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Based on observation, interview, and review of schematics, the facility failed to ensure a fire door on sixth floor latched and the firewall on the fifth floor was free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the sixth floor was completed on 11/05/12 at 12:10 P.M. with Staff E5 and F6. The tour revealed a fire door to stairwell E. Observation of that door revealed it did not close completely because the latch did not work appropriately.
During the tour, Staff E5 confirmed the observation.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Review of the schematic and observation revealed a two-hour fire rated wall running north/south in front of a bank of elevators. Observation of the wall above the double doors in the fire rated wall revealed a sprinkler line with an annular space.
During the tour, Staff F6 confirmed the finding.

Based on observation, interview, and review of schematics, the facility failed to ensure doors within a fire wall had legible rating labels, closed properly, and failed to ensure the firewall was free of penetrations. This was observed on the seventh floor and in the firewall surrounding the generator room. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the eighth floor on 11/05/12 at 11:35 A.M. with Staff E5 and F6 revealed the area to be a penthouse containing a generator room. Review of the schematic of the penthouse completed on 11/05/12 revealed the generator room to be separated from the rest of the penthouse by a two-hour fire wall. The tour revealed the double doors in this wall that lead to the generator room did not have a fire rating.
During the tour of 11/05/12 at 11:35 A.M., Staff F6 looked above the door, said he/she saw a painted tag, and was unable to read what the tag said.
The observation of the double doors also revealed they did not close properly.
During the tour of 11/05/12 at 11:35 A.M., Staff E5 stated in an interview that the doors needed to have a coordinator.
Observation of the wall outside the generator room and above the double doors revealed a one inch conduit penetration to the wall.
During the tour of 11/05/12 at 11:35 A.M., Staff F6 also observed the penetration and agreed.
On 11/05/12 at 11:52 A.M. a tour of the seventh floor with Staff E5 and F6 revealed the fire door to stairwell D had a label that was painted over.
During the tour of the seventh floor Staff F6 observed the label, and was unable to say what it said the rating was.



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Based on observation during tour and staff verification it was determined this facility failed to ensure the two hour fire rated common wall between nonconforming buildings was constructed in a manner in which the two hour fire rating was not compromised. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 170.
Findings include:
Lower level:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the lower level common wall located between the main building and tunnel leading to the library, adjacent to stairwell D, observation was made above the doors and ceiling tiles of a four inch open end conduit and a one inch open end conduit with wires passing through.
At the common wall separating the main building from Dowling Hall, observation was made above the ceiling tiles at the far south double doors adjacent to room 0259, of an approximate one inch by two foot opening in an abandoned fire damper. Additionally, the double doors a few feet to the north was observed to not latch properly when disengaged from the door holding device.

First floor:
At the common wall separating the hyperbaric facility from the main building, observation was made above the south double doors of one open end conduit. Above the north double doors observation was made of four open end conduits and a few small holes in the drywall. To the left of the doors observation was made of steel I-beams that had not been sealed around the annular space.
The double doors located at the back side of cath lab room #1204 and near the gift shop, were observed to not have a fire resistance rating.

These findings were verified by staff members present during tour.

Based on observation, interview, and review of schematics, the facility failed to ensure the fire wall separating the sleeping patient area from the non-sleeping patient area was free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Review of the schematic and observation of the floor revealed the in-patient sleeping area to be separated from two, outpatient, non-sleeping areas. Observation of the wall separating the two areas revealed the following.
Over the double doors and above the drop down ceiling and next to room 1003 a hole was observed on the outpatient side of the wall.
Over the other set of double doors on the southern end of the corridor and above the drop down ceiling a two inch conduit was observed to be open to air on both sides of the fire wall.
Over the door at the southern end of corridor 1002 a one inch conduit was observed to have white wires running through it and be open to air and an I-beam was observed to have open air channels.
During the tour, Staff E5 and F6 confirmed the observations.

Based on observation and interview, the facility failed to ensure a vertical opening between the fifth and fourth floor, and a vertical opening between the third and fourth floor were enclosed with construction having a fire resistance rating of at least two hours. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. The tour revealed an electrical closet, #5111. Within the closet and to the right, a two inch floor conduit for wiring lacked fire stopping. Observation of the same conduit in the same area in the ceiling on the fourth floor also did not reveal any fire stopping material, i.e., the conduit was open between floors.
During the tour of the fifth floor, Staff E5 confirmed the finding.

Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. The tour revealed room #3143 used for information technology. Observation of the ceiling of the room revealed two three inch conduits opening into the room. The conduits were traced to open onto the space between the ceiling and the drop down ceiling on the fourth floor. There was no fire stopping observed in the conduit between the floors.
During the tour of the third floor, Staff F6 confirmed the observation.

Based on observation during tour and staff verification it was determined this facility failed to ensure the vertical openings were protected with at least a two hour fire rated enclosure. This was specific to the doors located in a stairwell and shaft room. This had the potential to affect all those who were utilizing these areas of the facility. The patient census at the beginning of the survey was 170.
Findings include:
Lower level:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the lower level, observation was made of the door to stairwell G not having a fire rating tag.
During tour of the first floor and specifically at room #1014MS located by the elevators by stairwell E, observation was made of the door to room #1014MS having a disabled self-closing device.

