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Based on random observation during the survey walk-through, not all portions of the building comply with the designated construction type(s) to comply with 18/19.1.6.2. These deficiencies could affect all patients in the facility, as well as 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. Corrected 4/2/13.

B. A wood frame trellis was observed at 12:05pm on 12/12/12 adjacent the 1956 Addition Dining room at the Ground floor. The 1956 Addition is not fully sprinkler protected and a 2-hour separation from the combustible trellis construction is not otherwise maintained to comply with NFPA 80A, Protection of Buildings from Exterior Fire Exposures.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1 or otherwise protected in accordance with the exceptions. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke compromising the use of the facility's exit access corridors.

Findings include:

A. A sprinklered wheelchair equipment alcove of less than 50 SF on the 3rd floor of the 1968 Addition near the 2000 Addition Stair was observed at 9:00am on 12/12/12 to be open to the corridor and not provided with smoke detection or direct observation to comply with 19.3.6.1, Exception No. 1, parts (b) and (c).

B. The sprinklered 2004 Addition Surgery Reception desk area on the 2nd floor was observed at 10:45am on 12/12/12 to be open to the corridor and not provided with smoke detection or direct observation to comply with 18.3.6.1, Exception No. 1, parts (b) and (c).

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. On 12/12/12 at 2:15pm, it was observed that the corridor door at the Ground floor Doctor's Locker room (On-call) is not positive latching to comply with 19.3.6.3.2.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18/19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. Corrected 4/2/13.

B. At 11:20am on 12/12/12 at the 2nd floor of the 2004 Addition it was observed that the door between the Soiled Decontamination room and the Clean Work/Storage/Prep-Pack room was not fire resistance rated to comply with 18.3.2.1. However, if the Decontamination room and the Clean work/storage room were considered a single hazardous area, the dutch door accessing the Prep/Pack area from the corridor is not fire resistance rated. The dutch door also does not comply with the requirements of 18.3.6.3.6 because it is not equipped with an astragal, rabbit or bevel to permit the door leafs to act as a single leaf when operated for exiting.

UPDATE 4/2/13: The door has been equipped with an astragal, but the requirements of 18.3.2.1 are not met if the door assembly is not labeled as minimum 3/4-hour fire resistance rated.

C. At 2:15pm on 12/12/12 at the Ground floor it was observed that the HR storage room door was not self-closing to comply with 19.3.2.1.

UPDATE 4/2/13: The door has been equipped with a closer, but it was not functioning to properly close the door.

D. At 2:55pm on 12/12/12 at the Ground floor it was observed that two doors to the non-sprinklered Soiled Utility room within the Emergency room suite were equipped with louvers and not minimum 3/4-hour rated to comply with 19.3.2.1.

Based on random observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 2:05pm on 12/12/12 it was observed that the 1914 building stair contained a single sided drywall enclosure with an unrated access door to enclose recently installed conduits and data cables which are not permitted within the stair enclosure to comply with 7.1.3.2.1(e).

Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets or provided with dead bolt locks operated only by a key from either side. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. The key-only dead bolt locks are not operable for exiting without a key in noncompliance with 7.1.10.1. Locations observed include but are not necessarily limited to the following:

1. The corridor door which provides the only exit from the freight elevator lobby was observed at 9:55am on 12/12/12 to be provided with a combination lock which prevents access from the elevator lobby into the 3rd floor OB department if the combination is not known or remembered.

UPDATE 4/2/13: A magnetic locking device has been installed on the door which is released by keypad on the corridor side (to prevent access to the elevator). The elevator lobby side is provided with a push button to release the magnet, but is also equipped with a delayed egress sequence of operation. Surveyor observed that when the delayed egress function is activated by pulling on the door to exit the elevator lobby, the push button release does not function. However, the door can be opened immediately without delay if the push button release is activated prior to pulling on the door to open it. Surveyor observed that the installation does not comply completely with either 7.2.1.6.1 for Delayed-Egress Locks or 7.2.1.6.2 for Access-Controlled Egress Doors as follows:

a. If the delayed egress function is to remain, the exit path from the elevator lobby to a secondary exit route at the entrance to the OB department is also equipped with a delayed egress magnetic lock in non-compliance with 19.2.2.2.4 Exception No. 2. Only one delayed egress lock may exist in any egress path. The exit access serving the elevator lobby is considered to be contained within a suite because the door to the nursery does not comply with 19.3.6.3 as a corridor door. This door is not installed in a frame that is resistant to the passage of smoke to comply with 19.3.6.3.1 and is not provided with latching hardware to comply with 19.3.6.3.2. The OB department corridor does not currently direct exiting to the stair within the suite but rather to the southwest stair and the main entry to the OB department which has a magnetic lock with delayed egress. This arrangement is acceptable but will not permit the elevator lobby door to also be equipped with a delayed egress locking device.

