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The facility did not ensure that the interior finish for corridors and exit ways, including exposed interior surfaces of buildings such as fixed or moveable walls, partitions, columns, and ceilings had a flame spread rating of Class A or Class B as required by the referenced LSC standard.

On 10/09/12 at 10:00 AM the surveyor, accompanied by the Facility Fire Marshal, observed that the ceiling of Bliss #2 emergency egress stairwell ceiling has rigid foam insulation installed on the ceiling of the stairwell; i.e. facility staff did not produce documentation to indicate that the rigid insulation meets that referenced LSC standard for flame spread.

The facility did not ensure that the interior finish for rooms and spaces not used for corridors or exit ways, including exposed interior surface of buildings such as fixed or movable walls, partitions, columns, and ceilings had a flame spread rating of (select the proper flame spread rating depending upon use of either Existing or New, i.e. Class A or Class B or less/Class A or
less) as required by the referenced LSC.

On 10/12/12 at 11:00 AM the surveyor, accompanied by the Facility Fire Marshal, observed that within Room # B106 telecommunications equipment had been installed to a sheet of MDF sheathing that was affixed to the interior wall of the room; i.e. Facility staff did not produce documentation to indicate that the MDF sheathing meets that referenced LSC standard for flame spread.

The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch sold-bonded core wood, capable of resisting the passage of smoke.

On 10/09/12 at 1:10 PM and at various times throughout the day the surveyor, accompanied by the Facility Fire Marshal, observed that Bliss patient room door # 1183 and patient room door # 927 was damaged to the core; i.e. doors will not resist the passage of smoke.

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the LSC.

On 10/10/12 at 10:45 AM, the surveyor, while accompanied by the Director of Engineering & Facilities Development, observed that the recently installed, metallic, heating pipe running from Conklin basement into the Cardiac Rehab space in Conklin 1 was not sealed or protected with materials having at least a 1-hr fire resistance rating i.e. floor was core-bored during renovations and annual space around copper pipe stuffed with insulation only.

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 10/11/12 at 11:45 AM, the surveyor was provided with documentation from the Director of Engineering & Facilities Development to indicate that a fire drill was conducted in the 4th quarter of 2011 at the West Hartford (Blueback Square) satellite; i.e. documentation provided from the Dec. 2011 report indicates fire alarm not activated during this " tabletop " drill as required by the Life Safety Code.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

a. On 10/09/12 at 10:50 AM the surveyor, accompanied by the Facility Fire Marshal, observed that the fire sprinkler within Room # B-11B2 is not installed as required by section# 5-1.1 of NFPA 13, " Standard for the Installation of Sprinkler Systems "i.e: fire sprinkler head is installed in excess of three (3) feet below the deck above;

b. On 10/11/12 at 11:40 AM, the surveyor while accompanied by the Facility Fire Marshal observed that the gauges on the fire sprinkler system within the sprinkler test cabinet across from patient room C2047 are in excess of five (5) years old and not calibrated or replaced as required by NFPA 25, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems ";

c. On 10/10/12 at 9:35 AM, the surveyor, while accompanied by the Director of Engineering & Facilities Development, observed that the 3 (three), walk-in, refrigerators/freezers located in the Dietary Department (kitchen) at High Building-1st floor were not provided with sprinkler coverage as required by section# 5-1 of NFPA 13, " Standard for the Installation of Sprinkler Systems "i.e: fire sprinkler heads not installed in older coolers in kitchen;

d. On 10/09/12 at 10:25 AM, the surveyor, while accompanied by the Director of Engineering & Facilities Development, observed that recalled, Omega-model, sprinkler heads were in use at the facility and not removed as required by NFPA 13, " Standard for the Installation of Sprinkler Systems " and NFPA 25, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems "i.e: missing ascuteon in Perfusion Work Room-High Bldg.-room 439 reveals a sprinkler head that was recalled by its manufacturer and was to be previously replaced.

The facility did not ensure that linen and trash chutes, incinerators and trash collection rooms were protected as required by the referenced LSC.

