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Based on observation and interview, the facility failed to maintain corridor wall of one room smoke resistant in accordance with NFPA 101 19.3.6.2.1. This deficient practice had a potential of affecting 7 of 25 patients in 1 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed at 10:59 am that the corridor wall of Telecom Room 1B110 in the swing bed unit on the 1st Floor was not smoke tight due to one unsealed 1 ¼ " pipe penetration and one 9 " x 3 " piece of drywall missing on the corridor side of wall.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to maintain exit access corridor doors to latch in accordance with NFPA 101 19.3.6.3.2. This deficient practice affected 9 of 25 patients and an undetermined number of staff and visitors in 2 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 10 am and 2 pm that (i) the inactive leaf of ICU corridor doors was not kept latched at the top frame of door; (ii) the corridor door 1B080 to the swing bed unit did not latch; and (iii) the CT Scan Room corridor door did not latch due to inactive leaf of double doors was not kept latched at the top frame of door. This observed situation did not provide positive latching to keep the corridor doors closed in accordance with NFPA 101 19.3.6.3.2.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to install exit signs to direct occupants toward exits in two locations in the Primary Care Clinic in accordance with NFPA 101 7.10.1.4. This deficient practice occurred in 1 of 7 smoke compartments, and had the potential to affect an undetermined number of patients, staff and visitors in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 2:30 pm and 2:40 pm that there were no exit signs in the corridor 1J300 adjacent to the nurse station for Center for Women, and corridor 1J195 adjacent to the nurse station for Family Practice in the Primary Care Center outpatient clinic.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to (i) smoke barrier not extended to deck above in one location, and (ii) penetrations in smoke barrier in two locations that were not sealed in accordance with NFPA 101 19.3.7.3. This deficient practice affected an undetermined number of patients, staff and visitors 2 of 7 smoke compartments in the facility.

Findings include

1. During a tour of the facility with Staff C (plant services manager), and Staff D (director of facility management) on 6/15/15, surveyor observed between 1:30 pm and 2:30 pm that the smoke barrier adjacent to the Gift Shop and ER entrance terminated just above the ceiling and was not extended to the deck above in accordance with NFPA 101 19.3.7.3.

2. During a tour of the facility with Staff C and Staff D on 6/15/15, surveyor observed between 1:30 pm and 2:30 pm that the smoke barrier adjacent to the Clean Supply and Soiled Linen Rooms in the patient sleeping wing had top joint not sealed, drywall joints not mudded and taped, drywall screws not embedded in the sheetrock joint compound, and one duct penetration not properly sealed around the duct to provide the required fire resistance rating of at least ½ -hour fire resistance rating.

3. During a tour of the facility with Staff C and Staff D on 6/15/15, surveyor observed between 1:30 pm and 2:30 pm that the smoke barrier in between corridor 1F160 and 1F065 in the Radiology area had one 12 in. x 4 in. cable tray opening that was not sealed properly. There was no fire stopping in the rectangular space between the cables and top edge of opening. This deficient condition was not compliant with NFPA 101 19.3.7.3, 8.3.6.1

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to smoke barrier doors in one location not maintained to function properly in accordance with NFPA 101 19.3.7.6, 8.3.4.3. This deficient practice affected 10 of 25 patients, an undetermined number of staff and visitors in 1 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager), and Staff D (director of facility management) on 6/15/15, surveyor observed between 1:30 pm and 2:30 pm that the smoke barrier doors adjacent to the Clean Supply and Soiled Linen rooms in the patient sleeping wing could not be readily opened due to door binging at the top frame.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to enclose hazardous areas with a properly installed fire-rated walls and self-closing doors in three locations in accordance with NFPA 101 19.3.2.1. This deficient practice affected 3 of 7 smoke compartments in the non-patient sleeping areas of the facility.

Findings include

1. During a tour of the facility with Staff C (plant services manager) and Staff D (director of facilities management) on 6/15/15, surveyor observed between 2:20 pm and 2:30 pm that the File Room in the lower level considered as a hazardous area had no drywall on the inside face of west wall above door, steel beam pockets in 2-hour fire-rated north wall not sealed, and top joint of wall not sealed. This deficient practice did not provide the 2-hr fire resistance rating of the enclosing walls of the fire storage room in accordance with NFPA 101 8.2.3.1.1.