b. If the delayed egress lock is to remain, it was not confirmed that the lock releases upon activation of the sprinkler system, a heat detector or no more than two smoke detectors to comply with 7.2.1.6.1(a).

c. If the delayed egress lock is to remain, it was not confirmed that the lock releases upon loss of power to the lock or locking mechanism to comply with 7.2.1.6.1(b).

d. If the delayed egress lock is to remain, signage to comply with 7.2.1.6.1(d) is not provided.

e. If the delayed egress function of the lock is removed and the lock is installed to comply with 7.2.1.6.2 as an Access-Controlled Egress Door, the installation lacks the sensor to release the lock upon upon approach to the door from the elevator lobby side and upon loss of power to the sensor to comply with 7.2.1.6.2(a).

f. If the delayed egress function of the lock is removed and the lock is installed to comply with 7.2.1.6.2 as an Access-Controlled Egress Door, the installation lacks confirmation that the lock releases upon loss of power to the access control system to comply with 7.2.1.6.2(b).

g. If the delayed egress function of the lock is removed and the lock is installed to comply with 7.2.1.6.2 as an Access-Controlled Egress Door, the installation lacks confirmation that the lock releases upon activation of the fire alarm system to comply with 7.2.1.6.2(d) & (e).

2. The 1914 building 2nd floor Marketing Storage room corridor door was observed to be a dutch door with latch/locking hardware on both the upper and lower leafs. The door is not arranged in such a way as to always allow the lower leaf to be equipped with latching hardware to open the upper leaf to comply with 7.2.1.5.4. The storage room was not otherwise confirmed to comply with 39.3.2.1 and 8.4 as a hazardous area within a business occupancy. The dutch door was observed not to be self-closing to a latched condition.

3. The 1st floor Business Office area (separated business occupancy) was observed at 1:45pm on 12/12/12 to have multiple exit access doors equipped with dead bolt locks operated by keys only.

a. Corrected 4/2/13.
b. One door at the IT Server room.
c. One door at the Controllers office.

4. The Basement mechanical/equipment room in the far northwest corner and the File storage room were observed at 4:00pm on 12/12/12 to be equipped with both a dead bolt lock and a latchset.

5. A cross corridor door in the Basement of the 1914 building was observed at 4:00pm on 12/12/12 to be equipped with a dead bolt lock operable with key only from either side.

Based on random observation during the survey walk-through on 12/12/12, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. Exit discharge locations were observed to lack unswitched fixtures/lighting with more than one lamp equipped with instantaneous type lighting connected to the emergency power system to comply with 7.8.1.4. Lighting appeared to be HID type which requires restrike and/or warm-up period to provided illumination or only a single incandescent or fluorescent type fixture/lamp was provided. Connection to the emergency power system was not confirmed for all locations. Observed examples include but are not limited to the following:

1. At the 2000 Addition stair and corridor discharges.

2. At the Lab exterior door discharge.

3. At the Main Lobby entrance/exit discharge.

Based on document review and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. This deficiency could affect all patients in the facility as well as any staff and visitors present, because the failure to maintain a clear plan could result in confusion of expected responses to a fire or smoke condition within the building.

Findings include:

A. Corrected 4/2/13.
B. Corrected 4/2/13.
C. Corrected 4/2/13.

D. The Life Safety Reference Plans utilized during the survey were not clear relative to the designation of fire rated barrier walls and building separations. Examples include but are not necessarily limited to the following:

1. Stair and shaft fire rated enclosures were not shown on the plans.

2. The 2-hour fire/smoke barrier between the 2004 Addition 2nd floor and portions of the existing building were not indicated to form a complete separation from outside wall to outside wall or from another barrier of equal or greater rating to comply with 8.2.2.2. Area in question includes near the 2000 Addition stair.

3. The 2-hour fire/smoke barrier between the 1914 building and the 1956 Addition at the 2nd floor was observed at 10:20am on 12/12/12 to have 3/4-hour rated cross corridor doors in lieu of the 90 minute doors required to comply with 8.2.3.2.

4. The designation and separation of buildings and construction types is not clear. The 2004 Addition is indicated to be Type I (332) and the 1956 Addition is indicated to be Type II (222). The barrier between the different construction types is not located along the walls of the different dates of construction. Therefore, the 2004 Addition Type I (332) construction type appears to extend into the area of the lesser 1956 Addition Type II (222) construction.

