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Building A1- Penrose Main Hospital

Through observation during the survey, November 30 through December 2, 2011, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility, with the Maintenance Director, five (5) smoke barrier walls contained wire penetrations or openings without fire caulking or other approved method of maintaining the fire rating of the wall:

1. One (1) unsealed pipe penetration in the smoke wall on the tenth (10th) floor adjacent to the nurse station.
2. Three (3) unsealed pipe penetrations in the smoke wall on the second (2nd) floor at door #PAU2024.
3. One (1) unsealed pipe penetration at the smoke wall on the first (1st) floor at door #PAU1018.
4. One (1) unsealed pipe penetration at the smoke wall on the first (1st) floor at door #BT0046.
5. Two (2) unsealed wire penetrations at the smoke wall on the first (1st) floor at door #BT0063.
Note: All smoke wall penetrations were corrected during the survey by Maintenance staff.

Building A1- Penrose main Hospital

Through observation during the survey, November 30 through December 2, 2011, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility with the Maintenance Director, two (2) fire barrier doors would not latch into the frame when closed, which prevented a positive smoke seal;
1. ACC south door would not latch into the frame
2. Door #BT2043, one side would not latch into the frame
3. Door #BT1012 would not latch into the frame
Note: All cross corridor deficiencies were corrected during the survey.

Building AA- Penrose St. Francis Hospital

Through observation during the survey, conducted November 30 through December 2, 2011, it was determined that the facility was allowing the use of flammable decorations.

During the walk through of the facility with the Maintenance Director, the facility contained paper decorations in three (3) areas of the facility;
1) One (1) large eight foot by six foot (8' x 6') paper Christmas decoration on the wall outside of the "Surgical" nurse station.
2) One (1) small paper fireplace decoration on the nurse station wall in the "PACU" unit.
3) One (1) cardboard standing "Stork" decoration in the corridor outside of stairwell #S3-3. This standup decoration indicated that patrons should not move patients with wristbands beyond a certain point.

Note: The decorations were removed by staff during the survey.

Building A1- Penrose Main Hospital

Through observation during the survey, November 30 through December 2, 2011, it was determined the facility failed to maintain the oxygen storage rooms in accordance with NFPA 99, Healthcare Facilities, and NFPA 50, Bulk Oxygen Systems at Consumer Sites.

During the walk through of the facility with the Maintenance Director, the uninsulated portions of the bulk oxygen storage site (the facility maintains 6600 gallons of oxygen on site) on the Northeast side of the building failed to meet the distance requirements from combustibles:

1. The bulk storage location was within approximately 20 feet of three (3) newer trees and 25 feet of another older large tree, both considered fuels that would burn slowly.
Per NFPA 50, Standard for Bulk Oxygen Systems, Section 2-2.

Building A1- Penrose Main Hospital

Through observation during the survey, November 30 through December 2, 2011, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility, with the Maintenance Director, five (5) smoke barrier walls contained wire penetrations or openings without fire caulking or other approved method of maintaining the fire rating of the wall:

1. One (1) unsealed pipe penetration in the smoke wall on the tenth (10th) floor adjacent to the nurse station.
2. Three (3) unsealed pipe penetrations in the smoke wall on the second (2nd) floor at door #PAU2024.
3. One (1) unsealed pipe penetration at the smoke wall on the first (1st) floor at door #PAU1018.
4. One (1) unsealed pipe penetration at the smoke wall on the first (1st) floor at door #BT0046.
5. Two (2) unsealed wire penetrations at the smoke wall on the first (1st) floor at door #BT0063.
Note: All smoke wall penetrations were corrected during the survey by Maintenance staff.

Building A1- Penrose main Hospital

Through observation during the survey, November 30 through December 2, 2011, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility with the Maintenance Director, two (2) fire barrier doors would not latch into the frame when closed, which prevented a positive smoke seal;
1. ACC south door would not latch into the frame
2. Door #BT2043, one side would not latch into the frame
3. Door #BT1012 would not latch into the frame
Note: All cross corridor deficiencies were corrected during the survey.

Building AA- Penrose St. Francis Hospital

Through observation during the survey, conducted November 30 through December 2, 2011, it was determined that the facility was allowing the use of flammable decorations.

During the walk through of the facility with the Maintenance Director, the facility contained paper decorations in three (3) areas of the facility;
1) One (1) large eight foot by six foot (8' x 6') paper Christmas decoration on the wall outside of the "Surgical" nurse station.
2) One (1) small paper fireplace decoration on the nurse station wall in the "PACU" unit.
3) One (1) cardboard standing "Stork" decoration in the corridor outside of stairwell #S3-3. This standup decoration indicated that patrons should not move patients with wristbands beyond a certain point.

Note: The decorations were removed by staff during the survey.

Building A1- Penrose Main Hospital

Through observation during the survey, November 30 through December 2, 2011, it was determined the facility failed to maintain the oxygen storage rooms in accordance with NFPA 99, Healthcare Facilities, and NFPA 50, Bulk Oxygen Systems at Consumer Sites.

During the walk through of the facility with the Maintenance Director, the uninsulated portions of the bulk oxygen storage site (the facility maintains 6600 gallons of oxygen on site) on the Northeast side of the building failed to meet the distance requirements from combustibles:

1. The bulk storage location was within approximately 20 feet of three (3) newer trees and 25 feet of another older large tree, both considered fuels that would burn slowly.
Per NFPA 50, Standard for Bulk Oxygen Systems, Section 2-2.