2. During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 9 am and 10 am that the storage room with housekeeping chemical containers, mop carts and washer was deemed as a hazardous area, but not fully enclosed with fire-rated walls due to one 4 ' x 10 ' opening in one wall, and one 6 ' x 6 ' opening in the second wall. Both walls were built of concrete masonry units. The room was located adjacent to the Clean Linen Room 0E095 in the lower level.

3. While on a tour of the facility with Staff C on 6/16/15, surveyor observed at 11:55 am that the Surgery Clean-up Room 1E035 in the OR suite was considered a hazardous area, but did not have a self-closing device to keep the door closed when not in use in accordance with NFPA 101 8.2.3.2.1. The door was observed to be left open at the time of survey.

4. During a tour of the facility with Staff C on 6/16/15, surveyor observed at 2:20 pm that the Storage Room 1J270 in the primary care clinic area did not have a door closer in accordance with NFPA 101 19.3.2.1, 8.2.4.3.5.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief executive officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to maintain one exit door operable in accordance with NFPA 101 19.2.4.2, 19.2.1. This deficient practice affected an undetermined number of staff and visitors in 1 of 7 smoke compartments in the non-patient sleeping area of the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) and Staff D (director of facilities management) on 6/15/15, surveyor observed at 3:47 pm that the right leaf of exterior exit doors from the Shipping/Receiving area did not open. This deficient practice did not meet the requirement of NFPA 101 7.2.1.5.4.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to provide one exit access door from OR#2 to be readily operable in accordance with NFPA 101 19.2.1, 7.1. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in 1 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed at 11:20 pm that the exit access door from OR#2 to corridor had a dead bolt (thumb latch), which is not considered as an obvious method of operation to operate the door under all lighting conditions. The releasing mechanism to open the door also required more than one releasing operation. This observed situation is not compliant with NFPA 101 7.2.1.5.4.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.


NFPA 101 7.2.1.5.4*
"A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. "

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 in three areas: (i) elevator machine room; (ii) electrical switchgear room, and (ii) elevator hoistways in accordance with NFPA 101 19.3.5, 9.7.1.1, NFPA 13 5-13.6. The federal Centers for Medicare Services and state agency Wisconsin Department of Health Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self-preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in 2 of 7 smoke compartments in the facility.

Findings include

1. During a tour of the facility with Staff C (plant services manager) on 6/15/15, surveyor observed at 4 pm that the elevator machine room 0D045 located in the lower level was not sprinkler protected in accordance with NFPA 13 5-13.6.

2. During a tour of the facility with Staff C on 6/16/15, surveyor observed at 3:30 pm that the electrical switchgear room was not sprinkler protected, nor the 2-hr fire resistance rating of the walls enclosing the room was maintained due to two unsealed conduit and two unsealed 2 inch pipe penetrations in accordance with NFPA 13 5-13.11.

3. When interviewed during an exit conference with Staff C on 6/17/15 at 2:45 pm, Staff C stated that there were no sprinkler heads installed on top and bottom of elevator hoistways in accordance with NFPA 13 5-13.6.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), the plant services manager, Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

NFPA 13 5-13.6 Elevator Hoistways and Machine Rooms.
" 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.
5-13.6.2* Automatic sprinklers in elevator machine rooms or at the tops of hoistways shall be of ordinary- or intermediate-temperature rating.
5-13.6.3* Upright or pendent spray sprinklers shall be installed at the top of elevator hoistways.
Exception: Sprinklers are not required at the tops of noncombustible hoistways of passenger elevators with car enclosure materials that meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators. "

Based on observation and interview, the facility failed to provide immediate access from one area in a room to exit due to obstruction in accordance with NFPA 101 19.2.1, 7.1.10. This deficient practice had a potential to affect an undetermined number of staff and visitors in 1 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) and Staff D (director of facilities management) on 6/15/15, surveyor observed at 3:40 pm that exit access from an area with electrical transformer, electrical panel, and UPS Storage battery cabinet mounted on the floor was obstructed due to approximately 34 " high handrails installed in front of the equipment and panel. The equipment space was located in the Clean Linen Storage Room 0E095 in the lower level. This deficient practice did not meet the NFPA 101 7.1.10.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

NFPA 101 7.1.10.1
"Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency."