These findings were verified by staff members present during tour.

Based on observation, interview, review of schematics, and review of posted evacuation plans, the facility failed to ensure each path of egress had an exit sign. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. and corridor 1004 was observed to have two exit signs at either end. Review of the evacuation plan posted in the corridor revealed an additional path of egress down corridor 1006, which is perpendicular to corridor 1004.
An exit sign was not observed to direct people down this path of egress.
During the tour in an interview Staff E5 and F6 confirmed the observation.

Based on observation during tour and staff verification it was determined this facility failed to ensure the access to exits were marked by 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 those who were utilizing this area of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Lower level:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the lower level, observation was made from the elevators located between the lab and pharmacy, facing west down corridor 0018CR toward the boiler room, of no exit sign directing occupants around the corner to the exit access labeled as stairwell H.

These findings were verified by staff members present during tour.

Based on observation, interview, and review of schematics, the facility failed to ensure smoke barriers on the third, fourth, fifth, and sixth floor were free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the sixth floor was conducted on 11/05/12 at 12:10 P.M. with Staff E5 and F6. The tour revealed the floor to be separated into three smoke compartments with two smoke barriers: one between wing B and C, and one between wing C and D. Each smoke compartment contained sleeping patients. Observation of the smoke barrier that divides wing C and wing D revealed two penetrations above the south side of the double doors: a one inch conduit and a single wire.
During the tour of the sixth floor, Staff E5 verified the finding.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Observation and review of the schematic revealed the floor to be separated into three smoke compartments with two smoke barriers: one between wing B and C, and one between wing C and D. Each smoke compartment contained sleeping patients.
Observation of the wall above double doors in the smoke wall between wing C and D revealed a blue wire through a one inch open, unsealed conduit, located near the west side of the door.
Observation of the wall above the double doors in the smoke wall between wing B and C revealed a penetration by a two inch unsealed pipe containing blue wires.
During the tour Staff F6 confirmed the observations.
Tour of the fourth floor was conducted on 11/06/12 at 10:30 A.M. with Staff E5 and F6. Observation and review of the schematic revealed the floor to be separated into three smoke compartments with two smoke barriers: one between wing B and C, and one between wing C and D. Each smoke compartment contained sleeping patients.
Observation of the wall above the drop down ceiling over the north door in the smoke barrier that separated wing B and wing C, revealed a two inch conduit containing blue wires and no fire stopping. Other than the wires, it was left open to air.
During the tour, Staff F6 confirmed the observation.
Tour of the third floor was conducted on 11/06/12 at 11:35 A.M. with Staff E5 and F6. The tour revealed the floor to have sleeping patients and be divided into three smoke compartments. Observation of the wall above the drop drown ceiling over the double doors in the smoke barrier that ran across from room 3234 to 3239 revealed on the north side an open, one-inch conduit with red wiring, an open two inch conduit with blue wires, and an open one inch conduit with no wiring.
During the tour, Staff F6 confirmed the observation.
Observation of the same area revealed room 3234 to be a conference room that had unrated, approximately 12 inch by 18 inch windows in the smoke wall itself.
During the tour, Staff E5 confirmed this observation.

Based on observation, interview, and review of schematics, the facility failed to ensure the smoke barrier that divided the patient sleeping area was free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Review of the schematic and observation of the in-patient sleeping area revealed the sleeping area to be divided by a smoke barrier into two smoke compartments.
Observation of the smoke barrier separating room 1118 from room 1120 was made within room 1118. The observation revealed a hot water pipe with an annular space around it.
In an interview during the tour, Staff F6 confirmed the observation.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one-half hour fire resistance rating. This had the potential to affect all those who were utilizing these areas of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During facility tour observation was made of several penetrations in the smoke barriers above the ceiling tiles in the following locations:
Lower level:
*Above the smoke barrier doors at the back of room #0238, observation was made of a four inch unsealed conduit.
First floor:
*At the cath lab and above the door to room #1208, observation was made of a four inch open end conduit with blue wires passing through. Additionally, observation was made of a two inch conduit that was not completely sealed around the annular space.
*Above the door to room #1217, observation was made of one unsealed conduit with a red wire passing through.
*Above the east double doors at the main lobby and viewing from the south side, observation was made of an approximate one inch triangle opening in the drywall and a flex conduit that was not sealed around the annular space.
*Above the double doors to the heart and vascular department between room numbers 1179 and 1180, observation was made of one unsealed flex conduit penetrating the double layer drywall. Just west of these doors, observation was made of a four inch copper line and a cement support that was not sealed around the annular space.