UPDATE 4/2/13: The Plan of Correction for the above deficiencies 1, 2 & 4 were indicated to be "N/A". However, life safety plans were available but not reviewed in detail due to observations relating to item 4 as follows:

a. The designated 2-hour rated west wall of the north hall on the 2nd floor of the 1956 building was observed to have a duct penetration above the small storage room door which did not have a fire damper to comply with 8.2.3.2.4.2.

b. The designated 2-hour rated east wall of the 1956 building south of the cross corridor doors across from the Pharmacy door was observed to contain a 2'x3' recessed fire extinguisher cabinet which could not be confirmed to maintain the required 2-hour rating of the wall.

c. The 2004 addition is designated to be of Type I (332) construction type and the 1956 building is indicated to be of Type II (222) construction type. The demarkation between the construction types does not follow the structural lines of the building, therefore the Type I (332) construction must be considered only to qualify as Type II (222).

Based on record review it was determined that the facility failed to adequately document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. During the record review of fire drill information on the afternoon of 12/11/12 it was determined that quarterly fire drills are documented for specific zones of the building where the activation took place, but that response information beyond the zone of activation is not recorded. Therefore, it could not be determined that all areas of the hospital participate in the drill to substantiate the requirements of NFPA 101 Section 19.7.1.2.

UPDATE 4/2/13: Only a single drill for each of three shifts has occurred since the previous survey. Additional documentation will be required to verify compliance. Although a schedule of drills has been developed to ensure that all areas of the hospital are documented to participate in the drills, the information being documented thus far does not provide evidence that all areas are participating in a drill once per quarter per shift because response information from drill observers is limited to only specific areas of the facility rather than throughout the facility. Therfore, documentation appears to indicate that only portions of the facility personnel are participating during a drill and only a portion of the facility's fire alarm system components are being observed during a drill.

B. Fire drill response records for 10/25/12 indicated a drill at 10:00 AM for the Purchasing Department. Responses to questions such as audibility of alarms, functionality of chimes/strobes and patient room doors being closed and latched were marked as "N/A". During review with the Director of Environmental Services, it was discovered that the Purchasing Department is located in a separate building on the same property as the Hospital. The procedures followed for fire conditions for this building are for the purchasing staff to call the hospital switchboard to report a fire condition. The switchboard operator then activates the hospital fire alarm to summon the Fire Dept. The drill conducted at the Purchasing building is being utilized as one of the required drills for the hospital, but no response information from the Hospital zones is recorded to be able to substantiate the requirements of NFPA 101 Section 19.7.1.2. The Purchasing Department may be included as part of the drill activities, but response information relative to the hospital areas must be documented to consider the drill applicable to meeting the hospital requirements.

UPDATE 4/2/13: Only a single drill for each of three shifts has occurred since the previous survey. Additional documentation will be required to verify compliance.

Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with 18/19.3.4 and NFPA 72-1999. This could effect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Findings include:

A. On 12/12/12 at 8:50am, it was observed that three smoke detectors in the 2004 Mechaincal room were not mounted at the deck but rather at the bottom of 16-18" open web steel joist which does not comply with NFPA 72-1999, 2-3.4.3.1.

B. On 12/12/12 at 8:50am, it was observed that a wall mounted smoke detector in the stair accessing the 2004 Mechaincal room was not mounted between 4" and 12" from the ceiling to the top of the detector to comply with NFPA 72-1999, 2-3.4.3.1. The detector was mounted on the wall 24"+ from the ceiling.

C. On 12/12/12 at 10:30am, it was observed that smoke detectors in the 1956/2004 Storage room were not mounted at the deck to comply with NFPA 72-1999, 2-3.4.3.1.

D. On 12/12/12 at 3:20pm, it was observed that a smoke detector in the 1995 Main Lobby at the reception desk was not mounted 4" to 12" from the ceiling to the top of the detector to comply with NFPA 72-1999, 2-3.4.3.1. The detector was mounted at approximately 8' above the floor in a space with a 20'+ ceiling height.

E. The circuit breakers serving the fire alarm system are not marked in red and equipped with a locking device as required by NFPA-72, Section 1-5.2.5.2.

UPDATE 4/2/13: The fire alarm circuit has been marked in red and provided with a lock-on device. However, the circuit is located in a Critical Branch panel "C2AG" rather than a Life Safety Branch panel in noncompliance with NFPA 99-1999, 3-4.2.2.2(b).

F. Fire Alarm Control Panel is not labeled with the electrical panel designation and circuit number as required by NFPA 72-1-5.2.5.

UPDATE 4/2/13: The fire alarm control panel has been labeled to identify the circuit from which is is fed. However, the circuit is located in a Critical Branch panel "C2AG" rather than a Life Safety Branch panel in noncompliance with NFPA 99-1999, 3-4.2.2.2(b).

