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Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of fire rated occupancy separation wall between the hospital and the medical office building (MOB South) of business occupancy. The observed situation was not compliant with NFPA 101 sections 19.1.1.4.1, 19.1.2.1. This deficient practice affected 1 of 41 smoke compartments in the entire facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/5/13, surveyor observed between 9 AM and 12 PM that the Nuclear Medicine located on the 2nd floor of MOB South was not separated from business occupancy with a 2-hr fire rated vertical fire barrier in accordance with NFPA 101 19.1.2.1.

The type of construction, Type II(111), of the 3-story MOB South was compliant with the construction requirement, NFPA 101 19.1.6.2, for health care occupancy due to the building being fully sprinkler protected.

When interviewed on 3/5/13 at 10:50 AM, Staff M12 (nuclear med technician), and M13 (supervisor) stated that mostly outpatients are treated in the two procedure rooms, but some inpatients are also brought in for treatment from the hospital building, and the number of inpatients varies with time and day.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to one patient treatment area not separated from corridors in accordance with NFPA 101 section 19.3.6.1. This deficient practice affected 1 of 40 smoke compartments in the facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8(security supervisor), and Staff M14 (supervisor) on 3/5/13, surveyor observed between 9:30 AM and 10 AM that the Infusion Center with 3 treatment bays were open to Corridor 320 and not separated from corridor in accordance with the requirement of NFPA 101 section 19.3.6.1.

The above deficiency was confirmed by a phone conversation with the facilities supervisor on 3/12/13 between 10:30 AM and 11:30 AM.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to (i) failure to keep the inactive leaf of corridor doors latched to the top; and (ii) one set of corridor doors not latching. The observed situation was not compliant with NFPA 101 19.3.6.3.2. This deficient practice affected 2 of 41 smoke compartments in the entire facility.

Findings include:

(i) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/6/13, surveyor observed at 8:32 AM that the inactive leaf of double corridor doors to the Cath Lab #4 was partially open and not kept latched to the top frame of the door to ensure positive latching when the active leaf is closed.

(ii) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8(security supervisor), and Staff M20 (OB Supervisor) on 3/6/13, surveyor observed between 8:20 AM and 11 AM that the double corridor doors of the C-Section Suite that were electromagnetically help open did not latch when tested.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to a wide gap at the meeting edge of corridor doors. The observed situation was not compliant with NFPA 101 section 19.3.6.2.2. This deficient practice affected 1 of 41 smoke compartments in the facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/5/13, surveyor observed at 10 AM that there was more than 1/8 inch gap at the meeting edge of the double corridor doors of the PET/CT suite on the 1st Floor. This clearance at the meeting edge of these doors did not make the corridor wall smoke-tight in accordance with NFPA 101 section 19.3.6.2.2.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and staff interview, the facility failed to protect three hazardous areas with doors that have self-closing devices in accordance with NFPA 101 19.3.2.1. This deficient practice affected 2 of 41 smoke compartments in the facility.

Findings include:

(i) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/4/13, surveyor observed between 1 PM and 4:30 PM that solid-bonded wood core doors protecting openings to two medical record storage rooms south of the Canteen Waiting space on the 1st Floor did not have self-closing devices to keep the doors closed when not in use.

(ii) While on a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/6/13, surveyor observed at 8:25 AM that two doors of the Soiled Utility room in the Cath Lab on 2nd Floor did not have self-closing devices. The soiled utility room is considered a hazardous area and requires self-closing doors.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to obstructions in one means of egress corridor. This deficient practice affected 1 of 41 smoke compartments in the facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/4/13, surveyor observed between 1 PM and 4:30 PM that four clean supply carts and one gurney were found stored in the Corridor 1200 adjacent to the outpatient surgery rooms on the 1st Floor of Groth Center causing obstruction to people movement.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and interview, the facility failed to (i) provide a Fire Alarm system that was installed to minimum standards of NFPA 72, and (i) provide a properly installed and tested fire alarm system in accordance with the NFPA 72 Chapters 5 and 7 to transmit trouble signals, including trouble signals caused by phone line failure, from the main fire alarm panel to central station in accordance with NFPA 9.6.1.4, 9.6.3.2. The deficient practice affects all patients, staff and visitors.