Second floor:
*Observation was made of two unsealed conduits above the door to room # 2216.
*Double smoke barrier doors located between room # ' s 2217 and 2218 failed to close properly when disengaged from the hold open device.
*Above the double smoke barrier doors located adjacent to room # 2183 observation was made of one open end conduit with a red wire passing through and a two and a half inch unsealed silver conduit with blue wires passing through.
*Observation of the smoke barrier located between room # ' s 2166 and 2180 revealed an open end flex conduit and an open end solid conduit.
*Above the smoke barrier doors south of stairwell B observation was made of an open end silver conduit with red wires passing through.
*At the smoke barrier located between room # ' s 2012N and 2195S-1, observation was made of two open end conduits which were also not sealed around the annular space.

These findings were verified by staff members present during tour.

Based on observation, interview, and review of schematics, the facility failed to ensure all hazardous areas on the sixth, fifth, fourth, and third floor were enclosed with a one hour fire-rated barrier, and all hazardous areas on the sixth and fourth floors had three-quarter fire-rated doors. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the sixth floor was conducted on 11/05/12 at 12:10 P.M. with Staff E5 and F6. The tour revealed a soiled utility room, #6169, in wing D. Observation of the wall above the drop down ceiling revealed three openings: a two by two foot square in the east wall, two pipes with annular spaces on the west wall in the upper left corner, and a one by one foot square in the north wall.
The tour revealed a soiled laundry room in wing B, #6127. Observation of the room revealed its door unrated and a square opening in the east wall above the drop down ceiling.
During the tour of the sixth, Staff F6 observed the findings.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Observation of the floor revealed soiled utility room, #5169. Observation of the wall within the room, above the drop down ceiling, and near the door, revealed a penetration through the wall revealed a one inch steel conduit with an annular space around it.
During the tour, Staff F6 confirmed the observation during an interview.
Tour of the fourth floor was conducted on 11/06/12 at 10:30 A.M. with Staff E5 and F6. The tour revealed a soiled utility room in wing D, #4169. (Wing D contains sleeping patients.) Observation of the room revealed the door to be unrated, and the north wall above the drop down ceiling to be pierced with a white plumbing line having an annular space around it.
During the tour, Staff F6 confirmed the observation.
Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. During the tour a soiled utility room was observed in the D wing, #3169. Observation of the north wall above the drop down ceiling revealed two white pipes with annular spaces, and two air handling conduits with annular spaces.
The tour revealed a soiled utility room in wing A, #3119. Observation above drop down ceiling above the door revealed it to be insulated only, and the north wall to have a one inch conduit with a red wire out of it connecting to a smoke detector. The opening of the conduit was not sealed.
During the tour Staff F6 confirmed the observations

Based on observation during tour and staff verification it was determined this facility failed to ensure the hazardous area, specifically the lab, was constructed with at least three quarter hour fire rated doors. This had the potential to affect all those who were utilizing these areas of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the lab, observation was made of two sets of non-fire rated double doors located at the south end of the lab which also served as a portion of the smoke barrier.

These findings were verified by staff members present during tour.

Based on observation, interview, and review of schematics, the facility failed to ensure each path of egress had a paved pathway to a public area. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Review of the schematic and observation revealed the in-patient sleeping area to have a path of egress leading to an outside door in the southeast corner of the unit. Observation of the area outside of the door, and, hence, outside the building revealed the path of egress lead to a concrete pad. The concrete pad was observed to not be connected to a paved pathway to a public area.
In an interview during the tour, Staff E5 confirmed the observation.

Based on observation, interview, and review of schematics, the facility failed to ensure the width off all corridors serving as exit access on the third floor were at least eight feet in width. This has the potential to affect all patients, staff, and visitors on the third floor.
Findings include:
Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. During the tour, four cross-corridor, according style, unrated doors were observed in paths of egress. One was observed at the most south end of the main corridor. Behind this door were four patient sleeping rooms, rooms 3186 to 3189. The remaining three were in paths of egress within an intensive care unit. Behind one door were four patient sleeping rooms, rooms 3223 to 3229. Behind another were two sleeping patient rooms, rooms 3205 and 3207. The final one was observed to divide corridor 3016 from 3011. Corridor 3011 was observed to be in a path of egress leading from the intensive care unit to stairwell E.
Each of the doors was observed to be in the open position; however, the doors in their open position compressed the width of the corridor to six feet.
When the doors were observed in the their closed position, a red sticker on them read, " in case of emergency push to open. "
Staff E5 and F6 were observed to do this. They had difficulty pushing the doors open, taking several minutes to do so. Each door in the accordion had to be pushed out and then laterally toward the wall. The accordion door was not observed to push out as a single door in one smooth motion.
During the tour, Staff E5 and F6 confirmed the observations in an interview.

Based on observation, interview, and review of schematics, the facility failed to ensure all suites on the sixth, fifth, and third floor that were greater than 1,000 square feet in area had two remote exit access doors. This has the potential to affect all patients, staff, and visitors on the sixth, fifth, and third floors.
Findings include:
Tour of the sixth floor was conducted on 11/05/12 at 12:10 P.M. with Staff E5 and F6. Observation and review of the schematic revealed the south end of the floor to contain a suite of 1,400 square feet, containing space for sleeping patients, and one exit.
During the tour of the sixth floor, Staff E5 confirmed the finding.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Observation of the floor and review of the schematic revealed wing A and wing D to be suites. Review of the schematic revealed wing A to have 1800 square feet area and wing D to have 1435 square feet area.. Observation of both the suites did not reveal two remote exits.
During the tour of the fifth floor, Staff E5 confirmed the finding.
Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. Observation during the tour and review of the floor ' s schematic revealed a 1600 square foot suite in wing C. The suite contained sleeping patients. The suite was not observed to have more than one remote exit.
During the tour of the third floor, Staff E5 confirmed the finding.