G. The audible alarms were not loud enough to be heard from the ER, x-ray and lab area, and the business area to meet the requirements of NFPA-101, Section 9.6.3.8.

By direct observation on the morning of 12/12/12, the surveyor finds the facility failed to provide the kitchen grease hood with the correct filter installation. The kitchen exhaust hood for the removal of grease laden vapors has mesh filters in non-compliance with NFPA 96, 1998, 3-1.

Based upon observations during the Survey walk-through, it was determined that the facility failed to maintain the corridors free of obstructions. This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors.

Findings include:

A. At 9:40am on 12/12/12 it was observed that the corridor ceiling in the 3rd floor OB department was not at the minimum 7'-6" height required by 7.1.5. Height was approximately 7'-0".

Based on direct observation the afternoon of 12/12/12, the surveyor finds the facility failed to provide piped medical gas systems in accordance with NFPA 99, 1999, Chapter 4.

Findings include:

A. The medical gas valves located in the Ground floor Specialty Clinic were not confirmed to be part of the active system. The valves were "on" but the nitrous oxide gas gauge was reading "0". The valves were not labeled accurately and were not clearly legible to comply with NFPA 99-1999, 4-3.1.2.14(b).

UPDATE 4/2/13: The valves were labeled as "Not in Use" but Oxygen and Vacuum lines were pressurized. Therfore the Oxygen and Vacuum system appeared functional and available for use at an unidentified location because labeling of the outlets served was not provided. The Nitrous system did appear "Not in Use" because the outlet had been removed and the pressure gauge at the valve read "0". Proper labeling of a functional system does not appear to be maintained or complete identification of outlets and control valves and system components made inoperable was not provided.

B. Based on direct observation the morning of 12/12/12, the surveyor finds the facility failed to provide separation by an intervening wall between the medical gas zone valves and the outlets they serve to comply with NFPA 99, 1999, 4-3.1.2.3 (d). Locations observed include:

1. At the 2nd floor 2004 Addition Stage 1 Recovery.

2. At the Ground floor Cardiac Rehab.

Based on random observation during the survey walk-through on 12/12/12 the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The generator was not equipped with a battery heater to meet the requirements of NFPA-110, Section 3-3.1.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other Code requirements that are not documented under other K-Tags.

Findings include:

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 the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

A. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panel EC-2 had a circuit feeding the fire alarm system NAC panel, and the critical panel in the outpatient area was serving the main fire alarm panel along with the med gas alarm panel (these items should be served from the life safety panel). This does not meet the requirements of NFPA-70, Section 517-32 and 33.

B. Some panels in the older portion of the building including EM-1B, EM00, and EMP served a mix of life safety, critical, and equipment loads which does not meet the requirements of NFPA-70, Sections 517-30 through 35.

C. Some panels such as EMP need new updated and typed directories to meet the requirements of NFPA-70, Section 110-22.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. Normal power receptacles were not provided in operating rooms, and procedure rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. The domestic water service and the water service for the sprinkler system were not grounded in accordance with NFPA-70, Section 250-52. This could cause a potential difference between the water piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

C. Bonding of the piping for the medical gas system could not be located by staff as required by NFPA-70, Section 250-104(c). This could cause a potential difference between med gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

D. Emergency receptacles in the ER, ICU, and other patient bed locations were not all identified as emergency receptacles. All receptacles or cover plates served by critical power shall have a distinctive color or marking so as to be readily identifiable in accordance with NFPA-99, Section 3-4.2.2.4(a)2, and NFPA-70, Section 517-19(a). This could cause confusion during a power outage trying to locate an emergency receptacle for critical care equipment.

E. The receptacle near the sink in ER bay-6 was not a GFCI type receptacle to meet the requirements of NFPA-70, Section 210-8(b).

F. Electrical panel directories were observed that did not accurately or completely identify the use of all circuits to comply with NFPA 70-1999, 384-13. Example includes but is not limited to "Panel 52" located at the 1914 building 3rd floor OB north corridor.

UPDATE 4/2/13: The above noted panel was provided with a new updated directory but the original directory was still in-place. Review of electrical panels will be required to verify correction of K145 deficiencies.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor observed that the hydraulic elevator machine room was equipped with sprinkler protection, but there was not a heat detector within 2' of the sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. The surveyor did not find a single lockable disconnect or proper labeling for each elevator's emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

C. The surveyor did not find that the disconnect for the emergency lighting and controls for each elevator was fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

D. The elevators were not equipped with elevator recall systems as required by ASME A17.1-211.3.

Based on random observation during the survey walk-through, not all portions of the building comply with the designated construction type(s) to comply with 18/19.1.6.2. These deficiencies could affect all patients in the facility, as well as 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. Corrected 4/2/13.

