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Based on observation during tour and staff interview it was determined this facility failed to ensure all common walls with a nonconforming building is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition and communicating openings are protected by approved self-closing fire doors. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

Facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the sixth floor of the main building specifically at the connector to the medical office building observation was made of double metal and glass doors that lacked a fire resistance rating. This finding was acknowledged by all those who were present during tour of this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure all vertical openings, specifically stairs between floors, are enclosed with construction having a fire resistance rating of at least one hour and the vertical opening was not utilized for storage. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the sixth floor and within smoke compartment 6.07, observation was made of two stairwell doors, 0684.10a and 4683.1, which had the fire rating tag layered with a coat of paint. This writer was not able to verify the fire resistance rating of either door.

Within smoke compartment 6.09 observation was made of a stairwell equipped with a non-fire rated metal door identified as 0687.30.

During tour of the basement and within smoke compartment 00.2, observation was made of stairwell door 00143 which failed to shut properly when tested. Additionally, observation was made of storage under stairs ST-3 within smoke compartment 00.4. The storage consisted of wood, insulation, electrical junction boxes and a metal stud.
These findings were verified by all staff members during tour of these areas of the facility.

Based on observation during tour, staff verification and review of the fire escape plans it was determined this facility failed to ensure accesses to exits were marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

Facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of exits signs lacking or exit signs that were placed in corridors that were not designated accesses to exits. These observations were made in the following locations:

11th floor:
*Within smoke compartment 11.8 and directly in front of the communicating stairs which continue down to the seventh floor observation was made of a fire escape plan posted on an adjacent wall indicating this communicating stairs as an emergency exit. Observation was made of no exit sign mounted at the stairs or on either side of the corridor door south of the communicating stairs directing traffic flow from the south side of the door to the communicating stairs or from the north side of the door to another stairwell located in adjacent smoke compartment 11.1.

10th floor
*Within smoke compartment 10.1 standing in the corridor by the exercise rooms facing southeast down the corridor, observation was made that the exit directional sign further down the corridor was obstructed by the bulkhead.
*Within suite B of smoke compartment 10.2 observation was made of no directional signs located within the suite providing directions for a path of egress to either corridor which led to the stairwell within this smoke compartment or to another stairwell in the adjacent smoke compartment. Exit access from this suite was not obvious.

6th floor:
*Within smoke compartment 6.02 and in the angled corridor 0610.3 facing northeast, observation was made of no exit sign directing traffic flow to the stairwell located at the end of corridor 0610.2. Additionally, the exit sign mounted in front of the stairwell was not positioned in a manner that would be obvious to traffic flow from the south end of corridor 0610.2.

During tour of the 2nd and 3rd floors, on 03/13/13 with staff E5, L9, M10, two areas of the building containing offices were observed without approved, readily visible exit signs where the way to reach the exit was not readily apparent. These areas were located in Human Resources and Medical Records as follows:

On the 2nd floor in Suite C,
*The Human Resources (HR) offices was observed with a paper exit sign on the back of door 0252, located by office 0245. Door 0252 was observed dividing two different areas of the office. Staff accompanying the surveyor on tour verbalized this exit access door was used by potential employees when leaving the HR area. This door opened into a room with three doorways. Two of these door were at the entrances to offices, and one of the doors led to the exit access corridor. None of these three doors were equipped with an exit sign.

On the 3rd floor in Smoke Compartment SC-3.02,
*The Medical Records area was observed with an exit sign that led to a maze of offices and the physicians' lounge. The only visible exit sign in this area was located at the exit access door leading to the exit access corridor. The maze of rooms was not equipped with a directional exit sign.
In the main area of medical records storage, eixt access doo 0320 lacked an exit sign. Staff accompanying the survey on tour stated this door was used for staff and visitors to exit the area.


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This finding was verified by all staff members present during the tour of this area of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of penetrations in smoke/fire barriers at the following locations:

*At the smoke barrier doors separating smoke barrier 8.06 from 8.10 a gap greater than one eighth inch was observed between the door leafs when in a closed position.

*At the smoke barrier doors separating smoke barrier 8.09 from 8.10 a gap greater than one eighth inch was observed between the door leafs when in a closed position.

These findings were verified by all staff members present during tour of this area of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of penetrations in smoke/fire barriers at the following locations:

14th floor:
*Group of blue wires were not sealed around the annular space above the double smoke barrier doors separating smoke compartment 14.1 from 14.3

8th floor:
*Above smoke barrier doors 831.3 observation was made of an unsealed three inch conduit sleeve with blue wires passing through.
*At the corner of the smoke barrier and near doors 0800.12 observation was made of two approximately three inch by two inch openings in the drywall with flex conduits passing through.

7th floor:
*From within room 07133 observation was made of an approximate two inch by three inch opening in the smoke barrier.

6th floor:
*A smoke barrier door was missing at 0677.04 which divided smoke compartment 6.10 from 6.11. Additionally, observation was made of three open end conduits above that particular door area and within physician ' s office area 0677.01
*Within the pre-operating hold area specifically within the soiled room across from the nurse ' s station observation was made of an approximate two inch water line and a one inch copper line lacking a fire rated sealant around their annular space.

5th floor:
*Within smoke compartment 5.6 and above the refrigerator located near the west end of the smoke barrier observation was made of a silver conduit lacking a fire rated sealant around the annular space.
*Within the dining room about midway of the smoke barrier separating smoke compartment 5.4 from 5.7 observation was made of an approximate one inch opening in the drywall.
These findings were verified by all staff members present during tour of these areas.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke barrier doors which were not constructed of at least a one and three quarter inch solid bonded core wood were equipped with a fire resistance rating identification tag with at least a 20 minute fire resistance rating. Additionally, this facility failed to ensure all smoke barrier doors which had a fire resistance rating identification tag was legible, that is free from paint and mars which would not allow proper identification of the fire resistance rating and were equipped with a self closing or automatic closing device. The facility also failed to ensure the doors self closed and latched. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building an observation was made of metal smoke barrier doors lacking the required fire resistance rating identification tag at the following locations:

15th floor:
*At the double smoke barrier doors located between smoke compartments 15.1 and 15.3

14th floor:
*The door leading into the manager/charge office from smoke compartment 14.2 lacked a self closing or automatic closing device.

10th floor:
*At the double smoke barrier doors located between smoke compartment 10.4 and suite A of 10.2

8th floor:
*Door 870.0 separating smoke compartments 8.02 from 8.03 had fire rating tags painted over
*Staff lounge door 0892.3 separating smoke compartment 8.04 from 8.05 lacked a self or automatic closing device.

7th floor:
*Single smoke barrier door 0747 separating smoke compartment 7.06 from 7.08 lacked a self or automatic closing device.
*At the smoke barrier doors 0799.3 separating smoke barrier 7.04 from 7.05 a gap greater than one eighth inch was observed between the door leafs when in a closed position.
*At the smoke barrier doors separating smoke barrier 7.08 from 7.09 located by the public elevators a gap greater than one eighth inch was observed between the door leafs when in a closed position.

6th floor:
*At the smoke barrier doors 0675.5 separating smoke barrier 6.06 from 6.12 a gap greater than one eighth inch was observed between the door leafs when in a closed position.
*At the smoke barrier doors 0673 separating smoke barrier 6.04 from 6.06 a gap greater than one eighth inch was observed between the door leafs when in a closed position.

5th floor:
The double smoke barrier doors of the waiting room area identified as 0550.36 near elevators 12 and 13 was observed to be constructed of non-fire rated wood and glass.