Based on observation during tour, review of the floor plans and staff verification it was determined this facility failed to ensure suites of greater than 1000 sq. ft. had two exit accesses remotely located from each other. This had the potential to affect all those who were utilizing this area of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the second floor suite located adjacent to stairwell A observation was made of only one exit access from the suite. Review of the floor plans reveals this suite is approximately 1,800 sq. ft. and this finding was verified by staff members A1 and D4 on 11/06/12.

Based on observation during tour and staff verification it was determined this facility failed to ensure all sprinkler heads were continuously maintained in reliable operating condition. This had the potential to affect all those who were utilizing these areas of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the first and second floors observation was made of sprinkler heads which had dirt, dust and/or debris on them in the following locations:
First floor:
*Within room 1179 of the vascular ultrasound department.
*Within rooms 1302, 1285, 1276 and 1278 of the emergency department.
*Multiple dirty sprinkler heads were observed in the cafeteria area.

Second floor:
*Multiple dirty sprinkler heads located in the men's surgical locker room.

These findings were verified by staff members present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the medical gas storage rooms were protected with at least a one hour fire rated construction and all switches and receptacles were located at the proper distance from the floor. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 170.

Findings include:

Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the medical gas room number 0108 located in the lower level lab area, observation was made of an unrated door. This medical gas room had three H tanks of nitrogen, one H tank of argon and one small tank of argon.

During tour of the medical gas room number 136 located on the first floor adjacent to the hyperbaric room, observation was made of a light switch mounted less than five feet from the floor and a ventilation system that appeared to be tied into the hospital ventilation system due to the fact that it had a supply and return diffuser. This system was not able to be verified by this writer as a dedicated ventilation system as required.

These findings were verified by all staff present during tour. Staff A1 stated on 11/06/12 at approximately 11:15 AM that they will check to see if this ventilation system was a dedicated system. No verification was obtained by the end of the survey process.

Based on facility tour, staff interview, review of operating room relative humidity (RH) levels and verification it was determined this facility failed to ensure the relative humidity in all operating rooms was maintained to at least 35% or greater according to the National Fire Protection Association (NFPA) 99 Chapter 5.4.1.1. This had the potential to affect all those utilizing this area of the facility. The facility census was 170 at the beginning of the survey.
Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the operating rooms a question was proposed to staff A1 regarding how and what relative humidity levels are to be maintained. Staff A1 stated they are maintaining RH levels according to the ASHRAE standard which promotes 20-60% RH levels and not the NFPA standards which require a minimum of 35% RH levels in anesthetizing locations.
Documentation review of the operating room RH levels for 2012 took place on 11/07/12. It was noted that RH levels in every operating room was consistently below the required 35% level for the months of January through March. Also noted was RH levels sporadically below the required 35% in different operating rooms on varying months beyond March of 2012.
Additional documentation was provided on 11/08/12 regarding an incident in operating room # 8 on 05/16/12. This documentation revealed a reported fire during a procedure which was found to be initiated in an electrical unit for the operating table. Documentation revealed this to be smoke and not an active fire and in which no harm came to the patient or staff. Interview with staff E5 on 11/08/12 at approximately 1:15 PM reveals the unit was immediately removed and replaced and the procedure was completed without incident. This writer also reviewed the humidity level of operating room # 8 on the day of the incident 05/16/12, and was found to be documented at 25.4%, well below the required 35%. Interview with E5 on 11/08/12 at approximately 1:40 PM reveals the sensor for operating room # 8 had not been functioning correctly and felt the RH level was truly greater than what the sensor was reading. Further interview reveals this sensor had not functioned properly for at least two months prior to the incident and was not corrected until 09/16/12, four months after the incident.

These findings were verified by all staff present during interview and documentation review of operating room RH levels on 11/08/12.

LIFE SAFETY CODE 101, 2000 edition, 7.2.1.5.4: Doors shall be operable with not more than one releasing operation.
Based on observation and interview, the facility failed to ensure each door was operable with not more than one releasing operation, specifically the door on a seclusion room. This has the potential to affect any patient placed in the seclusion room.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Observation of the facility revealed a room 1113. The room was observed to have two locks. One was a sliding deadbolt, and the other was a locking latch. The sliding deadbolt was observed to have holes in its frame as well as in the bolt itself. Therefore, the bolt could be held in place with both a pin in a hole as well as when the bolt is latched.
During the tour, Staff Z1, a member of nursing administration, explained the room was used as a seclusion room. He/she explained a staff member is always outside the room when a patient is inside. He/she stated sometimes both the deadbolt and the locking latch are used.