B. A wood frame trellis was observed at 12:05pm on 12/12/12 adjacent the 1956 Addition Dining room at the Ground floor. The 1956 Addition is not fully sprinkler protected and a 2-hour separation from the combustible trellis construction is not otherwise maintained to comply with NFPA 80A, Protection of Buildings from Exterior Fire Exposures.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1 or otherwise protected in accordance with the exceptions. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke compromising the use of the facility's exit access corridors.

Findings include:

A. A sprinklered wheelchair equipment alcove of less than 50 SF on the 3rd floor of the 1968 Addition near the 2000 Addition Stair was observed at 9:00am on 12/12/12 to be open to the corridor and not provided with smoke detection or direct observation to comply with 19.3.6.1, Exception No. 1, parts (b) and (c).

B. The sprinklered 2004 Addition Surgery Reception desk area on the 2nd floor was observed at 10:45am on 12/12/12 to be open to the corridor and not provided with smoke detection or direct observation to comply with 18.3.6.1, Exception No. 1, parts (b) and (c).

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. On 12/12/12 at 2:15pm, it was observed that the corridor door at the Ground floor Doctor's Locker room (On-call) is not positive latching to comply with 19.3.6.3.2.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18/19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. Corrected 4/2/13.

B. At 11:20am on 12/12/12 at the 2nd floor of the 2004 Addition it was observed that the door between the Soiled Decontamination room and the Clean Work/Storage/Prep-Pack room was not fire resistance rated to comply with 18.3.2.1. However, if the Decontamination room and the Clean work/storage room were considered a single hazardous area, the dutch door accessing the Prep/Pack area from the corridor is not fire resistance rated. The dutch door also does not comply with the requirements of 18.3.6.3.6 because it is not equipped with an astragal, rabbit or bevel to permit the door leafs to act as a single leaf when operated for exiting.

UPDATE 4/2/13: The door has been equipped with an astragal, but the requirements of 18.3.2.1 are not met if the door assembly is not labeled as minimum 3/4-hour fire resistance rated.

C. At 2:15pm on 12/12/12 at the Ground floor it was observed that the HR storage room door was not self-closing to comply with 19.3.2.1.

UPDATE 4/2/13: The door has been equipped with a closer, but it was not functioning to properly close the door.

D. At 2:55pm on 12/12/12 at the Ground floor it was observed that two doors to the non-sprinklered Soiled Utility room within the Emergency room suite were equipped with louvers and not minimum 3/4-hour rated to comply with 19.3.2.1.

Based on random observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 2:05pm on 12/12/12 it was observed that the 1914 building stair contained a single sided drywall enclosure with an unrated access door to enclose recently installed conduits and data cables which are not permitted within the stair enclosure to comply with 7.1.3.2.1(e).

Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets or provided with dead bolt locks operated only by a key from either side. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. The key-only dead bolt locks are not operable for exiting without a key in noncompliance with 7.1.10.1. Locations observed include but are not necessarily limited to the following:

1. The corridor door which provides the only exit from the freight elevator lobby was observed at 9:55am on 12/12/12 to be provided with a combination lock which prevents access from the elevator lobby into the 3rd floor OB department if the combination is not known or remembered.

UPDATE 4/2/13: A magnetic locking device has been installed on the door which is released by keypad on the corridor side (to prevent access to the elevator). The elevator lobby side is provided with a push button to release the magnet, but is also equipped with a delayed egress sequence of operation. Surveyor observed that when the delayed egress function is activated by pulling on the door to exit the elevator lobby, the push button release does not function. However, the door can be opened immediately without delay if the push button release is activated prior to pulling on the door to open it. Surveyor observed that the installation does not comply completely with either 7.2.1.6.1 for Delayed-Egress Locks or 7.2.1.6.2 for Access-Controlled Egress Doors as follows:

a. If the delayed egress function is to remain, the exit path from the elevator lobby to a secondary exit route at the entrance to the OB department is also equipped with a delayed egress magnetic lock in non-compliance with 19.2.2.2.4 Exception No. 2. Only one delayed egress lock may exist in any egress path. The exit access serving the elevator lobby is considered to be contained within a suite because the door to the nursery does not comply with 19.3.6.3 as a corridor door. This door is not installed in a frame that is resistant to the passage of smoke to comply with 19.3.6.3.1 and is not provided with latching hardware to comply with 19.3.6.3.2. The OB department corridor does not currently direct exiting to the stair within the suite but rather to the southwest stair and the main entry to the OB department which has a magnetic lock with delayed egress. This arrangement is acceptable but will not permit the elevator lobby door to also be equipped with a delayed egress locking device.