Based on observation and interview, the facility did not provide medical vacuum system shutoff valve in one location in accordance with NFPA 99 (1999) 4-3.2.2.6(a). This deficient practice affected 13 of 25 patients in the entire facility.Findings include
During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed at 9:30 am and 10:30 am that there was no medical vacuum shutoff zone valve in a zone valve box to isolate the medical vacuum piping serving patient rooms along the southwest side of corridor in the patient sleeping wing.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), Staff C2 (director of safety), and Staff C3 (plant facilitator) on 6/17/15 at 2:45 pm.

NFPA 99 4-3.2.2.6 Vacuum System Shutoff Valves.
" (a) General. Shutoff valves shall be provided to isolate appropriate sections or portions of the piping system for maintenance, repair, or planned future expansion need, and to facilitate periodic testing. All valves, other than those in valve boxes, shall be located in a secure area accessible to authorized personnel only, or be locked or latched open or closed). "

Based on record review, the facility did not provide relative humidity in anesthetizing locations in accordance with NFPA 99 (1999) 5-4.1.1. This deficient practice affected 2 of 3 operation rooms in the facility.Findings include
During a record review of relative humidity logs with Staff C (plant services manager) on 6/16/15 between 1 pm and 1:15 pm, surveyor observed that the relative humidity readings in OR#1 and OR#2 during the period of January through March of 2015 varied from 6% to 34%, and not 35% or greater in accordance with NFPA 99 (1999) 5-4.1.1.

The above deficient practice was confirmed at the time of discovery by a concurrent record review and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and staff interview, the facility failed to (i) maintain working space in front of electrical equipment/panel in one location in accordance with NFPA 70 (1999) 110-26, Table 110-26(a); (ii) supply emergency electrical power to one patient recovery room in accordance with NFPA 70 517-19 and NFPA 99 (1999) 3-3.2.1.2; and (iii) maintain clear work spaces in front of electrical equipment and panel in two locations in accordance with NFPA 70 110-26(b). This deficient practice had a potential to affect 1 of 25 patients, and an undetermined number of staff and visitors in 3 of 7 smoke compartments in the facility.

Findings include

1. During a tour of the facility with Staff C (plant services manager) and Staff D (director of facilities management) on 6/15/15, surveyor observed at 3:40 pm that there was less than the required 3 ft working space in front of the electrical equipment/panel in the Clean Linen Storage Room 0E095 in the lower level due to handrails installed in front of the electrical equipment and panels. This deficient practice was not compliant with NFPA 70 110-26, Table 110-26(a).

2. During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 1 pm and 1:30 pm that the private Recovery Room 1E060 in the OR suite did not have at least one electrical duplex receptacle supplied by the critical branch of the essential electrical system. There were only normal power supplied electrical wall receptacles in the room. This deficient practice was not compliant with NFPA 70 517-19(a) and NFPA 99 3-3.2.1.2(a)1.


3. During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 2 pm and 2:30 pm that (i) one dolly was placed in front of an electrical switch gear in the electrical room adjacent to the high pressure boiler room in the Ambulance Garage addition; and (ii) one over-bed table with plastic trays was stored in front of an electrical panel in the Storage Room 1J270 in the Primary Care Center clinic. The objects did not provide required clear space in front of electrical equipment and panel in accordance with NFPA 70 110-26.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.