LIFE SAFETY CODE 101, 2000 edition, 19.2.2.2.5: Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

Based on observation and interview, the facility failed to ensure each door located in the means of egress, as defined by LIFE SAFETY CODE 101, 2000 edition, 3.3.121, had one locking device, specifically the door on the seclusion room. This has the potential to affect any patient placed in the seclusion room.

Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Observation of the facility revealed a room 1113. The room was observed to have two locks. One was a sliding deadbolt, and the other was a locking latch.
During the tour, Staff Z1, a member of nursing administration, explained the room was used as a seclusion room. He/she explained a staff member is always outside the room when a patient is inside. He/she stated sometimes both the deadbolt and the locking latch are used.

Based on observation during tour and staff interview it was determined this facility failed to ensure temporary fire pull station devices and exit signs were posted in areas under construction for the safety of construction crews. This facility failed to ensure exits signs were temporarily modified to direct occupant flow to proper exit accesses when current exit accesses were temporarily not available due to construction according to the National Fire Protection Association (NFPA) 101 Chapters 20.2.10, 7.10, 4.6.10.1 and 4.6.10.2.
This facility failed to ensure the medical gas room was protected with construction having a fire resistance rating of at least one hour and that the light switch was located at least five feet from the floor according to NFPA 99 Chapter 4-3.1.1.2.
This facility failed to ensure the occupancy separation between the main hospital building and the building housing the ASC was separated with at least a one hour fire rated construction as required by NFPA 101 20.3.7.1.
This facility failed to ensure the smoke barrier separating the ASC into two smoke compartments was constructed with at least a one hour fire resistance rating according to NFPA 101 Chapter 20.3.7.3.
This facility failed to ensure all anesthetizing locations maintained a relative humidity (RH) reading of at 35% or greater in all operating rooms according to NFPA 99 5.4.1.1.
This had the potential to affect all occupants utilizing this facility. The patient census at the beginning of the survey was 170.
Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of level zero near the outpatient rehabilitation area, observation was made near elevators 0501 and 0502 of an exit sign displayed directing occupant flow to the stairwell near the elevators. When this writer approached the door to the stairwell observation was made of a sign posted on the door stating " First floor access closed. " No direction was posted as an alternative exit access for occupants.
Additionally, just outside of the outpatient rehabilitation department in the corridor and near room 0060, observation was made of an exit sign posted directing occupant flow toward an open staircase. Directly in front of the staircase another exit sign was posted directing occupant flow up the stairs. The staircase was observed to be closed off due to construction. Again, no direction was posted as an alternative exit access for occupants.
During tour of level one and specifically adjacent to the construction area, observation was made of temporary walls and partitions placed in such a manner as to provide access to occupants to and from the surgery center. It was also observed by this writer of construction persons and visitors utilizing these temporary means of egress. From within the construction area, observation was made by this writer that this construction area lacked any temporary exit signs and fire pull station devices in order to provide safety measures for the construction crew and occupants outside of the construction area.
The medical gas room # 1552 located on level one was observed to have a non-fire rated door and the light switch located within the room was mounted less than five feet from the floor. This room contained four H-tanks of carbon dioxide, five E-tanks of oxygen, two E-tanks of compressed air and one E-tank of nitrous oxide.
During tour of level one occupancy separation located in the northeast section of the building and within corridor 1001, observation was made above the ceiling tiles located above the double fire rated doors of three unsealed conduits and a bundle of unsealed wires passing through the three hour fire rated construction.
During tour of level one smoke barrier located within the ASC, observation was made of penetrations above the ceiling tiles and above the smoke barrier doors between room numbers 1517 and 1554. The penetrations consisted of one open end conduit, unsealed electrical junction box and two flex conduits passing through holes approximately one and a half inches round.
These findings were verified by staff members present during tour.
A phone call was placed by this writer to staff C3 on 11/14/12 at 11:57 AM regarding maintaining RH levels within the ASC operating rooms and if they were maintained by the same heating ventilation air conditioning units as those in the main hospital building. Staff C3 stated they probably were but would have staff E5 call in order to verify this. This writer also requested a faxed copy of the ASC operating room humidity level readings for the months of January, February and March of 2010. Staff C3 stated he/she would make sure to pass the message on to the right person.
At 2:00 PM this writer received a telephone call from staff A1 who verified the parameters of RH in the ASC operating rooms are the same as those in the main building which is 20% -60% RH although the systems are separate. A request was made from staff A1 for a faxed copy of the humidity reading from January through March of 2012. Staff A1 stated he/she will fax them as soon as he/she has them. At 3:15 PM staff A1 called again and asked if there was a problem with the RH in the ASC operating rooms and this writer explained it is possible if the RH is less than 35%. This writer then asked staff A1 if he/she had faxed the information yet and staff A1 replied, "no, I'm still waiting on the information."
By the end of the day at approximately 4:00 PM this writer received an email from Staff A1 stating: "We did not track the Outpatient Surgery rooms during these months the same that was presented for the Main ORs during your visit." A call was place to staff A1 at 4:00 PM and discussion took place about whether the RH levels could be obtained from January 2012 or not. Staff A1 stated not being sure and the call ended with the discussion of; if the reports from January through March are able to be obtained later, and they do reveal RH levels greater than 35%, they could include the reports as verification in their plan of correction.
No faxed information was available in order to verify this facility maintains the RH levels at 35% or greater in all of the ASC's operating rooms.