On 10/10/12 at 12:20 PM the surveyor, accompanied by the Facility Director, observed that the trash chute door failed to close and latch properly after it was released in order to provide the proper vertical fire and smoke protection between floors as required by the referenced LSC standard. at the West Hartford Ambulatory Surgical Center

The facility did not ensure that means of egress is continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits.

1. On 10/11/12 at 11:20 AM the surveyor, accompanied by facility staff, observed furniture stored within the South egress corridors on the third (3rd) and fourth (4th) floor of the Brownstone building.

2. On 10/10/12 at 09:50 AM at the Newington Eye Surgery Center the surveyor, accompanied by the administrator, observed deadbolt locks installed on the rear emergency egress doors, not meeting the referenced LSC standard i.e.: emergency egress doors cannot be opened in a required single motion.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 10/09, 10/10 and 10/11 2012 the surveyors, while accompanied by the Director of Engineering & Facilities Development, Facility Fire Marshal and other Hartford Hospital staff observed that throughout the Core, Bliss, High and South Buildings soiled linen and trash collection receptacles that had capacity greater than 32 gallons that were placed in lobbies, back corridors, and egress corridors i.e. receptacles used for soiled linen, recycled containers and trash with capacities greater than 32 gallons not being stored in rooms protected as hazardous areas as required by section # 19.7.5.5 of the Life Safety Code

The facility did not ensure that piped in medical gas systems are in compliance with sections 4.1, 4.1.1 NFPA 99 " Health Care Facility ' s " , and NFPA 70, " National Electrical Code " .

On 10/11/12 at 11:35 AM, the surveyor was provided with documentation from the Director of Engineering to indicate that the control panel for the medical vacuum system located on Bliss 12th floor had been repaired or serviced after being identified on the Grainger Medical inspection report of 02/01/12 as requiring service; i.e. engineering staff not aware of deficiency and discovered it as not repaired after document review portion of survey.

The facility did not ensure that penetrations of smoke barriers by ducts are protected in accordance with LSC 8.3.5.

On 10/11/12 at 11:30 AM, the surveyor was not provided with documentation from the Director of Engineering & Facilities Development to indicate that the smoke dampers throughout the facility were inspected at least annually, as required by NFPA 72, " National Fire Alarm & Signal Code " , Table # 7-3.2; i.e. J Glaski report of 2011 indicates smoke dampers not inspected since 2009.

1. The facility did not ensure that patient care electrical devices in-patient areas were being inspected as required in NFPA 99 "Health Care Facilities" and the Hospital's Department of Biomedical Engineering Medical Equipment Management Plan.


a. On 11/09/12 at 12:30 PM, the surveyor was not provided with documentation by the RN # 17 Donnelly Three (3) North Nurse Manager and the Biomedical Engineering Project Manager, to indicate that the rental equipment, within Donnelly Three (3) Patient Room #8; i.e., adjustable electric bariatric bed with companion air pump for alternating air pressure bariatric mattress, and the electric bariatric chair that was ordered and or received by the Nursing Department on or before 08/31/12 had been tested and inspected before use as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2.; and as part of the Hospital's Department of Biomedical Engineering Medical Equipment Management Plan.

b. On 11/09/12 at 12:32 PM, the surveyor was not provided with documentation by the Donnelly Three (3) North Nurse Manager and the Biomedical Engineering Project Manager, to indicate that patient owned respiratory equipment within Donnelly Three (3) Patient Room #8 had been tested and inspected before use as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2.; and as part of the Hospital ' s Department of Biomedical Engineering Medical Equipment Management Plan.




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2. The facility did not ensure that patient care electrical devices in-patient areas were being inspected as required in NFPA 99 "Health Care Facilities" and the Hospital's Department of Biomedical Engineering Medical Equipment Management Plan

a. On 11/09/12 at 12:30 PM, the surveyor was not provided with documentation by the RN # 17 Donnelly Three (3) North Nurse Manager and the Biomedical Engineering Project Manager, to indicate that the rental equipment, within Donnelly Three (3) Patient Room #8; i.e., adjustable electric bariatric bed with companion air pump for alternating air pressure bariatric mattress, and the electric bariatric chair that was ordered and or received by the Nursing Department on or before 08/31/12 had been tested and inspected before use as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2.; and as part of the Hospital's Department of Biomedical Engineering Medical Equipment Management Plan;

b. On 11/09/12 at 12:32 PM, the surveyor was not provided with documentation by the Donnelly Three (3) North Nurse Manager and the Biomedical Engineering Project Manager, to indicate that patient owned respiratory equipment within Donnelly Three (3) Patient Room #8 had been tested and inspected before use as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2.; and as part of the Hospital ' s Department of Biomedical Engineering Medical Equipment Management Plan.

1. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99, " Health Care Facility ' s "

On 10/11/12 at 12:00 PM, the surveyor was provided with documentation from the Director of Engineering to indicate that the electrical receptacle outlets in patient areas at the Newington (eye center) satellite, the West Hartford (Blueback) satellite or the Dialysis Unit (Center 11, suite 1149) are inspected annually as required by sections 3-3.3.3 & 3-3.4.2.3 of NFPA 99, " Health Care Facility ' s " and as part of the facility ' s preventive maintenance program; i.e. document review revealed no annual, receptacle testing in these patient care areas

2. The facility did not ensure that construction, repair, and improvement operations were in compliance with section # 19.7.9 of the referenced, Life Safety Code

On 10/10/12 at 1:30 PM the surveyor, while accompanied by the Facility Fire Marshal, observed that the barrier between the renovation work and the occupied areas on Bliss 6 (Epilepsy Unit project) was not adequate and did not comply with NFPA 241, " Standard for Safeguarding Construction, Alteration, and Demolition Operations "; i.e. safeguards that were required as part of departmental, project approval and facility policies not being followed.

The facility did not ensure that electrical wiring and equipment is in accordance with NFPA 70, " National Electrical Code " .

On 10/10/12 at 10:40 AM, the surveyor, while accompanied by the Director of Engineering & Facilities Development, observed that 4 (four) of the 6 (six) electric, treadmills used in the Cardiac Rehab Department in Conklin Building-1st floor were provided with extension cords; i.e. large label on appliance power cord indicated DO NOT USE EXTENSION CORD.

The facility did not ensure that the interior finish for corridors and exit ways, including exposed interior surfaces of buildings such as fixed or moveable walls, partitions, columns, and ceilings had a flame spread rating of Class A or Class B as required by the referenced LSC standard.

On 10/09/12 at 10:00 AM the surveyor, accompanied by the Facility Fire Marshal, observed that the ceiling of Bliss #2 emergency egress stairwell ceiling has rigid foam insulation installed on the ceiling of the stairwell; i.e. facility staff did not produce documentation to indicate that the rigid insulation meets that referenced LSC standard for flame spread.

The facility did not ensure that the interior finish for rooms and spaces not used for corridors or exit ways, including exposed interior surface of buildings such as fixed or movable walls, partitions, columns, and ceilings had a flame spread rating of (select the proper flame spread rating depending upon use of either Existing or New, i.e. Class A or Class B or less/Class A or
less) as required by the referenced LSC.

On 10/12/12 at 11:00 AM the surveyor, accompanied by the Facility Fire Marshal, observed that within Room # B106 telecommunications equipment had been installed to a sheet of MDF sheathing that was affixed to the interior wall of the room; i.e. Facility staff did not produce documentation to indicate that the MDF sheathing meets that referenced LSC standard for flame spread.

The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch sold-bonded core wood, capable of resisting the passage of smoke.

On 10/09/12 at 1:10 PM and at various times throughout the day the surveyor, accompanied by the Facility Fire Marshal, observed that Bliss patient room door # 1183 and patient room door # 927 was damaged to the core; i.e. doors will not resist the passage of smoke.

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the LSC.

On 10/10/12 at 10:45 AM, the surveyor, while accompanied by the Director of Engineering & Facilities Development, observed that the recently installed, metallic, heating pipe running from Conklin basement into the Cardiac Rehab space in Conklin 1 was not sealed or protected with materials having at least a 1-hr fire resistance rating i.e. floor was core-bored during renovations and annual space around copper pipe stuffed with insulation only.