A facility tour took place on 03/13/13 staff members E5, F6, L9, and M10. A pair of fire barrier doors was observed in SC-4.6, on the 4th floor. Although equipped with latching hardware, these doors failed to latch when tested. This was verified with staff who accompanied the surveyor on tour.


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These findings were verified by all staff members present during tour of these areas.

Based on observations, staff interviews, and review of the Joint Commission floor plan drawings, the facility failed to ensure doors in smoke and fire barriers self-closed, and failed to ensure doors in fire barriers were equipped with the required fire protection rating as required by the code at 8.2.3.2.1. This involved 4 smoke and fire barriers. This could affect all patients in the building. The census on the first day of survey was 355 patients.

Findings include:

A tour was conducted on floors 1, 2, 3, and 4 on 03/13/13, with staff B2, E5, L9, and M10. During this tour, the following doors were observed:

1st floor:
*A smoke barrier door (01165) located in a one hour smoke barrier was observed without a self closing device. This door was located between the corridor and the finance office. Staff B2 verified the door lacked a self closing device, and verified the door should be equipped to self close.
*The double leaf fire doors leading to the North Elevators were observed with a 1/4 inch gap between the leafs, which is greater than the code requirement (NFPA 80, 2-3.1.7) of 1/8 inch.
*The 2 hour fire wall between the North Elevators and the Dixmyth parking garage elevators was observed with a pair of 3/4 hour fire resistance rated doors which failed to latch. These doors were observed equipped with a magnetic locking device and wipe card reader. According to staff M10, these doors remained unlocked during the daytime hours, and were locked after business hours to prevent visitors from entering the hospital from the parking garage. Staff M10 and E5 verified these doors lacked latching hardware. Staff E5 verified the floor plan diagram was correct for these doors being located in a 2 hour fire wall. Staff E5 also verified these doors should have a 1 and 1/2 hour fire resistance rating, and should be equipped with latching hardware.

4th floor:
*The 2 hour fire wall between the North Elevators and the Dixmyth parking garage elevators was observed with a fire door with a label stating conforms to 1 hour fire resistance rating (B). This label was verified with staff member E5, who verified this barrier has a 2 hour fire rating. Staff E5 verified the floor plan diagram was correct for these doors being located in a 2 hour fire wall. Staff E5 also verified these doors should have a 1 and 1/2 hour fire resistance rating, and should be equipped with latching hardware.

Based on observation during tour and staff verification it was determined this facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating, specifically in regard to fire resistance ratings of the hazardous room doors. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of one door which lacked a fire resistance rating at the following location:

8th floor:
*Within smoke compartment 8.03 and specifically room 0870.27, observation was made of a non-fire rated wood door.

This finding was verified by all staff members present during the tour of these penetrations.

Based on observation during tour and staff verification it was determined this facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of penetrations in hazardous area construction at the following locations:

9th floor:
Within the labor and delivery area of smoke compartment 9.9 specifically in the room across from operating room 2, observation was made of a silver open end conduit with white wires passing through lacking fire sealant around the annular space.

7th floor:
*Within the soiled utility room 07350 of smoke compartment 7.11, observation was made of a duct lacking a fire resistance sealant along the right side.

6th floor:
*Within storage room 0679.73 of smoke compartment 6.12, observation was made of five open end conduits and an approximate five to eight foot section at the top of the drywall where it meets the upper deck lacking a fire resistant sealant.

*Within equipment storage room 0676.09 of smoke compartment 6.11, observation was made of one unsealed green wire.

*Within suite A of smoke compartment 6.02 and within room 06130, observation was made of one open end flex conduit with a white wire passing through. Additionally, within room 06130 and 06115 observation was made of junction boxes having the " knock out " removed and not sealed.

5th floor:
Within smoke compartment 5.3 and specifically within the room located across from the exit access to the exterior stairs, observation was made of two unsealed lines around the annular space and an approximate 10 inch insulated line passing through a large unsealed rectangle opening in the drywall. Additionally, approximately a 12 foot section of drywall was not sealed where the top meets the upper deck.
Within smoke compartment 5.9 and in room 0548.48, observation was made of a half inch open end conduit and a one inch hole penetrating the block wall above the linen chute.
These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to maintain a clear path of egress to all exit discharges. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the seventh floor of the main building specifically in smoke compartment 7.01 and at stair K-3 observation was made of the exit access being obstructed with four chairs. This finding was acknowledged by all those who were present during tour of this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure continuous illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the seventh floor of the main building specifically in smoke compartment 7.01 and at stair K-3 observation was made once the stair door was opened that the area was in total darkness. This writer, and those who were present, made the observation that the stairs were not visible at all without a flashlight and all emergency lights located in the stairwell were either burned out or not functioning properly.

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building specifically in regard to manual fire pull devices. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the fifth floor of the main building, specifically in smoke compartment 5.2, observation was made at the exit located by elevator 2 having no manual fire pull device mounted near the exit access. This finding was verified by all staff present during tour of this area of the facility.

Based on observation during tour and staff verification, the facility failed to ensure the sprinkler system was continuously maintained in reliable operating condition and inspected and tested periodically specifically in regard to dust, debris and missing escutcheon rings from the sprinkler heads. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During facility tour observation was made of sprinkler heads that were coated with dust and/or debris or escutcheon rings missing in the following locations:

8th floor:
*Within smoke compartment 8.07 and within room 8802 observation was made of a dirty sprinkler head.
*Within smoke compartment 8.05 dirty sprinkler heads observed in rooms 0863.9A, 865.1A and 0892.2. Within the corridor observation was made of one dirty sprinkler head near 0867.2, escutcheon ring missing and open area in the ceiling tile around the escutcheon ring by 0899.12.
*Within smoke compartment 8.04, within room 0892 and within the corridor by 0890, dirty sprinkler heads were observed.
*Within smoke compartment 8.03, in storage room 0870.7and by door 0870.28; missing escutcheon rings.
*Within smoke compartment 8.01 and in room 0873.2; missing escutcheon ring.

7th floor:
*Within smoke compartment 7.09 dirty sprinkler heads were observed in the corridor near 0736
*Within smoke compartment 7.02 observation was made of two sprinkler heads which had missing escutcheon rings near 0799.144 and at the nurse ' s station. Additionally, a dirty sprinkler head was observed in corridor 0799.200.

6th floor:
*Within smoke compartment 6.05 observation was made of a ceiling tile which had a hole cut out too large for the escutcheon ring.
*Within smoke compartment 6.04 observation was made of a missing escutcheon ring in room 0613.
*Within smoke compartment 6.08 observation was made of a missing escutcheon ring around the corner from blue elevator numbers 36 and 37.
*Within smoke compartment 6.09 and near the two hour fire rated occupancy separation and the stairs, observation was made of a dirty sprinkle head.

5th floor:
*Within smoke compartment 5.9 and within the trash chute, observation was made of a dirty sprinkler head.
*Within smoke compartment 5.2 by elevator # 2, observation was made of a sprinkler head with a missing cover plate.

Basement:
*Within smoke compartment 00.2 observation was made of four dirty sprinkler heads near 0015.
*Within smoke compartment 00.3 and in the soiled linen room, observation was made of a sprinkler head which had a piece of plastic attached to it.

A facility tour took place on 03/13/13 staff members E5, F6, L9, and M10. During tour observation was made of sprinkler heads with a heavy buildup of dust and debris, or were missing escutcheon rings from the sprinkler heads. These sprinkler heads were located as follows:

1st floor:

*The admitting office, room 0108.3, was observed with 2 sprinkler heads which were heavily coated with dust and debris.

*Corridor 0109.2, located near the admitting office, was observed with a sprinkler head which was heavily coated with dust and debris.