Findings include:

Item #1: While on a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8 (security supervisor), and Staff M6 (Carpenter), surveyor observed on 3/5/13 between 9:20 AM and 9:30 AM that the Waiting Room adjacent to the Canteen and the Gift Shop were common spaces intended for use by two or more occupants and no visible notification appliances were found for occupant notification within the spaces on the 1st Floor;

Item #2: While on a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M6 (carpenter), and Staff M21 (technician), surveyor observed at 2:45 PM that there were no phone jacks with primary and secondary phone lines in or adjacent to the 1988 installed main fire alarm control unit (FACP) to ensure two separate means of transmission to central station. The 1988 FACP was located in the facility management control room on the 1st Floor.

There was no evidence available at the time of survey (i) that the facility's fire alarm control unit or fire alarm system had an automatic transmission equipment with two phone lines; (ii) that the fire alarm control unit was installed/arranged to transmit trouble signals caused by disconnection of phone line to the central monitoring station COPS in accordance with NFPA 72 1-5.4.6.1.

When interviewed on 3/6/13 at 2:45 PM, Staff M21 stated that the above 1988 FACP was interfaced with another fire alarm control unit located in the new 9-story patient bed tower addition (East Care Pavilion) constructed in 2010, and was arranged to transmit alarm signals from both fire alarm control units to central station. He further stated that trouble signals are not, however, monitored by the central station. This condition did not meet the requirement of NFPA 72, Section 1-5.4.6.1

The above finding was confirmed with the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

NFPA 72 (1999 edition), Section 1-5.4.6
"......The trouble signal(s) shall be located in an area where it is likely to be heard."

"NFPA 72, Section 1-5.4.4
"Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated."

"NFPA 72, Section 1-5.4.6.1
"Visible and audible trouble signals, and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit ....
(2) Building fire command center ...
(3) Central Station ... "

Based on observation, interview and record review, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with required testing. This deficiency could affect all patients on the 2nd and 4th floors out of the 147 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

On 3/07/2013 between 9 AM and 10:30 AM, surveyor observed during a review of facility fire alarm system maintenance and inspection that reports were not available to verify that batteries were tested for discharge test by disconnecting from charger. There was no evidence from the report that the discharge test of batteries was performed in accordance with NFPA 72 Chapter 7-2.2 & 7-3.2. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.7 and NFPA 72 (1999 edition), Chapter 7-2.2 & 7-3.2.

When interviewed later on 3/7/13 between 10 AM and 11 AM, Staff M2 (director of facilities) stated that the above referenced discharge test was performed during the annual testing and inspection of fire alarm system.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and interview, the facility failed to ensure safety to patients, visitors, and Staff of the facility due to lack of proper maintenance on automatic supervised sprinkler system in accordance with NFPA 101 section 9.7.5. This deficient practice affected 2 of 41 smoke compartments in the facility.

Findings include:

(i) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8(security supervisor), and Staff M19 (ED supervisor), surveyor observed on 3/4/13 at 2:30 PM that one dirty sprinkler head in the Exam Rm #4 in the emergency department was dirty, and was not free of foreign material;

(ii) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8(security supervisor), and Staff M15 (pharmacy supervisor), surveyor observed on 3/5/13 at 9:10 AM that three sprinkler heads in the 1st Floor Pharmacy were dirty, and were not free of foreign material;

(iii) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8 (security supervisor), surveyor observed one dirty sprinkler head in the Andrology Lab, and one missing escutcheon plate of a sprinkler head in the main Lab area on the 2nd Floor on 3/6/13 at 8:48 AM.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on record review and interview, the facility did not have documentation/record to show compliance with the maintenance requirement of NFPA 99 section 4-3.5.6.1(c). This deficiency affected the entire facility.

Findings include:

On 3/07/13, while reviewing the inspection, testing and maintenance record of the medical gas and vacuum system between 10 AM and 12 PM with Staff M2 (director of facilities), Staff M3 (facilities supervisor), Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M6 (carpenter), and Staff M7 (safety specialist), it was revealed that there was no evidence of the vacuum system station inlet performance test performed in accordance with NFPA 99 (1999) section 4-3.5.6.1(c). The 2011 and 2012 medical gas and vacuum system testing and inspection report prepared by A1 Medical Gas showed leak tests performed but did not show that adjacent station inlet tests were performed along with corresponding vacuum pressure readings at adjacent inlets.

When interviewed on 3/7/13 between 10 AM and 12 PM, the director of facilities claimed that the above referenced performance test was performed but not documented.

This observed situation was not compliant with NFPA 99 section 4-3.5.6.1(c).