b. If the delayed egress lock is to remain, it was not confirmed that the lock releases upon activation of the sprinkler system, a heat detector or no more than two smoke detectors to comply with 7.2.1.6.1(a).

c. If the delayed egress lock is to remain, it was not confirmed that the lock releases upon loss of power to the lock or locking mechanism to comply with 7.2.1.6.1(b).

d. If the delayed egress lock is to remain, signage to comply with 7.2.1.6.1(d) is not provided.

e. If the delayed egress function of the lock is removed and the lock is installed to comply with 7.2.1.6.2 as an Access-Controlled Egress Door, the installation lacks the sensor to release the lock upon upon approach to the door from the elevator lobby side and upon loss of power to the sensor to comply with 7.2.1.6.2(a).

f. If the delayed egress function of the lock is removed and the lock is installed to comply with 7.2.1.6.2 as an Access-Controlled Egress Door, the installation lacks confirmation that the lock releases upon loss of power to the access control system to comply with 7.2.1.6.2(b).

g. If the delayed egress function of the lock is removed and the lock is installed to comply with 7.2.1.6.2 as an Access-Controlled Egress Door, the installation lacks confirmation that the lock releases upon activation of the fire alarm system to comply with 7.2.1.6.2(d) & (e).

2. The 1914 building 2nd floor Marketing Storage room corridor door was observed to be a dutch door with latch/locking hardware on both the upper and lower leafs. The door is not arranged in such a way as to always allow the lower leaf to be equipped with latching hardware to open the upper leaf to comply with 7.2.1.5.4. The storage room was not otherwise confirmed to comply with 39.3.2.1 and 8.4 as a hazardous area within a business occupancy. The dutch door was observed not to be self-closing to a latched condition.

3. The 1st floor Business Office area (separated business occupancy) was observed at 1:45pm on 12/12/12 to have multiple exit access doors equipped with dead bolt locks operated by keys only.

a. Corrected 4/2/13.
b. One door at the IT Server room.
c. One door at the Controllers office.

4. The Basement mechanical/equipment room in the far northwest corner and the File storage room were observed at 4:00pm on 12/12/12 to be equipped with both a dead bolt lock and a latchset.

5. A cross corridor door in the Basement of the 1914 building was observed at 4:00pm on 12/12/12 to be equipped with a dead bolt lock operable with key only from either side.

Based on random observation during the survey walk-through on 12/12/12, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. Exit discharge locations were observed to lack unswitched fixtures/lighting with more than one lamp equipped with instantaneous type lighting connected to the emergency power system to comply with 7.8.1.4. Lighting appeared to be HID type which requires restrike and/or warm-up period to provided illumination or only a single incandescent or fluorescent type fixture/lamp was provided. Connection to the emergency power system was not confirmed for all locations. Observed examples include but are not limited to the following:

1. At the 2000 Addition stair and corridor discharges.

2. At the Lab exterior door discharge.

3. At the Main Lobby entrance/exit discharge.

Based on document review and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. This deficiency could affect all patients in the facility as well as any staff and visitors present, because the failure to maintain a clear plan could result in confusion of expected responses to a fire or smoke condition within the building.

Findings include:

A. Corrected 4/2/13.
B. Corrected 4/2/13.
C. Corrected 4/2/13.

D. The Life Safety Reference Plans utilized during the survey were not clear relative to the designation of fire rated barrier walls and building separations. Examples include but are not necessarily limited to the following:

1. Stair and shaft fire rated enclosures were not shown on the plans.

2. The 2-hour fire/smoke barrier between the 2004 Addition 2nd floor and portions of the existing building were not indicated to form a complete separation from outside wall to outside wall or from another barrier of equal or greater rating to comply with 8.2.2.2. Area in question includes near the 2000 Addition stair.

3. The 2-hour fire/smoke barrier between the 1914 building and the 1956 Addition at the 2nd floor was observed at 10:20am on 12/12/12 to have 3/4-hour rated cross corridor doors in lieu of the 90 minute doors required to comply with 8.2.3.2.

4. The designation and separation of buildings and construction types is not clear. The 2004 Addition is indicated to be Type I (332) and the 1956 Addition is indicated to be Type II (222). The barrier between the different construction types is not located along the walls of the different dates of construction. Therefore, the 2004 Addition Type I (332) construction type appears to extend into the area of the lesser 1956 Addition Type II (222) construction.