4th floor:

*The mechanical space F-G was observed with a sprinkler head outside the linen chute discharge room. This sprinkler head was missing the escutcheon ring.

*The pharmacy office was observed with a missing escutcheon ring around one sprinkler head.

These sprinkler heads were verified with the aformentioned staff during tour.



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These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were mounted less than five feet from the floor, and were readily visible. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

A tour was conducted in the facility on 03/13/13 with staff E5, F6, L9, M10. During this tour, fire extinguishers were not clearly identified as to location in the following areas:

2nd floor:
*In the administration office area, a fire extinguisher was observed located behind a door (258), and lacked signage to indicate the location.

4th floor:
*In the fitness center, Staff E5 and the surveyor were unable to locate the fire extinguisher. Staff F6 discovered the fire extinguisher located under a television. The extinguisher was observed in a recessed area in the wall. The area surrounding the fire extinguisher was observed congested with a portable soiled linen hamper and a chair with a milkcrate of folders. There was no signage indicating the location of the fire extinguisher.
*In the egress corridor by the radiology/oncology suite, the fire extinguisher was located in an alcove and was not visible when facing the exit discharge door. The extinguisher was visible only when entering the corridor from the exit discharge door.

These fire extinguishers were verified with staff who accompanied the surveyor during tour.



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Findings include:
A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of several fire extinguishers that were mounted above the required level of not higher that five feet from the floor in the following locations:

11th floor:
Within the lab area of smoke compartment 11.8 observation was made of two fire extinguishers mounted above the required five foot level. They were also mounted on a wall over a counter top which made them more difficult to reach in the event of an emergency.

5th floor:
Within smoke compartment 5.6 and located by stairwell D near 0514, observation was made of a portable fire extinguisher mounted higher than five feet from the floor.

These findings were verified by all staff members present during tour of these areas.

Based on observations and staff interviews, the facility failed to ensure portable heating devices did not exceed 212 degrees Fahrenheit (F.), and failed to be aware of the areas in which the devices were located. The census on the first survey day was 355.

Findings include:

A tour was conducted in the facility on 03/13/13 with staff E5, L9, M10. During this tour, portable space heaters were observed in different non-sleeping areas of the facility as follows:

*On the first floor under the information desk, and
*On the second floor in Human Resources offices. One employee stated the area is cold, and this employee had to bring in their own portable space heater. An employee across the hall stated the facility provided these employees with a space heater 5 years ago. Interviews with staff E5 and M10, during tour, revealed the facility was not aware of these heaters being used, and verified they had not been evaluated by maintenance for safety. These employees also verified they did not know if the heating elements remained less than 212 degrees Fahrenheit.

Based on observation during tour and staff verification it was determined this facility failed to ensure the trash and laundry chutes accesses were located within rooms used exclusively for that purpose and which contained at least a one hour fire rated construction, and failed to ensure either the chute doors were equipped with a key lock or the door to the chute room was secured. This is in accordance with the National Fire Protection Association (NFPA) 101 Chapter 9.5.1, NFPA 82 Chapter 3-2.4.3 and 3-2.4.3.2. The trash chute discharge door, in one location, was observed blocked with bags of trash. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

A tour was conducted on 03/13/13 with staff E5, F6, L9, M10. During this tour, the trash chute discharge room was observed at 4:43 PM with a large mobile container located underneath the trash chute opening. The mobile container was observed overflowing with bags of trash, resulting in the trash being backed up into the trash chute, and blocking the chute discharge door. This door was observed equipped with a fusible link which would melt in the event of heat, causing the chute door to slide closed. Staff M10 verified the trash was backed up into the chute, stating this would not permit the chute door to close in the event the fusible link melted during a fire.


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Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the 15th floor specifically in smoke compartment 15.3, observation was made within soiled holding room 1501 of a trash and laundry chute access. The laundry chute access was disabled and according to staff A during interview on 03/07/13 at approximately 9:00 AM this chute access was disabled for several floors below the 15th floor although at one unspecified floor the laundry chute becomes assessable again.
The door to the chute access room was observed to be a 20 minute fire rated door and was noted to be unsecured. The trash chute door was also unsecured and observation was made of several items stored within this room such as cleaning supplies, boxes and miscellaneous items. Additionally, this room was observed to have double elevator access for employees transporting various types of stock and equipment.

During the interview with staff A it was stated that this finding will be the same all the way through the entire 15 stories and into the basement of this section of this building and as the tour progressed this writer and all staff members who were present during tour verified this to be true.

Additionally, tour of the seventh floor smoke compartment 7.03 reveals a room adjacent to a large mechanical room which housed a linen chute. The entrance to this room was equipped with a double wood door that lacked a fire resistance rating. This door was not secured nor was the linen chute access door. From within this room and at the opposite side from the double wood doors were double metal doors which were not fire rated. These doors were the entrance doors which lead into the mechanical room. Within the mechanical room observation was made of a trash chute access which was also noted to be unsecured.

During tour of the sixth floor and within smoke compartment 6.11, observation was made of trash and linen chutes located in separate rooms in which neither the access door to the room nor the chute access doors were secured.

During tour of the fifth floor and within smoke compartment 5.9, observation was made of a trash and linen chute located in the same room. The door to this room and the access doors to the chutes were not secured. Additionally, within smoke compartment 5.2, observation was made of a trash and linen chute located within a restroom.

All of these findings were verified by all staff present during tour of these areas of this facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were located as to be readily visible. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A tour was conducted in the facility on 03/14/13 with staff L9, R15, and Q14 between 8:00 AM and 9:00 AM. Observations revealed a fire extinguisher located under the receptionist's desk, which was not visible except when inside the receptionist desk area. There was no signage indicating a fire extinguisher was located underneath the desk. This was verified with the aforementioned staff during tour.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patients, staff and visitors utilizing the facility. The patient census was 355 at the beginning of the survey.
Findings include:

During tour of floors 1, 2, 3, and 4 on 03/13/13, with staff E5, L9, M10, observation revealed smoke detectors were located less than 36 inches from air flow devices at the following locations:

On the 2nd floor:
*Three smoke detectors in the corridor by Room 0235 and the North Elevator lobby.

On the 4th floor:
*In the Northwest conference room, and
*In the main corridor btween SC04.1 and SC-4.3.

These smoke detector locations were verified with staff who accompanied the surveyor on tour.
An interview was conducted with staff B2, on 03/12/13 at 4:00 PM, in regards to the type of smoke detectors used in the facility. Staff B2 verified these smoke detectors are not designed to be less than 36 inches from air flow devices.


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A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During facility tour an observation was made of smoke detectors located near air flow devices at the following locations:

9th floor:
*Within the open use area by the north elevators of smoke compartment 9.9

8th floor:
*By room 8147 and 8430 of smoke compartment 8.10

7th floor:
By the double smoke barrier doors 7140 and by room 07365 of smoke compartment 7.11

6th floor:
*In the corridor by rooms 06420 and 06405 of smoke compartment 6.01

These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

During tour of floors 1, 2, 3, and 4 on 03/13/13, with staff E5, L9, and M10, observation revealed smoke detectors were located less than 36 inches from air flow devices at the following locations:

1st floor:

*In the main lobby atrium between the front doors and the finance office.
2nd floor:

*In Suite A (Administration) in room 0220,
*In the Power Plant in room in room 0206,
3rd floor:

*In the corridor by electrical supply room 0334.
4th floor:

*In the corridor by Elevator #18.
*In the pharmacy offices.
These smoke detector locations were verified with staff who accompanied the surveyor on tour. An interview was conducted with staff B2, on 03/12/13 at 4:00 PM, in regards to the type of smoke detectors used in the facility. Staff B2 verified these smoke detectors are not designed to be less than 36 inches from air flow devices.


