HospitalInspections.org

Based on random observation during the survey walk-through, staff interview and review of Life Safety Plans produced by Shive-Hattery Architects in Moline, IL, the construction type of the building does not comply with NFPA 101 - 2000, 19.1.6.2. This deficiency could affect all in-patients in the facility, as well as those residents of the Long Term Care portion of the building and any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:
A. The original 1934 building area is partially sprinklered and indicated to be of Type III (000) construction type and is two stories with a basement. Although the floors are concrete construction, the columns and roof construction are unprotected or of wood frame construction which is not permitted under Table 19.1.6.2. Although the 2nd floor is provided with sprinkler protection, the wood frame roof is not separated from the rooms below due to holes in the original plaster ceiling above the suspended tile ceiling at the corridor and the conference room. Surveyor notes that the original building area is not otherwise separated from the Hospital by 2-hour rated construction on all floor levels to allow it to be classified as a separate non-healthcare occupancy building. The 2-hour separation is indicated to only exist on the 2nd floor.

UPDATE 4/9/15: See K044 relative to deficiencies remaining concerning building separation corrective work.

B. The 1954 and 1974 building areas are indicated to be of Type II (000) construction type. These building areas are also two stories with a basement. The building construction type is not permitted under Table 19.1.6.2 without full sprinkler protection. The building areas are only partially sprinkler protected.

UPDATE 4/9/15: Sprinkler protection for the entire building is ongoing. Portions of the 2nd floor remain to be provided with sprinkler protection.

Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.2.3 and 7.2. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching the public way from an exit from the building.

Findings include:
A. Corrected 4/9/15.
B. Corrected 4/9/15.

C. At 10:00am on 4/9/15 it was observed that the former communicating stair adjacent the elevator in the 1954 building is now designated as an exit stair only from the Basement level. This stair is not designated as an exit for the 2nd floor. The discharge level of this exit stair is the 1st floor level. The 1st floor discharge door is not identified as the exit discharge level for the exit stair. A gate or barrier to prevent travel beyond the discharge level is not provided to comply with 7.7.3.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or 2-hour fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one fire compartment into adjacent fire compartments.

Findings include:
A. Corrected 4/9/15.

B. At 8:30am on 4/9/15 it was observed that the 2-hour fire barrier wall and spray fireproofing for the steel floor structure constructed to separate the 1934 non-conforming building construction type from the hospital was complete, but fire stopping had yet to be installed as part of the corrective work and separation at the Lab area was yet to be completed. (See k012 also). Surveyor notes that the 1/8/15 PoC indicates a May 15, 2015 completion date for this building separation.

Based on random observation during the survey walk-through, and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:
A. On 9/17-18/14 and during the walk-through survey, a series of apparent errors were observed in the Life Safety Plans 10/15/10. These plans are thus not sufficiently accurate to comply with 19.7.1.1. Apparent errors include:

1. Corrected 4/9/15.
2. Corrected 4/9/15.
3. Corrected 4/9/15.
4. Corrected 4/9/15.

5. New 4/9/15: The Life Safety Plans have been updated as part of the 1/8/15 PoC to indicate conditions at the completion of all building PoC work. However, the plans do not reflect the actual conditions of the building until this work is completed. Descrepancies noted during review of the revised plans on 4/9/15 at 10:30am include the following:

a. The Basement level suite containing the mechanical/boiler rooms was not separated from the adjacent suite due to the lack of a pair of doors in the corridor near the 1954 building elevator & stair. Exit access for the mechanical/boiler room suite was not confirmed to meet the requirements of 19.2.5 and 7.5.1.4 relative to remoteness.

b. Not all Soiled rooms or Clean Supply storage rooms are identified as hazardous areas in accordance with 19.3.2.1.

c. Not all hazardous area rooms (particularly on the 2nd floor) which lack 1-hour enclosure are compliant until completion of sprinkler system.

d. Multi-room Bathing areas on the 2nd floor are not identified as suites.

e. The ramp in the 1934 building was not identified as being separated from adjacent areas to comply with 7.2.5.5.

f. The separation of the 1934 building from the hospital at the Lab was not yet complete.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through, not all portions of the facility's electrical distribution system are in accordance with NFPA 70-1999.

Findings include:
A. At 2:40pm on 9/17/14 it was observed that the "X5" panel noted to be an essential electrical system emergency power supply panel contained non-essential load circuits and no separation of the three required branches of Critical, Life Safety and Equipment branches in accordance with 517-30 (b).