UPDATE 4/2/13: The Plan of Correction for the above deficiencies 1, 2 & 4 were indicated to be "N/A". However, life safety plans were available but not reviewed in detail due to observations relating to item 4 as follows:

a. The designated 2-hour rated west wall of the north hall on the 2nd floor of the 1956 building was observed to have a duct penetration above the small storage room door which did not have a fire damper to comply with 8.2.3.2.4.2.

b. The designated 2-hour rated east wall of the 1956 building south of the cross corridor doors across from the Pharmacy door was observed to contain a 2'x3' recessed fire extinguisher cabinet which could not be confirmed to maintain the required 2-hour rating of the wall.

c. The 2004 addition is designated to be of Type I (332) construction type and the 1956 building is indicated to be of Type II (222) construction type. The demarkation between the construction types does not follow the structural lines of the building, therefore the Type I (332) construction must be considered only to qualify as Type II (222).

Based on record review it was determined that the facility failed to adequately document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. During the record review of fire drill information on the afternoon of 12/11/12 it was determined that quarterly fire drills are documented for specific zones of the building where the activation took place, but that response information beyond the zone of activation is not recorded. Therefore, it could not be determined that all areas of the hospital participate in the drill to substantiate the requirements of NFPA 101 Section 19.7.1.2.

UPDATE 4/2/13: Only a single drill for each of three shifts has occurred since the previous survey. Additional documentation will be required to verify compliance. Although a schedule of drills has been developed to ensure that all areas of the hospital are documented to participate in the drills, the information being documented thus far does not provide evidence that all areas are participating in a drill once per quarter per shift because response information from drill observers is limited to only specific areas of the facility rather than throughout the facility. Therfore, documentation appears to indicate that only portions of the facility personnel are participating during a drill and only a portion of the facility's fire alarm system components are being observed during a drill.

B. Fire drill response records for 10/25/12 indicated a drill at 10:00 AM for the Purchasing Department. Responses to questions such as audibility of alarms, functionality of chimes/strobes and patient room doors being closed and latched were marked as "N/A". During review with the Director of Environmental Services, it was discovered that the Purchasing Department is located in a separate building on the same property as the Hospital. The procedures followed for fire conditions for this building are for the purchasing staff to call the hospital switchboard to report a fire condition. The switchboard operator then activates the hospital fire alarm to summon the Fire Dept. The drill conducted at the Purchasing building is being utilized as one of the required drills for the hospital, but no response information from the Hospital zones is recorded to be able to substantiate the requirements of NFPA 101 Section 19.7.1.2. The Purchasing Department may be included as part of the drill activities, but response information relative to the hospital areas must be documented to consider the drill applicable to meeting the hospital requirements.

UPDATE 4/2/13: Only a single drill for each of three shifts has occurred since the previous survey. Additional documentation will be required to verify compliance.

Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with 18/19.3.4 and NFPA 72-1999. This could effect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Findings include:

A. On 12/12/12 at 8:50am, it was observed that three smoke detectors in the 2004 Mechaincal room were not mounted at the deck but rather at the bottom of 16-18" open web steel joist which does not comply with NFPA 72-1999, 2-3.4.3.1.

B. On 12/12/12 at 8:50am, it was observed that a wall mounted smoke detector in the stair accessing the 2004 Mechaincal room was not mounted between 4" and 12" from the ceiling to the top of the detector to comply with NFPA 72-1999, 2-3.4.3.1. The detector was mounted on the wall 24"+ from the ceiling.

C. On 12/12/12 at 10:30am, it was observed that smoke detectors in the 1956/2004 Storage room were not mounted at the deck to comply with NFPA 72-1999, 2-3.4.3.1.

D. On 12/12/12 at 3:20pm, it was observed that a smoke detector in the 1995 Main Lobby at the reception desk was not mounted 4" to 12" from the ceiling to the top of the detector to comply with NFPA 72-1999, 2-3.4.3.1. The detector was mounted at approximately 8' above the floor in a space with a 20'+ ceiling height.

E. The circuit breakers serving the fire alarm system are not marked in red and equipped with a locking device as required by NFPA-72, Section 1-5.2.5.2.

UPDATE 4/2/13: The fire alarm circuit has been marked in red and provided with a lock-on device. However, the circuit is located in a Critical Branch panel "C2AG" rather than a Life Safety Branch panel in noncompliance with NFPA 99-1999, 3-4.2.2.2(b).

F. Fire Alarm Control Panel is not labeled with the electrical panel designation and circuit number as required by NFPA 72-1-5.2.5.

UPDATE 4/2/13: The fire alarm control panel has been labeled to identify the circuit from which is is fed. However, the circuit is located in a Critical Branch panel "C2AG" rather than a Life Safety Branch panel in noncompliance with NFPA 99-1999, 3-4.2.2.2(b).