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Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During facility tour observation was made of smoke detectors located near air flow devices at the following locations:

15th floor:
*Within the library room 1509 of smoke compartment 15.5

14th floor:
*At the west smoke barrier doors of smoke compartment 14.3
*Within room 1400 of smoke compartment 14.3
*At the public lobby elevators and patient elevators of smoke compartment 14.03.
*At the south smoke barrier doors of smoke compartment 14.2

13th floor:
*At the south smoke barrier doors of smoke compartment 13.2
*At the north smoke barrier doors of smoke compartment 13.1
*Within the clean room 1300, soiled holding room 1301
*At the public lobby elevators and patient elevators of smoke compartment 13.03
*At the north smoke barrier doors of smoke compartment 13.4
*At the south smoke barrier doors of smoke compartment 13.5
*Within the V.I.P. room 1309 of smoke compartment 13.5

12th floor:
*At the public lobby elevators and patient elevators of smoke compartment 12.03
*In rooms 1265 and 1267 of smoke compartment 12.02
*In rooms 1208 and 1209 of smoke compartment 12.05

11th floor
*Within the waiting area of the heart and vascular area of smoke compartment 11.1
*At the public lobby elevators and patient elevators of smoke compartment 11.4
*Within the waiting area adjacent to break room 1139 of suite A.
*At the north smoke barrier doors of smoke compartment 11.7
*Within the V.I.P. room 1109 of smoke compartment 11.6
*Within rooms 1111 and 1112 of smoke compartment 11.6

10th floor:
*Within room 1089 of smoke compartment 10.3
*Within room 1038.6 and group room A of suite B in smoke compartment 10.2
*At the public lobby elevators and patient elevators of units A-E.

9th floor:
*By 0993 of smoke compartment 9.3
*By elevators 12 and 13 of smoke compartment 9.5
*In corridor by 0975.23A of smoke compartment 9.5
*In corridor west of storage room 912 and also in corridor northeast of storage room 912 of smoke compartment 9.04. Both smoke detectors are located adjacent to the one hour smoke barrier.
*Near stair C of and within operating rooms 3, 4 and 5 of smoke compartment 9.7.

8th floor:
*Within the corridor by 800.1A of smoke compartment 8.06
*Within the corridor by 864.11 of smoke compartment 8.05
*Within the corridor by 878 of smoke compartment 8.04
*Within storage room 0870.7 and 870.24A of smoke compartment 8.03
*Near the mechanical room entrance and the corridor adjacent to the mechanical room of smoke compartment 8.03
*Five smoke detectors near vents in suite A of smoke compartment 8.02
*Near 869.1 of smoke compartment 8.02

7th floor:
*Within rooms 0740 and 0741 of smoke compartment 7.09
*At the public lobby elevators and patient elevators of smoke compartment 7.08
*Within rooms 0774.28A, 0774.29, 0775.1, 0775.1A, 0779.8 and 0799 of smoke compartment 7.05
*Within the corridors near rooms 2307, 0799.69 and 0799.82 of smoke compartment 7.01
*Within the corridor by the elevators near the wound center and within the corridor near room 0799.209 of smoke compartment 7.02

6th floor:
*Within the operating room numbers 1 through 12 of smoke compartments 6.03 and 6.05
*Within the corridor adjacent to and south of the surgical waiting area and near the patient transport elevators of smoke compartment 6.04
*Within smoke compartment 6.06 near 0673.23, 0674.14, within the hybrid operating room across from the stairs and within control room 0673.1
*Within smoke compartment 6.11 near 0677.43, 0677.3, 0677.32, 0677.30 and within the corridor near 0676.12
*Within smoke compartment 6.09 and at the back side of an air conditioning unit near 0687.55
*Within suite B of smoke compartment 6.10 near rooms 0681.07 and 0681.15
*Two smoke detectors by ventilation devices within the corridor of smoke compartment 6.08
*Within smoke compartment 6.02 near 0617, bay 19 and 20 and operating rooms 17 and 18

5th floor:
*By level five north elevators and by elevators 12 and 13; by room 0550A of smoke compartment 5.4
*Within room by door 0555.19 of smoke compartment 5.1
*Within staff lounge 0551.24 and room 0551.40 and within the corridor by room 0551.36 of smoke compartment 5.3

Basement:
*Within the lobby area of transport elevators and within the corridor by doors 001.11
These findings were verified by all staff members present during tour of these areas.

Based on observations and staff interview, the facility failed to ensure smoke detectors were located at least 36 inches from an air supply. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility also failed to ensure one of one stairwell doors latched into the frame as required by the code at 38.2.1.1 and 7.2.1.8.2. This had the potential to affect all patients, staff and visitors utilizing the facility. The patient census was 355 at the beginning of the survey.

Findings include:

A tour was conducted in the facility on 03/14/13 between 10:00 AM and 11:10 AM with staff A1, F6, L9, V19, W20, and X21. Observations revealed the stairwell door, located by the front entrance, was equipped with a Class B (1 hour fire resistance rated door) which was non-latching. Although the door was in the closed position, the door did not latch. An interview with staff A1, during tour, verified this door is required to latch.

During this tour, one smoke detector located in the triage nursing area, was observed located approximately one foot away from an air supply diffuser. This was verified with the aforementioned staff on tour.

Based on observations, review of sprinkler inspection reports, and staff interviews, the facility failed to take action when issues were identified with the sprinkler system in accordance with the code at NFPA 25. 9.7.5 The facility also failed to ensure one exit discharge remained free from snow at 7.7, and failed to perform an annual ninety-minute battery test on emergency lighting as required by the code at 7.9.3. This could potentially affect all patients, staff, and visitors. The census on the first survey day was 355 patients.

Findings include:

A tour was conducted in the facility on 03/14/13 between 11:55 AM and 12:16 PM with staff L9, N11, O12, and P13. During this tour, the north exit discharge was observed with a snow covered exit ramp which was approximately 15-20 feet in length. Staff cautioned the surveyor to be careful as the ramp may be slick, when the surveyor stepped outside onto the ramp.

The facility was observed with battery back up emergency lighting throughout the facility. Interview with staff P13, and a review of testing records, revealed these lights are tested weekly; however, the testing records lacked information on how many seconds the test was conducted for each battery pack. This employee also verified there is no annual ninety-minute test currently in process for these lights.

During the tour, the facility was observed with an automatic sprinkler system throughout the space. A review of the previous two sprinkler inpsection reports, by an outside contractor, revealed the following concerns:

The 04/07/11 report stated water motor gong did not ring, had to close valve off to it, would not stop water coming through bell drain. P.I.V. (post indicator valve) is locked open and not supervised.

The 04/30/12 inspection report stated gauges over 5 years old, water motor gong does not work, alarm valve bypass leaks through and had to leave valve off, P.I.V is locked, tamper has been bent, not in working order.

At the conclusion of the review of these sprinkler inspection reports, the aforementioned staff revealed they were not aware of any followup to these concerns listed on the reports. After being questioned by the surveyor as to whether the sprinkler system was currently functional, Staff N11 revealed he/she would contact the outside service company to see if there had been any action taken in regard to these recommendations.

Interview with staff A1 (Director of Facilitity Services) on 03/14/13 at 3:00 PM revealed this employee was concerned regarding the lack of follow-up in the past two years for these identified problems. According to a letter, dated 03/15/13, from this contractor, the sprinkler system is functional and fully operational, and the items listed in the inspector's comment section will be followed up with and quotes will be provided if the facility approves the sprinkler company to proceed.