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 10/11/12 at 11:45 AM, the surveyor was provided with documentation from the Director of Engineering & Facilities Development to indicate that a fire drill was conducted in the 4th quarter of 2011 at the West Hartford (Blueback Square) satellite; i.e. documentation provided from the Dec. 2011 report indicates fire alarm not activated during this " tabletop " drill as required by the Life Safety Code.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

a. On 10/09/12 at 10:50 AM the surveyor, accompanied by the Facility Fire Marshal, observed that the fire sprinkler within Room # B-11B2 is not installed as required by section# 5-1.1 of NFPA 13, " Standard for the Installation of Sprinkler Systems "i.e: fire sprinkler head is installed in excess of three (3) feet below the deck above;

b. On 10/11/12 at 11:40 AM, the surveyor while accompanied by the Facility Fire Marshal observed that the gauges on the fire sprinkler system within the sprinkler test cabinet across from patient room C2047 are in excess of five (5) years old and not calibrated or replaced as required by NFPA 25, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems ";

c. On 10/10/12 at 9:35 AM, the surveyor, while accompanied by the Director of Engineering & Facilities Development, observed that the 3 (three), walk-in, refrigerators/freezers located in the Dietary Department (kitchen) at High Building-1st floor were not provided with sprinkler coverage as required by section# 5-1 of NFPA 13, " Standard for the Installation of Sprinkler Systems "i.e: fire sprinkler heads not installed in older coolers in kitchen;

d. On 10/09/12 at 10:25 AM, the surveyor, while accompanied by the Director of Engineering & Facilities Development, observed that recalled, Omega-model, sprinkler heads were in use at the facility and not removed as required by NFPA 13, " Standard for the Installation of Sprinkler Systems " and NFPA 25, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems "i.e: missing ascuteon in Perfusion Work Room-High Bldg.-room 439 reveals a sprinkler head that was recalled by its manufacturer and was to be previously replaced.

The facility did not ensure that linen and trash chutes, incinerators and trash collection rooms were protected as required by the referenced LSC.

On 10/10/12 at 12:20 PM the surveyor, accompanied by the Facility Director, observed that the trash chute door failed to close and latch properly after it was released in order to provide the proper vertical fire and smoke protection between floors as required by the referenced LSC standard. at the West Hartford Ambulatory Surgical Center

The facility did not ensure that means of egress is continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits.

1. On 10/11/12 at 11:20 AM the surveyor, accompanied by facility staff, observed furniture stored within the South egress corridors on the third (3rd) and fourth (4th) floor of the Brownstone building.

2. On 10/10/12 at 09:50 AM at the Newington Eye Surgery Center the surveyor, accompanied by the administrator, observed deadbolt locks installed on the rear emergency egress doors, not meeting the referenced LSC standard i.e.: emergency egress doors cannot be opened in a required single motion.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 10/09, 10/10 and 10/11 2012 the surveyors, while accompanied by the Director of Engineering & Facilities Development, Facility Fire Marshal and other Hartford Hospital staff observed that throughout the Core, Bliss, High and South Buildings soiled linen and trash collection receptacles that had capacity greater than 32 gallons that were placed in lobbies, back corridors, and egress corridors i.e. receptacles used for soiled linen, recycled containers and trash with capacities greater than 32 gallons not being stored in rooms protected as hazardous areas as required by section # 19.7.5.5 of the Life Safety Code

The facility did not ensure that piped in medical gas systems are in compliance with sections 4.1, 4.1.1 NFPA 99 " Health Care Facility ' s " , and NFPA 70, " National Electrical Code " .

On 10/11/12 at 11:35 AM, the surveyor was provided with documentation from the Director of Engineering to indicate that the control panel for the medical vacuum system located on Bliss 12th floor had been repaired or serviced after being identified on the Grainger Medical inspection report of 02/01/12 as requiring service; i.e. engineering staff not aware of deficiency and discovered it as not repaired after document review portion of survey.

The facility did not ensure that penetrations of smoke barriers by ducts are protected in accordance with LSC 8.3.5.