NFPA 70 110-26.
" Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ... "

NFPA 70 110-26(b) Clear Spaces.
" Working space required by this section shall not be used for storage ... "

Based on observation and interview, the facility failed to maintain corridor wall of one room smoke resistant in accordance with NFPA 101 19.3.6.2.1. This deficient practice had a potential of affecting 7 of 25 patients in 1 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed at 10:59 am that the corridor wall of Telecom Room 1B110 in the swing bed unit on the 1st Floor was not smoke tight due to one unsealed 1 ¼ " pipe penetration and one 9 " x 3 " piece of drywall missing on the corridor side of wall.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to maintain exit access corridor doors to latch in accordance with NFPA 101 19.3.6.3.2. This deficient practice affected 9 of 25 patients and an undetermined number of staff and visitors in 2 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 10 am and 2 pm that (i) the inactive leaf of ICU corridor doors was not kept latched at the top frame of door; (ii) the corridor door 1B080 to the swing bed unit did not latch; and (iii) the CT Scan Room corridor door did not latch due to inactive leaf of double doors was not kept latched at the top frame of door. This observed situation did not provide positive latching to keep the corridor doors closed in accordance with NFPA 101 19.3.6.3.2.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to install exit signs to direct occupants toward exits in two locations in the Primary Care Clinic in accordance with NFPA 101 7.10.1.4. This deficient practice occurred in 1 of 7 smoke compartments, and had the potential to affect an undetermined number of patients, staff and visitors in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 2:30 pm and 2:40 pm that there were no exit signs in the corridor 1J300 adjacent to the nurse station for Center for Women, and corridor 1J195 adjacent to the nurse station for Family Practice in the Primary Care Center outpatient clinic.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to (i) smoke barrier not extended to deck above in one location, and (ii) penetrations in smoke barrier in two locations that were not sealed in accordance with NFPA 101 19.3.7.3. This deficient practice affected an undetermined number of patients, staff and visitors 2 of 7 smoke compartments in the facility.

Findings include

1. During a tour of the facility with Staff C (plant services manager), and Staff D (director of facility management) on 6/15/15, surveyor observed between 1:30 pm and 2:30 pm that the smoke barrier adjacent to the Gift Shop and ER entrance terminated just above the ceiling and was not extended to the deck above in accordance with NFPA 101 19.3.7.3.

2. During a tour of the facility with Staff C and Staff D on 6/15/15, surveyor observed between 1:30 pm and 2:30 pm that the smoke barrier adjacent to the Clean Supply and Soiled Linen Rooms in the patient sleeping wing had top joint not sealed, drywall joints not mudded and taped, drywall screws not embedded in the sheetrock joint compound, and one duct penetration not properly sealed around the duct to provide the required fire resistance rating of at least ½ -hour fire resistance rating.

3. During a tour of the facility with Staff C and Staff D on 6/15/15, surveyor observed between 1:30 pm and 2:30 pm that the smoke barrier in between corridor 1F160 and 1F065 in the Radiology area had one 12 in. x 4 in. cable tray opening that was not sealed properly. There was no fire stopping in the rectangular space between the cables and top edge of opening. This deficient condition was not compliant with NFPA 101 19.3.7.3, 8.3.6.1

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to smoke barrier doors in one location not maintained to function properly in accordance with NFPA 101 19.3.7.6, 8.3.4.3. This deficient practice affected 10 of 25 patients, an undetermined number of staff and visitors in 1 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager), and Staff D (director of facility management) on 6/15/15, surveyor observed between 1:30 pm and 2:30 pm that the smoke barrier doors adjacent to the Clean Supply and Soiled Linen rooms in the patient sleeping wing could not be readily opened due to door binging at the top frame.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to enclose hazardous areas with a properly installed fire-rated walls and self-closing doors in three locations in accordance with NFPA 101 19.3.2.1. This deficient practice affected 3 of 7 smoke compartments in the non-patient sleeping areas of the facility.

Findings include

1. During a tour of the facility with Staff C (plant services manager) and Staff D (director of facilities management) on 6/15/15, surveyor observed between 2:20 pm and 2:30 pm that the File Room in the lower level considered as a hazardous area had no drywall on the inside face of west wall above door, steel beam pockets in 2-hour fire-rated north wall not sealed, and top joint of wall not sealed. This deficient practice did not provide the 2-hr fire resistance rating of the enclosing walls of the fire storage room in accordance with NFPA 101 8.2.3.1.1.