Based on observation during tour and staff interview it was determined this facility failed to ensure all common walls with a nonconforming building is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition and communicating openings are protected by approved self-closing fire doors. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

Facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the sixth floor of the main building specifically at the connector to the medical office building observation was made of double metal and glass doors that lacked a fire resistance rating. This finding was acknowledged by all those who were present during tour of this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure all vertical openings, specifically stairs between floors, are enclosed with construction having a fire resistance rating of at least one hour and the vertical opening was not utilized for storage. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the sixth floor and within smoke compartment 6.07, observation was made of two stairwell doors, 0684.10a and 4683.1, which had the fire rating tag layered with a coat of paint. This writer was not able to verify the fire resistance rating of either door.

Within smoke compartment 6.09 observation was made of a stairwell equipped with a non-fire rated metal door identified as 0687.30.

During tour of the basement and within smoke compartment 00.2, observation was made of stairwell door 00143 which failed to shut properly when tested. Additionally, observation was made of storage under stairs ST-3 within smoke compartment 00.4. The storage consisted of wood, insulation, electrical junction boxes and a metal stud.
These findings were verified by all staff members during tour of these areas of the facility.

Based on observation during tour, staff verification and review of the fire escape plans it was determined this facility failed to ensure accesses to exits were marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

Facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of exits signs lacking or exit signs that were placed in corridors that were not designated accesses to exits. These observations were made in the following locations:

11th floor:
*Within smoke compartment 11.8 and directly in front of the communicating stairs which continue down to the seventh floor observation was made of a fire escape plan posted on an adjacent wall indicating this communicating stairs as an emergency exit. Observation was made of no exit sign mounted at the stairs or on either side of the corridor door south of the communicating stairs directing traffic flow from the south side of the door to the communicating stairs or from the north side of the door to another stairwell located in adjacent smoke compartment 11.1.

10th floor
*Within smoke compartment 10.1 standing in the corridor by the exercise rooms facing southeast down the corridor, observation was made that the exit directional sign further down the corridor was obstructed by the bulkhead.
*Within suite B of smoke compartment 10.2 observation was made of no directional signs located within the suite providing directions for a path of egress to either corridor which led to the stairwell within this smoke compartment or to another stairwell in the adjacent smoke compartment. Exit access from this suite was not obvious.

6th floor:
*Within smoke compartment 6.02 and in the angled corridor 0610.3 facing northeast, observation was made of no exit sign directing traffic flow to the stairwell located at the end of corridor 0610.2. Additionally, the exit sign mounted in front of the stairwell was not positioned in a manner that would be obvious to traffic flow from the south end of corridor 0610.2.

During tour of the 2nd and 3rd floors, on 03/13/13 with staff E5, L9, M10, two areas of the building containing offices were observed without approved, readily visible exit signs where the way to reach the exit was not readily apparent. These areas were located in Human Resources and Medical Records as follows:

On the 2nd floor in Suite C,
*The Human Resources (HR) offices was observed with a paper exit sign on the back of door 0252, located by office 0245. Door 0252 was observed dividing two different areas of the office. Staff accompanying the surveyor on tour verbalized this exit access door was used by potential employees when leaving the HR area. This door opened into a room with three doorways. Two of these door were at the entrances to offices, and one of the doors led to the exit access corridor. None of these three doors were equipped with an exit sign.

On the 3rd floor in Smoke Compartment SC-3.02,
*The Medical Records area was observed with an exit sign that led to a maze of offices and the physicians' lounge. The only visible exit sign in this area was located at the exit access door leading to the exit access corridor. The maze of rooms was not equipped with a directional exit sign.
In the main area of medical records storage, eixt access doo 0320 lacked an exit sign. Staff accompanying the survey on tour stated this door was used for staff and visitors to exit the area.


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This finding was verified by all staff members present during the tour of this area of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of penetrations in smoke/fire barriers at the following locations:

*At the smoke barrier doors separating smoke barrier 8.06 from 8.10 a gap greater than one eighth inch was observed between the door leafs when in a closed position.

*At the smoke barrier doors separating smoke barrier 8.09 from 8.10 a gap greater than one eighth inch was observed between the door leafs when in a closed position.

These findings were verified by all staff members present during tour of this area of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of penetrations in smoke/fire barriers at the following locations:

14th floor:
*Group of blue wires were not sealed around the annular space above the double smoke barrier doors separating smoke compartment 14.1 from 14.3

8th floor:
*Above smoke barrier doors 831.3 observation was made of an unsealed three inch conduit sleeve with blue wires passing through.
*At the corner of the smoke barrier and near doors 0800.12 observation was made of two approximately three inch by two inch openings in the drywall with flex conduits passing through.

7th floor:
*From within room 07133 observation was made of an approximate two inch by three inch opening in the smoke barrier.

6th floor:
*A smoke barrier door was missing at 0677.04 which divided smoke compartment 6.10 from 6.11. Additionally, observation was made of three open end conduits above that particular door area and within physician ' s office area 0677.01
*Within the pre-operating hold area specifically within the soiled room across from the nurse ' s station observation was made of an approximate two inch water line and a one inch copper line lacking a fire rated sealant around their annular space.

5th floor:
*Within smoke compartment 5.6 and above the refrigerator located near the west end of the smoke barrier observation was made of a silver conduit lacking a fire rated sealant around the annular space.
*Within the dining room about midway of the smoke barrier separating smoke compartment 5.4 from 5.7 observation was made of an approximate one inch opening in the drywall.
These findings were verified by all staff members present during tour of these areas.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke barrier doors which were not constructed of at least a one and three quarter inch solid bonded core wood were equipped with a fire resistance rating identification tag with at least a 20 minute fire resistance rating. Additionally, this facility failed to ensure all smoke barrier doors which had a fire resistance rating identification tag was legible, that is free from paint and mars which would not allow proper identification of the fire resistance rating and were equipped with a self closing or automatic closing device. The facility also failed to ensure the doors self closed and latched. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building an observation was made of metal smoke barrier doors lacking the required fire resistance rating identification tag at the following locations:

15th floor:
*At the double smoke barrier doors located between smoke compartments 15.1 and 15.3

14th floor:
*The door leading into the manager/charge office from smoke compartment 14.2 lacked a self closing or automatic closing device.

10th floor:
*At the double smoke barrier doors located between smoke compartment 10.4 and suite A of 10.2

8th floor:
*Door 870.0 separating smoke compartments 8.02 from 8.03 had fire rating tags painted over
*Staff lounge door 0892.3 separating smoke compartment 8.04 from 8.05 lacked a self or automatic closing device.

7th floor:
*Single smoke barrier door 0747 separating smoke compartment 7.06 from 7.08 lacked a self or automatic closing device.
*At the smoke barrier doors 0799.3 separating smoke barrier 7.04 from 7.05 a gap greater than one eighth inch was observed between the door leafs when in a closed position.
*At the smoke barrier doors separating smoke barrier 7.08 from 7.09 located by the public elevators a gap greater than one eighth inch was observed between the door leafs when in a closed position.

6th floor:
*At the smoke barrier doors 0675.5 separating smoke barrier 6.06 from 6.12 a gap greater than one eighth inch was observed between the door leafs when in a closed position.
*At the smoke barrier doors 0673 separating smoke barrier 6.04 from 6.06 a gap greater than one eighth inch was observed between the door leafs when in a closed position.

5th floor:
The double smoke barrier doors of the waiting room area identified as 0550.36 near elevators 12 and 13 was observed to be constructed of non-fire rated wood and glass.

A facility tour took place on 03/13/13 staff members E5, F6, L9, and M10. A pair of fire barrier doors was observed in SC-4.6, on the 4th floor. Although equipped with latching hardware, these doors failed to latch when tested. This was verified with staff who accompanied the surveyor on tour.