On 10/11/12 at 11:30 AM, the surveyor was not provided with documentation from the Director of Engineering & Facilities Development to indicate that the smoke dampers throughout the facility were inspected at least annually, as required by NFPA 72, " National Fire Alarm & Signal Code " , Table # 7-3.2; i.e. J Glaski report of 2011 indicates smoke dampers not inspected since 2009.

1. The facility did not ensure that patient care electrical devices in-patient areas were being inspected as required in NFPA 99 "Health Care Facilities" and the Hospital's Department of Biomedical Engineering Medical Equipment Management Plan.


a. On 11/09/12 at 12:30 PM, the surveyor was not provided with documentation by the RN # 17 Donnelly Three (3) North Nurse Manager and the Biomedical Engineering Project Manager, to indicate that the rental equipment, within Donnelly Three (3) Patient Room #8; i.e., adjustable electric bariatric bed with companion air pump for alternating air pressure bariatric mattress, and the electric bariatric chair that was ordered and or received by the Nursing Department on or before 08/31/12 had been tested and inspected before use as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2.; and as part of the Hospital's Department of Biomedical Engineering Medical Equipment Management Plan.

b. On 11/09/12 at 12:32 PM, the surveyor was not provided with documentation by the Donnelly Three (3) North Nurse Manager and the Biomedical Engineering Project Manager, to indicate that patient owned respiratory equipment within Donnelly Three (3) Patient Room #8 had been tested and inspected before use as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2.; and as part of the Hospital ' s Department of Biomedical Engineering Medical Equipment Management Plan.




27293


2. The facility did not ensure that patient care electrical devices in-patient areas were being inspected as required in NFPA 99 "Health Care Facilities" and the Hospital's Department of Biomedical Engineering Medical Equipment Management Plan

a. On 11/09/12 at 12:30 PM, the surveyor was not provided with documentation by the RN # 17 Donnelly Three (3) North Nurse Manager and the Biomedical Engineering Project Manager, to indicate that the rental equipment, within Donnelly Three (3) Patient Room #8; i.e., adjustable electric bariatric bed with companion air pump for alternating air pressure bariatric mattress, and the electric bariatric chair that was ordered and or received by the Nursing Department on or before 08/31/12 had been tested and inspected before use as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2.; and as part of the Hospital's Department of Biomedical Engineering Medical Equipment Management Plan;

b. On 11/09/12 at 12:32 PM, the surveyor was not provided with documentation by the Donnelly Three (3) North Nurse Manager and the Biomedical Engineering Project Manager, to indicate that patient owned respiratory equipment within Donnelly Three (3) Patient Room #8 had been tested and inspected before use as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2.; and as part of the Hospital ' s Department of Biomedical Engineering Medical Equipment Management Plan.

1. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99, " Health Care Facility ' s "

On 10/11/12 at 12:00 PM, the surveyor was provided with documentation from the Director of Engineering to indicate that the electrical receptacle outlets in patient areas at the Newington (eye center) satellite, the West Hartford (Blueback) satellite or the Dialysis Unit (Center 11, suite 1149) are inspected annually as required by sections 3-3.3.3 & 3-3.4.2.3 of NFPA 99, " Health Care Facility ' s " and as part of the facility ' s preventive maintenance program; i.e. document review revealed no annual, receptacle testing in these patient care areas

2. The facility did not ensure that construction, repair, and improvement operations were in compliance with section # 19.7.9 of the referenced, Life Safety Code

On 10/10/12 at 1:30 PM the surveyor, while accompanied by the Facility Fire Marshal, observed that the barrier between the renovation work and the occupied areas on Bliss 6 (Epilepsy Unit project) was not adequate and did not comply with NFPA 241, " Standard for Safeguarding Construction, Alteration, and Demolition Operations "; i.e. safeguards that were required as part of departmental, project approval and facility policies not being followed.

The facility did not ensure that electrical wiring and equipment is in accordance with NFPA 70, " National Electrical Code " .

On 10/10/12 at 10:40 AM, the surveyor, while accompanied by the Director of Engineering & Facilities Development, observed that 4 (four) of the 6 (six) electric, treadmills used in the Cardiac Rehab Department in Conklin Building-1st floor were provided with extension cords; i.e. large label on appliance power cord indicated DO NOT USE EXTENSION CORD.