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of a visual and audible derangement signal at a continuously monitored location for emergency generators of the essential electrical system. This deficient practice affected the entire facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8 (security supervisor) surveyor observed on 3/7/13 between 8:30 AM and 9:30 AM that there was no generator specific visual and audible derangement signal to annunciate a generator fault condition in accordance with NFPA 99 (1999) section 3-4.1.1.15, NFPA 110 section 3-5.6.1 (1999) at a continuously monitored location. The visual and audible signal indicated in a panel located in the emergency department was for annunciating any alarm condition with the fire alarm system and essential electrical system, but not solely intended for generator fault conditions as required.

The observed situation did not comply with the derangement signal requirement of NFPA 99 section 3-4.1.1.15, where the remote alarm annunciator that displays fault conditions individually is not located in a continuously monitored location. The remote alarm annunciators for both generators were located in the facility management control room on the 1st Floor that was not 24 hour attended by facility staff.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and interview, the facility failed to ensure safety to patients, visitors, and staff of the facility due to one hazardous area not protected as a hazardous area in accordance with NFPA 101 section 38.3.2.1. This deficiency practice affected the ambulatory health care unit in 1 of 2 smoke compartments on the 2nd Floor.

Findings include:

While on a tour of the Encircle Health offsite clinic with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M7 (safety specialist), Staff M8 (security supervisor), Staff M10 (supervisor), M11 (manager), and M16 (facilities coordinator) on 3/5/13, surveyor observed at 2:31 PM that the Soiled Utility Room N2822 across the Recovery Room 1 on the 2nd Floor had an opening in corridor wall, but the door protecting the opening did not have a self-closing device in accordance with NFPA 101 section 38.3.2.1 and 8.2.4.3.5.

The above condition was confirmed at the time of discovery by a concurrent observation and interview with the facilities supervisor, manager, and facilities coordinator.

Based on observation and interview, the facility failed to ensure safety to patients, visitors, and staff of the facility due to one stairwell exit door not latching in accordance with NFPA 101 section 8.2.5.2. This deficiency practice affected 1 of 2 stairwells in the clinic building.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8 (security supervisor) on 3/5/13, surveyor observed at 11:08 AM that the Stairwell #2 exit door protecting an opening in the fire barrier enclosing stairwell did not latch.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of fire rated occupancy separation wall between the hospital and the medical office building (MOB South) of business occupancy. The observed situation was not compliant with NFPA 101 sections 19.1.1.4.1, 19.1.2.1. This deficient practice affected 1 of 41 smoke compartments in the entire facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/5/13, surveyor observed between 9 AM and 12 PM that the Nuclear Medicine located on the 2nd floor of MOB South was not separated from business occupancy with a 2-hr fire rated vertical fire barrier in accordance with NFPA 101 19.1.2.1.

The type of construction, Type II(111), of the 3-story MOB South was compliant with the construction requirement, NFPA 101 19.1.6.2, for health care occupancy due to the building being fully sprinkler protected.

When interviewed on 3/5/13 at 10:50 AM, Staff M12 (nuclear med technician), and M13 (supervisor) stated that mostly outpatients are treated in the two procedure rooms, but some inpatients are also brought in for treatment from the hospital building, and the number of inpatients varies with time and day.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to one patient treatment area not separated from corridors in accordance with NFPA 101 section 19.3.6.1. This deficient practice affected 1 of 40 smoke compartments in the facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8(security supervisor), and Staff M14 (supervisor) on 3/5/13, surveyor observed between 9:30 AM and 10 AM that the Infusion Center with 3 treatment bays were open to Corridor 320 and not separated from corridor in accordance with the requirement of NFPA 101 section 19.3.6.1.

The above deficiency was confirmed by a phone conversation with the facilities supervisor on 3/12/13 between 10:30 AM and 11:30 AM.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to (i) failure to keep the inactive leaf of corridor doors latched to the top; and (ii) one set of corridor doors not latching. The observed situation was not compliant with NFPA 101 19.3.6.3.2. This deficient practice affected 2 of 41 smoke compartments in the entire facility.

Findings include:

(i) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/6/13, surveyor observed at 8:32 AM that the inactive leaf of double corridor doors to the Cath Lab #4 was partially open and not kept latched to the top frame of the door to ensure positive latching when the active leaf is closed.

