potential to affect more than a very limited number of patients, staff, and visitors.

Finding include:

In accordance with CMS interpretations (Ref: S&C-05-33) issued on June 9, 2005, Alcohol Based Hand Rub (ABHR) dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Sate Survey Agency (SA) enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.

The housekeeping room in the Emergency Department was observed at 3:00 p.m. on 10/22/13. An ABHR was installed directly over an electrical source in the room.