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These findings were verified by all staff members present during tour of these areas.

Based on observations, staff interviews, and review of the Joint Commission floor plan drawings, the facility failed to ensure doors in smoke and fire barriers self-closed, and failed to ensure doors in fire barriers were equipped with the required fire protection rating as required by the code at 8.2.3.2.1. This involved 4 smoke and fire barriers. This could affect all patients in the building. The census on the first day of survey was 355 patients.

Findings include:

A tour was conducted on floors 1, 2, 3, and 4 on 03/13/13, with staff B2, E5, L9, and M10. During this tour, the following doors were observed:

1st floor:
*A smoke barrier door (01165) located in a one hour smoke barrier was observed without a self closing device. This door was located between the corridor and the finance office. Staff B2 verified the door lacked a self closing device, and verified the door should be equipped to self close.
*The double leaf fire doors leading to the North Elevators were observed with a 1/4 inch gap between the leafs, which is greater than the code requirement (NFPA 80, 2-3.1.7) of 1/8 inch.
*The 2 hour fire wall between the North Elevators and the Dixmyth parking garage elevators was observed with a pair of 3/4 hour fire resistance rated doors which failed to latch. These doors were observed equipped with a magnetic locking device and wipe card reader. According to staff M10, these doors remained unlocked during the daytime hours, and were locked after business hours to prevent visitors from entering the hospital from the parking garage. Staff M10 and E5 verified these doors lacked latching hardware. Staff E5 verified the floor plan diagram was correct for these doors being located in a 2 hour fire wall. Staff E5 also verified these doors should have a 1 and 1/2 hour fire resistance rating, and should be equipped with latching hardware.

4th floor:
*The 2 hour fire wall between the North Elevators and the Dixmyth parking garage elevators was observed with a fire door with a label stating conforms to 1 hour fire resistance rating (B). This label was verified with staff member E5, who verified this barrier has a 2 hour fire rating. Staff E5 verified the floor plan diagram was correct for these doors being located in a 2 hour fire wall. Staff E5 also verified these doors should have a 1 and 1/2 hour fire resistance rating, and should be equipped with latching hardware.

Based on observation during tour and staff verification it was determined this facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating, specifically in regard to fire resistance ratings of the hazardous room doors. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of one door which lacked a fire resistance rating at the following location:

8th floor:
*Within smoke compartment 8.03 and specifically room 0870.27, observation was made of a non-fire rated wood door.

This finding was verified by all staff members present during the tour of these penetrations.

Based on observation during tour and staff verification it was determined this facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of penetrations in hazardous area construction at the following locations:

9th floor:
Within the labor and delivery area of smoke compartment 9.9 specifically in the room across from operating room 2, observation was made of a silver open end conduit with white wires passing through lacking fire sealant around the annular space.

7th floor:
*Within the soiled utility room 07350 of smoke compartment 7.11, observation was made of a duct lacking a fire resistance sealant along the right side.

6th floor:
*Within storage room 0679.73 of smoke compartment 6.12, observation was made of five open end conduits and an approximate five to eight foot section at the top of the drywall where it meets the upper deck lacking a fire resistant sealant.

*Within equipment storage room 0676.09 of smoke compartment 6.11, observation was made of one unsealed green wire.

*Within suite A of smoke compartment 6.02 and within room 06130, observation was made of one open end flex conduit with a white wire passing through. Additionally, within room 06130 and 06115 observation was made of junction boxes having the " knock out " removed and not sealed.

5th floor:
Within smoke compartment 5.3 and specifically within the room located across from the exit access to the exterior stairs, observation was made of two unsealed lines around the annular space and an approximate 10 inch insulated line passing through a large unsealed rectangle opening in the drywall. Additionally, approximately a 12 foot section of drywall was not sealed where the top meets the upper deck.
Within smoke compartment 5.9 and in room 0548.48, observation was made of a half inch open end conduit and a one inch hole penetrating the block wall above the linen chute.
These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to maintain a clear path of egress to all exit discharges. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the seventh floor of the main building specifically in smoke compartment 7.01 and at stair K-3 observation was made of the exit access being obstructed with four chairs. This finding was acknowledged by all those who were present during tour of this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure continuous illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the seventh floor of the main building specifically in smoke compartment 7.01 and at stair K-3 observation was made once the stair door was opened that the area was in total darkness. This writer, and those who were present, made the observation that the stairs were not visible at all without a flashlight and all emergency lights located in the stairwell were either burned out or not functioning properly.

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building specifically in regard to manual fire pull devices. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the fifth floor of the main building, specifically in smoke compartment 5.2, observation was made at the exit located by elevator 2 having no manual fire pull device mounted near the exit access. This finding was verified by all staff present during tour of this area of the facility.

Based on observation during tour and staff verification, the facility failed to ensure the sprinkler system was continuously maintained in reliable operating condition and inspected and tested periodically specifically in regard to dust, debris and missing escutcheon rings from the sprinkler heads. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During facility tour observation was made of sprinkler heads that were coated with dust and/or debris or escutcheon rings missing in the following locations:

8th floor:
*Within smoke compartment 8.07 and within room 8802 observation was made of a dirty sprinkler head.
*Within smoke compartment 8.05 dirty sprinkler heads observed in rooms 0863.9A, 865.1A and 0892.2. Within the corridor observation was made of one dirty sprinkler head near 0867.2, escutcheon ring missing and open area in the ceiling tile around the escutcheon ring by 0899.12.
*Within smoke compartment 8.04, within room 0892 and within the corridor by 0890, dirty sprinkler heads were observed.
*Within smoke compartment 8.03, in storage room 0870.7and by door 0870.28; missing escutcheon rings.
*Within smoke compartment 8.01 and in room 0873.2; missing escutcheon ring.

7th floor:
*Within smoke compartment 7.09 dirty sprinkler heads were observed in the corridor near 0736
*Within smoke compartment 7.02 observation was made of two sprinkler heads which had missing escutcheon rings near 0799.144 and at the nurse ' s station. Additionally, a dirty sprinkler head was observed in corridor 0799.200.

6th floor:
*Within smoke compartment 6.05 observation was made of a ceiling tile which had a hole cut out too large for the escutcheon ring.
*Within smoke compartment 6.04 observation was made of a missing escutcheon ring in room 0613.
*Within smoke compartment 6.08 observation was made of a missing escutcheon ring around the corner from blue elevator numbers 36 and 37.
*Within smoke compartment 6.09 and near the two hour fire rated occupancy separation and the stairs, observation was made of a dirty sprinkle head.

5th floor:
*Within smoke compartment 5.9 and within the trash chute, observation was made of a dirty sprinkler head.
*Within smoke compartment 5.2 by elevator # 2, observation was made of a sprinkler head with a missing cover plate.

Basement:
*Within smoke compartment 00.2 observation was made of four dirty sprinkler heads near 0015.
*Within smoke compartment 00.3 and in the soiled linen room, observation was made of a sprinkler head which had a piece of plastic attached to it.

A facility tour took place on 03/13/13 staff members E5, F6, L9, and M10. During tour observation was made of sprinkler heads with a heavy buildup of dust and debris, or were missing escutcheon rings from the sprinkler heads. These sprinkler heads were located as follows:

1st floor:

*The admitting office, room 0108.3, was observed with 2 sprinkler heads which were heavily coated with dust and debris.

*Corridor 0109.2, located near the admitting office, was observed with a sprinkler head which was heavily coated with dust and debris.

4th floor:

*The mechanical space F-G was observed with a sprinkler head outside the linen chute discharge room. This sprinkler head was missing the escutcheon ring.