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 occupants utilizing these areas of the facility. The facility census was 170 at the beginning of the survey.

Findings include:

Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the first floor emergency department observation was made of smoke detectors located near air flow devices in room number 1253 and in the corridor just outside of room number 1254.
Tour of the radiology department finds a smoke detector located near an air flow device in room 1221A.
Tour of the corridor near the gift shop reveals a smoke detector located near an air flow device.
Tour of the second floor operating room suites reveals a smoke detector located near an air flow device across from room 2266.

These findings were verified by all staff present during tour.

Based on observation, interview, and review of schematics, the facility failed to ensure a fire door on sixth floor latched and the firewall on the fifth floor was free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the sixth floor was completed on 11/05/12 at 12:10 P.M. with Staff E5 and F6. The tour revealed a fire door to stairwell E. Observation of that door revealed it did not close completely because the latch did not work appropriately.
During the tour, Staff E5 confirmed the observation.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Review of the schematic and observation revealed a two-hour fire rated wall running north/south in front of a bank of elevators. Observation of the wall above the double doors in the fire rated wall revealed a sprinkler line with an annular space.
During the tour, Staff F6 confirmed the finding.

Based on observation, interview, and review of schematics, the facility failed to ensure doors within a fire wall had legible rating labels, closed properly, and failed to ensure the firewall was free of penetrations. This was observed on the seventh floor and in the firewall surrounding the generator room. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the eighth floor on 11/05/12 at 11:35 A.M. with Staff E5 and F6 revealed the area to be a penthouse containing a generator room. Review of the schematic of the penthouse completed on 11/05/12 revealed the generator room to be separated from the rest of the penthouse by a two-hour fire wall. The tour revealed the double doors in this wall that lead to the generator room did not have a fire rating.
During the tour of 11/05/12 at 11:35 A.M., Staff F6 looked above the door, said he/she saw a painted tag, and was unable to read what the tag said.
The observation of the double doors also revealed they did not close properly.
During the tour of 11/05/12 at 11:35 A.M., Staff E5 stated in an interview that the doors needed to have a coordinator.
Observation of the wall outside the generator room and above the double doors revealed a one inch conduit penetration to the wall.
During the tour of 11/05/12 at 11:35 A.M., Staff F6 also observed the penetration and agreed.
On 11/05/12 at 11:52 A.M. a tour of the seventh floor with Staff E5 and F6 revealed the fire door to stairwell D had a label that was painted over.
During the tour of the seventh floor Staff F6 observed the label, and was unable to say what it said the rating was.



21957


Based on observation during tour and staff verification it was determined this facility failed to ensure the two hour fire rated common wall between nonconforming buildings was constructed in a manner in which the two hour fire rating was not compromised. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 170.
Findings include:
Lower level:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the lower level common wall located between the main building and tunnel leading to the library, adjacent to stairwell D, observation was made above the doors and ceiling tiles of a four inch open end conduit and a one inch open end conduit with wires passing through.
At the common wall separating the main building from Dowling Hall, observation was made above the ceiling tiles at the far south double doors adjacent to room 0259, of an approximate one inch by two foot opening in an abandoned fire damper. Additionally, the double doors a few feet to the north was observed to not latch properly when disengaged from the door holding device.

First floor:
At the common wall separating the hyperbaric facility from the main building, observation was made above the south double doors of one open end conduit. Above the north double doors observation was made of four open end conduits and a few small holes in the drywall. To the left of the doors observation was made of steel I-beams that had not been sealed around the annular space.
The double doors located at the back side of cath lab room #1204 and near the gift shop, were observed to not have a fire resistance rating.

These findings were verified by staff members present during tour.

Based on observation, interview, and review of schematics, the facility failed to ensure the fire wall separating the sleeping patient area from the non-sleeping patient area was free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Review of the schematic and observation of the floor revealed the in-patient sleeping area to be separated from two, outpatient, non-sleeping areas. Observation of the wall separating the two areas revealed the following.
Over the double doors and above the drop down ceiling and next to room 1003 a hole was observed on the outpatient side of the wall.
Over the other set of double doors on the southern end of the corridor and above the drop down ceiling a two inch conduit was observed to be open to air on both sides of the fire wall.
Over the door at the southern end of corridor 1002 a one inch conduit was observed to have white wires running through it and be open to air and an I-beam was observed to have open air channels.
During the tour, Staff E5 and F6 confirmed the observations.