(ii) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8(security supervisor), and Staff M20 (OB Supervisor) on 3/6/13, surveyor observed between 8:20 AM and 11 AM that the double corridor doors of the C-Section Suite that were electromagnetically help open did not latch when tested.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to a wide gap at the meeting edge of corridor doors. The observed situation was not compliant with NFPA 101 section 19.3.6.2.2. This deficient practice affected 1 of 41 smoke compartments in the facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/5/13, surveyor observed at 10 AM that there was more than 1/8 inch gap at the meeting edge of the double corridor doors of the PET/CT suite on the 1st Floor. This clearance at the meeting edge of these doors did not make the corridor wall smoke-tight in accordance with NFPA 101 section 19.3.6.2.2.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and staff interview, the facility failed to protect three hazardous areas with doors that have self-closing devices in accordance with NFPA 101 19.3.2.1. This deficient practice affected 2 of 41 smoke compartments in the facility.

Findings include:

(i) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/4/13, surveyor observed between 1 PM and 4:30 PM that solid-bonded wood core doors protecting openings to two medical record storage rooms south of the Canteen Waiting space on the 1st Floor did not have self-closing devices to keep the doors closed when not in use.

(ii) While on a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/6/13, surveyor observed at 8:25 AM that two doors of the Soiled Utility room in the Cath Lab on 2nd Floor did not have self-closing devices. The soiled utility room is considered a hazardous area and requires self-closing doors.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to obstructions in one means of egress corridor. This deficient practice affected 1 of 41 smoke compartments in the facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/4/13, surveyor observed between 1 PM and 4:30 PM that four clean supply carts and one gurney were found stored in the Corridor 1200 adjacent to the outpatient surgery rooms on the 1st Floor of Groth Center causing obstruction to people movement.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and interview, the facility failed to (i) provide a Fire Alarm system that was installed to minimum standards of NFPA 72, and (i) provide a properly installed and tested fire alarm system in accordance with the NFPA 72 Chapters 5 and 7 to transmit trouble signals, including trouble signals caused by phone line failure, from the main fire alarm panel to central station in accordance with NFPA 9.6.1.4, 9.6.3.2. The deficient practice affects all patients, staff and visitors.

Findings include:

Item #1: While on a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8 (security supervisor), and Staff M6 (Carpenter), surveyor observed on 3/5/13 between 9:20 AM and 9:30 AM that the Waiting Room adjacent to the Canteen and the Gift Shop were common spaces intended for use by two or more occupants and no visible notification appliances were found for occupant notification within the spaces on the 1st Floor;

Item #2: While on a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M6 (carpenter), and Staff M21 (technician), surveyor observed at 2:45 PM that there were no phone jacks with primary and secondary phone lines in or adjacent to the 1988 installed main fire alarm control unit (FACP) to ensure two separate means of transmission to central station. The 1988 FACP was located in the facility management control room on the 1st Floor.

There was no evidence available at the time of survey (i) that the facility's fire alarm control unit or fire alarm system had an automatic transmission equipment with two phone lines; (ii) that the fire alarm control unit was installed/arranged to transmit trouble signals caused by disconnection of phone line to the central monitoring station COPS in accordance with NFPA 72 1-5.4.6.1.

When interviewed on 3/6/13 at 2:45 PM, Staff M21 stated that the above 1988 FACP was interfaced with another fire alarm control unit located in the new 9-story patient bed tower addition (East Care Pavilion) constructed in 2010, and was arranged to transmit alarm signals from both fire alarm control units to central station. He further stated that trouble signals are not, however, monitored by the central station. This condition did not meet the requirement of NFPA 72, Section 1-5.4.6.1

The above finding was confirmed with the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

NFPA 72 (1999 edition), Section 1-5.4.6
"......The trouble signal(s) shall be located in an area where it is likely to be heard."

"NFPA 72, Section 1-5.4.4
"Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated."

"NFPA 72, Section 1-5.4.6.1
"Visible and audible trouble signals, and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit ....
(2) Building fire command center ...
(3) Central Station ... "

Based on observation, interview and record review, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with required testing. This deficiency could affect all patients on the 2nd and 4th floors out of the 147 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

On 3/07/2013 between 9 AM and 10:30 AM, surveyor observed during a review of facility fire alarm system maintenance and inspection that reports were not available to verify that batteries were tested for discharge test by disconnecting from charger. There was no evidence from the report that the discharge test of batteries was performed in accordance with NFPA 72 Chapter 7-2.2 & 7-3.2. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.7 and NFPA 72 (1999 edition), Chapter 7-2.2 & 7-3.2.