2. During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 9 am and 10 am that the storage room with housekeeping chemical containers, mop carts and washer was deemed as a hazardous area, but not fully enclosed with fire-rated walls due to one 4 ' x 10 ' opening in one wall, and one 6 ' x 6 ' opening in the second wall. Both walls were built of concrete masonry units. The room was located adjacent to the Clean Linen Room 0E095 in the lower level.

3. While on a tour of the facility with Staff C on 6/16/15, surveyor observed at 11:55 am that the Surgery Clean-up Room 1E035 in the OR suite was considered a hazardous area, but did not have a self-closing device to keep the door closed when not in use in accordance with NFPA 101 8.2.3.2.1. The door was observed to be left open at the time of survey.

4. During a tour of the facility with Staff C on 6/16/15, surveyor observed at 2:20 pm that the Storage Room 1J270 in the primary care clinic area did not have a door closer in accordance with NFPA 101 19.3.2.1, 8.2.4.3.5.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief executive officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to maintain one exit door operable in accordance with NFPA 101 19.2.4.2, 19.2.1. This deficient practice affected an undetermined number of staff and visitors in 1 of 7 smoke compartments in the non-patient sleeping area of the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) and Staff D (director of facilities management) on 6/15/15, surveyor observed at 3:47 pm that the right leaf of exterior exit doors from the Shipping/Receiving area did not open. This deficient practice did not meet the requirement of NFPA 101 7.2.1.5.4.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and interview, the facility failed to provide one exit access door from OR#2 to be readily operable in accordance with NFPA 101 19.2.1, 7.1. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in 1 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed at 11:20 pm that the exit access door from OR#2 to corridor had a dead bolt (thumb latch), which is not considered as an obvious method of operation to operate the door under all lighting conditions. The releasing mechanism to open the door also required more than one releasing operation. This observed situation is not compliant with NFPA 101 7.2.1.5.4.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.


NFPA 101 7.2.1.5.4*
"A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. "

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 in three areas: (i) elevator machine room; (ii) electrical switchgear room, and (ii) elevator hoistways in accordance with NFPA 101 19.3.5, 9.7.1.1, NFPA 13 5-13.6. The federal Centers for Medicare Services and state agency Wisconsin Department of Health Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self-preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in 2 of 7 smoke compartments in the facility.

Findings include

1. During a tour of the facility with Staff C (plant services manager) on 6/15/15, surveyor observed at 4 pm that the elevator machine room 0D045 located in the lower level was not sprinkler protected in accordance with NFPA 13 5-13.6.

2. During a tour of the facility with Staff C on 6/16/15, surveyor observed at 3:30 pm that the electrical switchgear room was not sprinkler protected, nor the 2-hr fire resistance rating of the walls enclosing the room was maintained due to two unsealed conduit and two unsealed 2 inch pipe penetrations in accordance with NFPA 13 5-13.11.

3. When interviewed during an exit conference with Staff C on 6/17/15 at 2:45 pm, Staff C stated that there were no sprinkler heads installed on top and bottom of elevator hoistways in accordance with NFPA 13 5-13.6.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), the plant services manager, Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

NFPA 13 5-13.6 Elevator Hoistways and Machine Rooms.
" 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.
5-13.6.2* Automatic sprinklers in elevator machine rooms or at the tops of hoistways shall be of ordinary- or intermediate-temperature rating.
5-13.6.3* Upright or pendent spray sprinklers shall be installed at the top of elevator hoistways.
Exception: Sprinklers are not required at the tops of noncombustible hoistways of passenger elevators with car enclosure materials that meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators. "

Based on observation and interview, the facility failed to provide immediate access from one area in a room to exit due to obstruction in accordance with NFPA 101 19.2.1, 7.1.10. This deficient practice had a potential to affect an undetermined number of staff and visitors in 1 of 7 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (plant services manager) and Staff D (director of facilities management) on 6/15/15, surveyor observed at 3:40 pm that exit access from an area with electrical transformer, electrical panel, and UPS Storage battery cabinet mounted on the floor was obstructed due to approximately 34 " high handrails installed in front of the equipment and panel. The equipment space was located in the Clean Linen Storage Room 0E095 in the lower level. This deficient practice did not meet the NFPA 101 7.1.10.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

NFPA 101 7.1.10.1
"Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency."