G. The audible alarms were not loud enough to be heard from the ER, x-ray and lab area, and the business area to meet the requirements of NFPA-101, Section 9.6.3.8.

By direct observation on the morning of 12/12/12, the surveyor finds the facility failed to provide the kitchen grease hood with the correct filter installation. The kitchen exhaust hood for the removal of grease laden vapors has mesh filters in non-compliance with NFPA 96, 1998, 3-1.

Based upon observations during the Survey walk-through, it was determined that the facility failed to maintain the corridors free of obstructions. This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors.

Findings include:

A. At 9:40am on 12/12/12 it was observed that the corridor ceiling in the 3rd floor OB department was not at the minimum 7'-6" height required by 7.1.5. Height was approximately 7'-0".

Based on direct observation the afternoon of 12/12/12, the surveyor finds the facility failed to provide piped medical gas systems in accordance with NFPA 99, 1999, Chapter 4.

Findings include:

A. The medical gas valves located in the Ground floor Specialty Clinic were not confirmed to be part of the active system. The valves were "on" but the nitrous oxide gas gauge was reading "0". The valves were not labeled accurately and were not clearly legible to comply with NFPA 99-1999, 4-3.1.2.14(b).

UPDATE 4/2/13: The valves were labeled as "Not in Use" but Oxygen and Vacuum lines were pressurized. Therfore the Oxygen and Vacuum system appeared functional and available for use at an unidentified location because labeling of the outlets served was not provided. The Nitrous system did appear "Not in Use" because the outlet had been removed and the pressure gauge at the valve read "0". Proper labeling of a functional system does not appear to be maintained or complete identification of outlets and control valves and system components made inoperable was not provided.

B. Based on direct observation the morning of 12/12/12, the surveyor finds the facility failed to provide separation by an intervening wall between the medical gas zone valves and the outlets they serve to comply with NFPA 99, 1999, 4-3.1.2.3 (d). Locations observed include:

1. At the 2nd floor 2004 Addition Stage 1 Recovery.

2. At the Ground floor Cardiac Rehab.

Based on random observation during the survey walk-through on 12/12/12 the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The generator was not equipped with a battery heater to meet the requirements of NFPA-110, Section 3-3.1.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other Code requirements that are not documented under other K-Tags.

Findings include:

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 the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

A. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panel EC-2 had a circuit feeding the fire alarm system NAC panel, and the critical panel in the outpatient area was serving the main fire alarm panel along with the med gas alarm panel (these items should be served from the life safety panel). This does not meet the requirements of NFPA-70, Section 517-32 and 33.

B. Some panels in the older portion of the building including EM-1B, EM00, and EMP served a mix of life safety, critical, and equipment loads which does not meet the requirements of NFPA-70, Sections 517-30 through 35.

C. Some panels such as EMP need new updated and typed directories to meet the requirements of NFPA-70, Section 110-22.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. Normal power receptacles were not provided in operating rooms, and procedure rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. The domestic water service and the water service for the sprinkler system were not grounded in accordance with NFPA-70, Section 250-52. This could cause a potential difference between the water piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

C. Bonding of the piping for the medical gas system could not be located by staff as required by NFPA-70, Section 250-104(c). This could cause a potential difference between med gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

D. Emergency receptacles in the ER, ICU, and other patient bed locations were not all identified as emergency receptacles. All receptacles or cover plates served by critical power shall have a distinctive color or marking so as to be readily identifiable in accordance with NFPA-99, Section 3-4.2.2.4(a)2, and NFPA-70, Section 517-19(a). This could cause confusion during a power outage trying to locate an emergency receptacle for critical care equipment.

E. The receptacle near the sink in ER bay-6 was not a GFCI type receptacle to meet the requirements of NFPA-70, Section 210-8(b).

F. Electrical panel directories were observed that did not accurately or completely identify the use of all circuits to comply with NFPA 70-1999, 384-13. Example includes but is not limited to "Panel 52" located at the 1914 building 3rd floor OB north corridor.

UPDATE 4/2/13: The above noted panel was provided with a new updated directory but the original directory was still in-place. Review of electrical panels will be required to verify correction of K145 deficiencies.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor observed that the hydraulic elevator machine room was equipped with sprinkler protection, but there was not a heat detector within 2' of the sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. The surveyor did not find a single lockable disconnect or proper labeling for each elevator's emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

C. The surveyor did not find that the disconnect for the emergency lighting and controls for each elevator was fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

D. The elevators were not equipped with elevator recall systems as required by ASME A17.1-211.3.