When interviewed later on 3/7/13 between 10 AM and 11 AM, Staff M2 (director of facilities) stated that the above referenced discharge test was performed during the annual testing and inspection of fire alarm system.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and interview, the facility failed to ensure safety to patients, visitors, and Staff of the facility due to lack of proper maintenance on automatic supervised sprinkler system in accordance with NFPA 101 section 9.7.5. This deficient practice affected 2 of 41 smoke compartments in the facility.

Findings include:

(i) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8(security supervisor), and Staff M19 (ED supervisor), surveyor observed on 3/4/13 at 2:30 PM that one dirty sprinkler head in the Exam Rm #4 in the emergency department was dirty, and was not free of foreign material;

(ii) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8(security supervisor), and Staff M15 (pharmacy supervisor), surveyor observed on 3/5/13 at 9:10 AM that three sprinkler heads in the 1st Floor Pharmacy were dirty, and were not free of foreign material;

(iii) During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8 (security supervisor), surveyor observed one dirty sprinkler head in the Andrology Lab, and one missing escutcheon plate of a sprinkler head in the main Lab area on the 2nd Floor on 3/6/13 at 8:48 AM.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on record review and interview, the facility did not have documentation/record to show compliance with the maintenance requirement of NFPA 99 section 4-3.5.6.1(c). This deficiency affected the entire facility.

Findings include:

On 3/07/13, while reviewing the inspection, testing and maintenance record of the medical gas and vacuum system between 10 AM and 12 PM with Staff M2 (director of facilities), Staff M3 (facilities supervisor), Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M6 (carpenter), and Staff M7 (safety specialist), it was revealed that there was no evidence of the vacuum system station inlet performance test performed in accordance with NFPA 99 (1999) section 4-3.5.6.1(c). The 2011 and 2012 medical gas and vacuum system testing and inspection report prepared by A1 Medical Gas showed leak tests performed but did not show that adjacent station inlet tests were performed along with corresponding vacuum pressure readings at adjacent inlets.

When interviewed on 3/7/13 between 10 AM and 12 PM, the director of facilities claimed that the above referenced performance test was performed but not documented.

This observed situation was not compliant with NFPA 99 section 4-3.5.6.1(c).

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of a visual and audible derangement signal at a continuously monitored location for emergency generators of the essential electrical system. This deficient practice affected the entire facility.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8 (security supervisor) surveyor observed on 3/7/13 between 8:30 AM and 9:30 AM that there was no generator specific visual and audible derangement signal to annunciate a generator fault condition in accordance with NFPA 99 (1999) section 3-4.1.1.15, NFPA 110 section 3-5.6.1 (1999) at a continuously monitored location. The visual and audible signal indicated in a panel located in the emergency department was for annunciating any alarm condition with the fire alarm system and essential electrical system, but not solely intended for generator fault conditions as required.

The observed situation did not comply with the derangement signal requirement of NFPA 99 section 3-4.1.1.15, where the remote alarm annunciator that displays fault conditions individually is not located in a continuously monitored location. The remote alarm annunciators for both generators were located in the facility management control room on the 1st Floor that was not 24 hour attended by facility staff.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.

Based on observation and interview, the facility failed to ensure safety to patients, visitors, and staff of the facility due to one hazardous area not protected as a hazardous area in accordance with NFPA 101 section 38.3.2.1. This deficiency practice affected the ambulatory health care unit in 1 of 2 smoke compartments on the 2nd Floor.

Findings include:

While on a tour of the Encircle Health offsite clinic with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M7 (safety specialist), Staff M8 (security supervisor), Staff M10 (supervisor), M11 (manager), and M16 (facilities coordinator) on 3/5/13, surveyor observed at 2:31 PM that the Soiled Utility Room N2822 across the Recovery Room 1 on the 2nd Floor had an opening in corridor wall, but the door protecting the opening did not have a self-closing device in accordance with NFPA 101 section 38.3.2.1 and 8.2.4.3.5.

The above condition was confirmed at the time of discovery by a concurrent observation and interview with the facilities supervisor, manager, and facilities coordinator.

Based on observation and interview, the facility failed to ensure safety to patients, visitors, and staff of the facility due to one stairwell exit door not latching in accordance with NFPA 101 section 8.2.5.2. This deficiency practice affected 1 of 2 stairwells in the clinic building.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8 (security supervisor) on 3/5/13, surveyor observed at 11:08 AM that the Stairwell #2 exit door protecting an opening in the fire barrier enclosing stairwell did not latch.

The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 PM.