Based on observation and interview, the facility failed to ensure a vertical opening between the fifth and fourth floor, and a vertical opening between the third and fourth floor were enclosed with construction having a fire resistance rating of at least two hours. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. The tour revealed an electrical closet, #5111. Within the closet and to the right, a two inch floor conduit for wiring lacked fire stopping. Observation of the same conduit in the same area in the ceiling on the fourth floor also did not reveal any fire stopping material, i.e., the conduit was open between floors.
During the tour of the fifth floor, Staff E5 confirmed the finding.

Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. The tour revealed room #3143 used for information technology. Observation of the ceiling of the room revealed two three inch conduits opening into the room. The conduits were traced to open onto the space between the ceiling and the drop down ceiling on the fourth floor. There was no fire stopping observed in the conduit between the floors.
During the tour of the third floor, Staff F6 confirmed the observation.

Based on observation during tour and staff verification it was determined this facility failed to ensure the vertical openings were protected with at least a two hour fire rated enclosure. This was specific to the doors located in a stairwell and shaft room. This had the potential to affect all those who were utilizing these areas of the facility. The patient census at the beginning of the survey was 170.
Findings include:
Lower level:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the lower level, observation was made of the door to stairwell G not having a fire rating tag.
During tour of the first floor and specifically at room #1014MS located by the elevators by stairwell E, observation was made of the door to room #1014MS having a disabled self-closing device.

These findings were verified by staff members present during tour.

Based on observation, interview, review of schematics, and review of posted evacuation plans, the facility failed to ensure each path of egress had an exit sign. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. and corridor 1004 was observed to have two exit signs at either end. Review of the evacuation plan posted in the corridor revealed an additional path of egress down corridor 1006, which is perpendicular to corridor 1004.
An exit sign was not observed to direct people down this path of egress.
During the tour in an interview Staff E5 and F6 confirmed the observation.

Based on observation during tour and staff verification it was determined this facility failed to ensure the access to exits were marked by 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 those who were utilizing this area of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Lower level:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the lower level, observation was made from the elevators located between the lab and pharmacy, facing west down corridor 0018CR toward the boiler room, of no exit sign directing occupants around the corner to the exit access labeled as stairwell H.

These findings were verified by staff members present during tour.

Based on observation, interview, and review of schematics, the facility failed to ensure smoke barriers on the third, fourth, fifth, and sixth floor were free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the sixth floor was conducted on 11/05/12 at 12:10 P.M. with Staff E5 and F6. The tour revealed the floor to be separated into three smoke compartments with two smoke barriers: one between wing B and C, and one between wing C and D. Each smoke compartment contained sleeping patients. Observation of the smoke barrier that divides wing C and wing D revealed two penetrations above the south side of the double doors: a one inch conduit and a single wire.
During the tour of the sixth floor, Staff E5 verified the finding.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Observation and review of the schematic revealed the floor to be separated into three smoke compartments with two smoke barriers: one between wing B and C, and one between wing C and D. Each smoke compartment contained sleeping patients.
Observation of the wall above double doors in the smoke wall between wing C and D revealed a blue wire through a one inch open, unsealed conduit, located near the west side of the door.
Observation of the wall above the double doors in the smoke wall between wing B and C revealed a penetration by a two inch unsealed pipe containing blue wires.
During the tour Staff F6 confirmed the observations.
Tour of the fourth floor was conducted on 11/06/12 at 10:30 A.M. with Staff E5 and F6. Observation and review of the schematic revealed the floor to be separated into three smoke compartments with two smoke barriers: one between wing B and C, and one between wing C and D. Each smoke compartment contained sleeping patients.
Observation of the wall above the drop down ceiling over the north door in the smoke barrier that separated wing B and wing C, revealed a two inch conduit containing blue wires and no fire stopping. Other than the wires, it was left open to air.
During the tour, Staff F6 confirmed the observation.
Tour of the third floor was conducted on 11/06/12 at 11:35 A.M. with Staff E5 and F6. The tour revealed the floor to have sleeping patients and be divided into three smoke compartments. Observation of the wall above the drop drown ceiling over the double doors in the smoke barrier that ran across from room 3234 to 3239 revealed on the north side an open, one-inch conduit with red wiring, an open two inch conduit with blue wires, and an open one inch conduit with no wiring.
During the tour, Staff F6 confirmed the observation.
Observation of the same area revealed room 3234 to be a conference room that had unrated, approximately 12 inch by 18 inch windows in the smoke wall itself.
During the tour, Staff E5 confirmed this observation.

Based on observation, interview, and review of schematics, the facility failed to ensure the smoke barrier that divided the patient sleeping area was free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Review of the schematic and observation of the in-patient sleeping area revealed the sleeping area to be divided by a smoke barrier into two smoke compartments.
Observation of the smoke barrier separating room 1118 from room 1120 was made within room 1118. The observation revealed a hot water pipe with an annular space around it.
In an interview during the tour, Staff F6 confirmed the observation.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one-half hour fire resistance rating. This had the potential to affect all those who were utilizing these areas of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During facility tour observation was made of several penetrations in the smoke barriers above the ceiling tiles in the following locations:
Lower level:
*Above the smoke barrier doors at the back of room #0238, observation was made of a four inch unsealed conduit.
First floor:
*At the cath lab and above the door to room #1208, observation was made of a four inch open end conduit with blue wires passing through. Additionally, observation was made of a two inch conduit that was not completely sealed around the annular space.
*Above the door to room #1217, observation was made of one unsealed conduit with a red wire passing through.
*Above the east double doors at the main lobby and viewing from the south side, observation was made of an approximate one inch triangle opening in the drywall and a flex conduit that was not sealed around the annular space.
*Above the double doors to the heart and vascular department between room numbers 1179 and 1180, observation was made of one unsealed flex conduit penetrating the double layer drywall. Just west of these doors, observation was made of a four inch copper line and a cement support that was not sealed around the annular space.