Based on observation and interview, the facility did not provide medical vacuum system shutoff valve in one location in accordance with NFPA 99 (1999) 4-3.2.2.6(a). This deficient practice affected 13 of 25 patients in the entire facility.Findings include
During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed at 9:30 am and 10:30 am that there was no medical vacuum shutoff zone valve in a zone valve box to isolate the medical vacuum piping serving patient rooms along the southwest side of corridor in the patient sleeping wing.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), Staff C2 (director of safety), and Staff C3 (plant facilitator) on 6/17/15 at 2:45 pm.

NFPA 99 4-3.2.2.6 Vacuum System Shutoff Valves.
" (a) General. Shutoff valves shall be provided to isolate appropriate sections or portions of the piping system for maintenance, repair, or planned future expansion need, and to facilitate periodic testing. All valves, other than those in valve boxes, shall be located in a secure area accessible to authorized personnel only, or be locked or latched open or closed). "

Based on record review, the facility did not provide relative humidity in anesthetizing locations in accordance with NFPA 99 (1999) 5-4.1.1. This deficient practice affected 2 of 3 operation rooms in the facility.Findings include
During a record review of relative humidity logs with Staff C (plant services manager) on 6/16/15 between 1 pm and 1:15 pm, surveyor observed that the relative humidity readings in OR#1 and OR#2 during the period of January through March of 2015 varied from 6% to 34%, and not 35% or greater in accordance with NFPA 99 (1999) 5-4.1.1.

The above deficient practice was confirmed at the time of discovery by a concurrent record review and interview with the plant services manager, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation and staff interview, the facility failed to (i) maintain working space in front of electrical equipment/panel in one location in accordance with NFPA 70 (1999) 110-26, Table 110-26(a); (ii) supply emergency electrical power to one patient recovery room in accordance with NFPA 70 517-19 and NFPA 99 (1999) 3-3.2.1.2; and (iii) maintain clear work spaces in front of electrical equipment and panel in two locations in accordance with NFPA 70 110-26(b). This deficient practice had a potential to affect 1 of 25 patients, and an undetermined number of staff and visitors in 3 of 7 smoke compartments in the facility.

Findings include

1. During a tour of the facility with Staff C (plant services manager) and Staff D (director of facilities management) on 6/15/15, surveyor observed at 3:40 pm that there was less than the required 3 ft working space in front of the electrical equipment/panel in the Clean Linen Storage Room 0E095 in the lower level due to handrails installed in front of the electrical equipment and panels. This deficient practice was not compliant with NFPA 70 110-26, Table 110-26(a).

2. During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 1 pm and 1:30 pm that the private Recovery Room 1E060 in the OR suite did not have at least one electrical duplex receptacle supplied by the critical branch of the essential electrical system. There were only normal power supplied electrical wall receptacles in the room. This deficient practice was not compliant with NFPA 70 517-19(a) and NFPA 99 3-3.2.1.2(a)1.


3. During a tour of the facility with Staff C (plant services manager) on 6/16/15, surveyor observed between 2 pm and 2:30 pm that (i) one dolly was placed in front of an electrical switch gear in the electrical room adjacent to the high pressure boiler room in the Ambulance Garage addition; and (ii) one over-bed table with plastic trays was stored in front of an electrical panel in the Storage Room 1J270 in the Primary Care Center clinic. The objects did not provide required clear space in front of electrical equipment and panel in accordance with NFPA 70 110-26.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager and director of facilities management, and at the time of exit conference with Staff A (chief nursing officer), Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.


NFPA 70 110-26.
" Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ... "

NFPA 70 110-26(b) Clear Spaces.
" Working space required by this section shall not be used for storage ... "