*The pharmacy office was observed with a missing escutcheon ring around one sprinkler head.

These sprinkler heads were verified with the aformentioned staff during tour.



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These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were mounted less than five feet from the floor, and were readily visible. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

A tour was conducted in the facility on 03/13/13 with staff E5, F6, L9, M10. During this tour, fire extinguishers were not clearly identified as to location in the following areas:

2nd floor:
*In the administration office area, a fire extinguisher was observed located behind a door (258), and lacked signage to indicate the location.

4th floor:
*In the fitness center, Staff E5 and the surveyor were unable to locate the fire extinguisher. Staff F6 discovered the fire extinguisher located under a television. The extinguisher was observed in a recessed area in the wall. The area surrounding the fire extinguisher was observed congested with a portable soiled linen hamper and a chair with a milkcrate of folders. There was no signage indicating the location of the fire extinguisher.
*In the egress corridor by the radiology/oncology suite, the fire extinguisher was located in an alcove and was not visible when facing the exit discharge door. The extinguisher was visible only when entering the corridor from the exit discharge door.

These fire extinguishers were verified with staff who accompanied the surveyor during tour.



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Findings include:
A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the main building observation was made of several fire extinguishers that were mounted above the required level of not higher that five feet from the floor in the following locations:

11th floor:
Within the lab area of smoke compartment 11.8 observation was made of two fire extinguishers mounted above the required five foot level. They were also mounted on a wall over a counter top which made them more difficult to reach in the event of an emergency.

5th floor:
Within smoke compartment 5.6 and located by stairwell D near 0514, observation was made of a portable fire extinguisher mounted higher than five feet from the floor.

These findings were verified by all staff members present during tour of these areas.

Based on observations and staff interviews, the facility failed to ensure portable heating devices did not exceed 212 degrees Fahrenheit (F.), and failed to be aware of the areas in which the devices were located. The census on the first survey day was 355.

Findings include:

A tour was conducted in the facility on 03/13/13 with staff E5, L9, M10. During this tour, portable space heaters were observed in different non-sleeping areas of the facility as follows:

*On the first floor under the information desk, and
*On the second floor in Human Resources offices. One employee stated the area is cold, and this employee had to bring in their own portable space heater. An employee across the hall stated the facility provided these employees with a space heater 5 years ago. Interviews with staff E5 and M10, during tour, revealed the facility was not aware of these heaters being used, and verified they had not been evaluated by maintenance for safety. These employees also verified they did not know if the heating elements remained less than 212 degrees Fahrenheit.

Based on observation during tour and staff verification it was determined this facility failed to ensure the trash and laundry chutes accesses were located within rooms used exclusively for that purpose and which contained at least a one hour fire rated construction, and failed to ensure either the chute doors were equipped with a key lock or the door to the chute room was secured. This is in accordance with the National Fire Protection Association (NFPA) 101 Chapter 9.5.1, NFPA 82 Chapter 3-2.4.3 and 3-2.4.3.2. The trash chute discharge door, in one location, was observed blocked with bags of trash. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

A tour was conducted on 03/13/13 with staff E5, F6, L9, M10. During this tour, the trash chute discharge room was observed at 4:43 PM with a large mobile container located underneath the trash chute opening. The mobile container was observed overflowing with bags of trash, resulting in the trash being backed up into the trash chute, and blocking the chute discharge door. This door was observed equipped with a fusible link which would melt in the event of heat, causing the chute door to slide closed. Staff M10 verified the trash was backed up into the chute, stating this would not permit the chute door to close in the event the fusible link melted during a fire.


21957

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During tour of the 15th floor specifically in smoke compartment 15.3, observation was made within soiled holding room 1501 of a trash and laundry chute access. The laundry chute access was disabled and according to staff A during interview on 03/07/13 at approximately 9:00 AM this chute access was disabled for several floors below the 15th floor although at one unspecified floor the laundry chute becomes assessable again.
The door to the chute access room was observed to be a 20 minute fire rated door and was noted to be unsecured. The trash chute door was also unsecured and observation was made of several items stored within this room such as cleaning supplies, boxes and miscellaneous items. Additionally, this room was observed to have double elevator access for employees transporting various types of stock and equipment.

During the interview with staff A it was stated that this finding will be the same all the way through the entire 15 stories and into the basement of this section of this building and as the tour progressed this writer and all staff members who were present during tour verified this to be true.

Additionally, tour of the seventh floor smoke compartment 7.03 reveals a room adjacent to a large mechanical room which housed a linen chute. The entrance to this room was equipped with a double wood door that lacked a fire resistance rating. This door was not secured nor was the linen chute access door. From within this room and at the opposite side from the double wood doors were double metal doors which were not fire rated. These doors were the entrance doors which lead into the mechanical room. Within the mechanical room observation was made of a trash chute access which was also noted to be unsecured.

During tour of the sixth floor and within smoke compartment 6.11, observation was made of trash and linen chutes located in separate rooms in which neither the access door to the room nor the chute access doors were secured.

During tour of the fifth floor and within smoke compartment 5.9, observation was made of a trash and linen chute located in the same room. The door to this room and the access doors to the chutes were not secured. Additionally, within smoke compartment 5.2, observation was made of a trash and linen chute located within a restroom.

All of these findings were verified by all staff present during tour of these areas of this facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were located as to be readily visible. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

Findings include:

A tour was conducted in the facility on 03/14/13 with staff L9, R15, and Q14 between 8:00 AM and 9:00 AM. Observations revealed a fire extinguisher located under the receptionist's desk, which was not visible except when inside the receptionist desk area. There was no signage indicating a fire extinguisher was located underneath the desk. This was verified with the aforementioned staff during tour.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patients, staff and visitors utilizing the facility. The patient census was 355 at the beginning of the survey.
Findings include:

During tour of floors 1, 2, 3, and 4 on 03/13/13, with staff E5, L9, M10, observation revealed smoke detectors were located less than 36 inches from air flow devices at the following locations:

On the 2nd floor:
*Three smoke detectors in the corridor by Room 0235 and the North Elevator lobby.

On the 4th floor:
*In the Northwest conference room, and
*In the main corridor btween SC04.1 and SC-4.3.

These smoke detector locations were verified with staff who accompanied the surveyor on tour.
An interview was conducted with staff B2, on 03/12/13 at 4:00 PM, in regards to the type of smoke detectors used in the facility. Staff B2 verified these smoke detectors are not designed to be less than 36 inches from air flow devices.


21957

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During facility tour an observation was made of smoke detectors located near air flow devices at the following locations:

9th floor:
*Within the open use area by the north elevators of smoke compartment 9.9

8th floor:
*By room 8147 and 8430 of smoke compartment 8.10

7th floor:
By the double smoke barrier doors 7140 and by room 07365 of smoke compartment 7.11

6th floor:
*In the corridor by rooms 06420 and 06405 of smoke compartment 6.01

These findings were verified by all staff members present during tour of these areas.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patients, staff and visitors utilizing this facility. The patient census was 355 at the beginning of the survey.

During tour of floors 1, 2, 3, and 4 on 03/13/13, with staff E5, L9, and M10, observation revealed smoke detectors were located less than 36 inches from air flow devices at the following locations:

1st floor:

*In the main lobby atrium between the front doors and the finance office.
2nd floor:

*In Suite A (Administration) in room 0220,
*In the Power Plant in room in room 0206,
3rd floor:

*In the corridor by electrical supply room 0334.
4th floor:

*In the corridor by Elevator #18.
*In the pharmacy offices.
These smoke detector locations were verified with staff who accompanied the surveyor on tour. An interview was conducted with staff B2, on 03/12/13 at 4:00 PM, in regards to the type of smoke detectors used in the facility. Staff B2 verified these smoke detectors are not designed to be less than 36 inches from air flow devices.


21957

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7. During facility tour observation was made of smoke detectors located near air flow devices at the following locations:

15th floor:
*Within the library room 1509 of smoke compartment 15.5

14th floor:
*At the west smoke barrier doors of smoke compartment 14.3
*Within room 1400 of smoke compartment 14.3
*At the public lobby elevators and patient elevators of smoke compartment 14.03.
*At the south smoke barrier doors of smoke compartment 14.2

13th floor:
*At the south smoke barrier doors of smoke compartment 13.2
*At the north smoke barrier doors of smoke compartment 13.1
*Within the clean room 1300, soiled holding room 1301
*At the public lobby elevators and patient elevators of smoke compartment 13.03
*At the north smoke barrier doors of smoke compartment 13.4
*At the south smoke barrier doors of smoke compartment 13.5
*Within the V.I.P. room 1309 of smoke compartment 13.5

12th floor:
*At the public lobby elevators and patient elevators of smoke compartment 12.03
*In rooms 1265 and 1267 of smoke compartment 12.02
*In rooms 1208 and 1209 of smoke compartment 12.05

11th floor
*Within the waiting area of the heart and vascular area of smoke compartment 11.1
*At the public lobby elevators and patient elevators of smoke compartment 11.4
*Within the waiting area adjacent to break room 1139 of suite A.
*At the north smoke barrier doors of smoke compartment 11.7
*Within the V.I.P. room 1109 of smoke compartment 11.6
*Within rooms 1111 and 1112 of smoke compartment 11.6

10th floor:
*Within room 1089 of smoke compartment 10.3
*Within room 1038.6 and group room A of suite B in smoke compartment 10.2
*At the public lobby elevators and patient elevators of units A-E.

9th floor:
*By 0993 of smoke compartment 9.3
*By elevators 12 and 13 of smoke compartment 9.5
*In corridor by 0975.23A of smoke compartment 9.5
*In corridor west of storage room 912 and also in corridor northeast of storage room 912 of smoke compartment 9.04. Both smoke detectors are located adjacent to the one hour smoke barrier.
*Near stair C of and within operating rooms 3, 4 and 5 of smoke compartment 9.7.

8th floor:
*Within the corridor by 800.1A of smoke compartment 8.06
*Within the corridor by 864.11 of smoke compartment 8.05
*Within the corridor by 878 of smoke compartment 8.04
*Within storage room 0870.7 and 870.24A of smoke compartment 8.03
*Near the mechanical room entrance and the corridor adjacent to the mechanical room of smoke compartment 8.03
*Five smoke detectors near vents in suite A of smoke compartment 8.02
*Near 869.1 of smoke compartment 8.02

7th floor:
*Within rooms 0740 and 0741 of smoke compartment 7.09
*At the public lobby elevators and patient elevators of smoke compartment 7.08
*Within rooms 0774.28A, 0774.29, 0775.1, 0775.1A, 0779.8 and 0799 of smoke compartment 7.05
*Within the corridors near rooms 2307, 0799.69 and 0799.82 of smoke compartment 7.01
*Within the corridor by the elevators near the wound center and within the corridor near room 0799.209 of smoke compartment 7.02

6th floor:
*Within the operating room numbers 1 through 12 of smoke compartments 6.03 and 6.05
*Within the corridor adjacent to and south of the surgical waiting area and near the patient transport elevators of smoke compartment 6.04
*Within smoke compartment 6.06 near 0673.23, 0674.14, within the hybrid operating room across from the stairs and within control room 0673.1
*Within smoke compartment 6.11 near 0677.43, 0677.3, 0677.32, 0677.30 and within the corridor near 0676.12
*Within smoke compartment 6.09 and at the back side of an air conditioning unit near 0687.55
*Within suite B of smoke compartment 6.10 near rooms 0681.07 and 0681.15
*Two smoke detectors by ventilation devices within the corridor of smoke compartment 6.08
*Within smoke compartment 6.02 near 0617, bay 19 and 20 and operating rooms 17 and 18

5th floor:
*By level five north elevators and by elevators 12 and 13; by room 0550A of smoke compartment 5.4
*Within room by door 0555.19 of smoke compartment 5.1
*Within staff lounge 0551.24 and room 0551.40 and within the corridor by room 0551.36 of smoke compartment 5.3

Basement:
*Within the lobby area of transport elevators and within the corridor by doors 001.11
These findings were verified by all staff members present during tour of these areas.

Based on observations and staff interview, the facility failed to ensure smoke detectors were located at least 36 inches from an air supply. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility also failed to ensure one of one stairwell doors latched into the frame as required by the code at 38.2.1.1 and 7.2.1.8.2. This had the potential to affect all patients, staff and visitors utilizing the facility. The patient census was 355 at the beginning of the survey.

Findings include:

A tour was conducted in the facility on 03/14/13 between 10:00 AM and 11:10 AM with staff A1, F6, L9, V19, W20, and X21. Observations revealed the stairwell door, located by the front entrance, was equipped with a Class B (1 hour fire resistance rated door) which was non-latching. Although the door was in the closed position, the door did not latch. An interview with staff A1, during tour, verified this door is required to latch.

During this tour, one smoke detector located in the triage nursing area, was observed located approximately one foot away from an air supply diffuser. This was verified with the aforementioned staff on tour.

Based on observations, review of sprinkler inspection reports, and staff interviews, the facility failed to take action when issues were identified with the sprinkler system in accordance with the code at NFPA 25. 9.7.5 The facility also failed to ensure one exit discharge remained free from snow at 7.7, and failed to perform an annual ninety-minute battery test on emergency lighting as required by the code at 7.9.3. This could potentially affect all patients, staff, and visitors. The census on the first survey day was 355 patients.

Findings include:

A tour was conducted in the facility on 03/14/13 between 11:55 AM and 12:16 PM with staff L9, N11, O12, and P13. During this tour, the north exit discharge was observed with a snow covered exit ramp which was approximately 15-20 feet in length. Staff cautioned the surveyor to be careful as the ramp may be slick, when the surveyor stepped outside onto the ramp.

The facility was observed with battery back up emergency lighting throughout the facility. Interview with staff P13, and a review of testing records, revealed these lights are tested weekly; however, the testing records lacked information on how many seconds the test was conducted for each battery pack. This employee also verified there is no annual ninety-minute test currently in process for these lights.

During the tour, the facility was observed with an automatic sprinkler system throughout the space. A review of the previous two sprinkler inpsection reports, by an outside contractor, revealed the following concerns:

The 04/07/11 report stated water motor gong did not ring, had to close valve off to it, would not stop water coming through bell drain. P.I.V. (post indicator valve) is locked open and not supervised.

The 04/30/12 inspection report stated gauges over 5 years old, water motor gong does not work, alarm valve bypass leaks through and had to leave valve off, P.I.V is locked, tamper has been bent, not in working order.

At the conclusion of the review of these sprinkler inspection reports, the aforementioned staff revealed they were not aware of any followup to these concerns listed on the reports. After being questioned by the surveyor as to whether the sprinkler system was currently functional, Staff N11 revealed he/she would contact the outside service company to see if there had been any action taken in regard to these recommendations.

Interview with staff A1 (Director of Facilitity Services) on 03/14/13 at 3:00 PM revealed this employee was concerned regarding the lack of follow-up in the past two years for these identified problems. According to a letter, dated 03/15/13, from this contractor, the sprinkler system is functional and fully operational, and the items listed in the inspector's comment section will be followed up with and quotes will be provided if the facility approves the sprinkler company to proceed.