Second floor:
*Observation was made of two unsealed conduits above the door to room # 2216.
*Double smoke barrier doors located between room # ' s 2217 and 2218 failed to close properly when disengaged from the hold open device.
*Above the double smoke barrier doors located adjacent to room # 2183 observation was made of one open end conduit with a red wire passing through and a two and a half inch unsealed silver conduit with blue wires passing through.
*Observation of the smoke barrier located between room # ' s 2166 and 2180 revealed an open end flex conduit and an open end solid conduit.
*Above the smoke barrier doors south of stairwell B observation was made of an open end silver conduit with red wires passing through.
*At the smoke barrier located between room # ' s 2012N and 2195S-1, observation was made of two open end conduits which were also not sealed around the annular space.

These findings were verified by staff members present during tour.

Based on observation, interview, and review of schematics, the facility failed to ensure all hazardous areas on the sixth, fifth, fourth, and third floor were enclosed with a one hour fire-rated barrier, and all hazardous areas on the sixth and fourth floors had three-quarter fire-rated doors. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the sixth floor was conducted on 11/05/12 at 12:10 P.M. with Staff E5 and F6. The tour revealed a soiled utility room, #6169, in wing D. Observation of the wall above the drop down ceiling revealed three openings: a two by two foot square in the east wall, two pipes with annular spaces on the west wall in the upper left corner, and a one by one foot square in the north wall.
The tour revealed a soiled laundry room in wing B, #6127. Observation of the room revealed its door unrated and a square opening in the east wall above the drop down ceiling.
During the tour of the sixth, Staff F6 observed the findings.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Observation of the floor revealed soiled utility room, #5169. Observation of the wall within the room, above the drop down ceiling, and near the door, revealed a penetration through the wall revealed a one inch steel conduit with an annular space around it.
During the tour, Staff F6 confirmed the observation during an interview.
Tour of the fourth floor was conducted on 11/06/12 at 10:30 A.M. with Staff E5 and F6. The tour revealed a soiled utility room in wing D, #4169. (Wing D contains sleeping patients.) Observation of the room revealed the door to be unrated, and the north wall above the drop down ceiling to be pierced with a white plumbing line having an annular space around it.
During the tour, Staff F6 confirmed the observation.
Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. During the tour a soiled utility room was observed in the D wing, #3169. Observation of the north wall above the drop down ceiling revealed two white pipes with annular spaces, and two air handling conduits with annular spaces.
The tour revealed a soiled utility room in wing A, #3119. Observation above drop down ceiling above the door revealed it to be insulated only, and the north wall to have a one inch conduit with a red wire out of it connecting to a smoke detector. The opening of the conduit was not sealed.
During the tour Staff F6 confirmed the observations

Based on observation during tour and staff verification it was determined this facility failed to ensure the hazardous area, specifically the lab, was constructed with at least three quarter hour fire rated doors. This had the potential to affect all those who were utilizing these areas of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the lab, observation was made of two sets of non-fire rated double doors located at the south end of the lab which also served as a portion of the smoke barrier.

These findings were verified by staff members present during tour.

Based on observation, interview, and review of schematics, the facility failed to ensure each path of egress had a paved pathway to a public area. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Review of the schematic and observation revealed the in-patient sleeping area to have a path of egress leading to an outside door in the southeast corner of the unit. Observation of the area outside of the door, and, hence, outside the building revealed the path of egress lead to a concrete pad. The concrete pad was observed to not be connected to a paved pathway to a public area.
In an interview during the tour, Staff E5 confirmed the observation.

Based on observation, interview, and review of schematics, the facility failed to ensure the width off all corridors serving as exit access on the third floor were at least eight feet in width. This has the potential to affect all patients, staff, and visitors on the third floor.
Findings include:
Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. During the tour, four cross-corridor, according style, unrated doors were observed in paths of egress. One was observed at the most south end of the main corridor. Behind this door were four patient sleeping rooms, rooms 3186 to 3189. The remaining three were in paths of egress within an intensive care unit. Behind one door were four patient sleeping rooms, rooms 3223 to 3229. Behind another were two sleeping patient rooms, rooms 3205 and 3207. The final one was observed to divide corridor 3016 from 3011. Corridor 3011 was observed to be in a path of egress leading from the intensive care unit to stairwell E.
Each of the doors was observed to be in the open position; however, the doors in their open position compressed the width of the corridor to six feet.
When the doors were observed in the their closed position, a red sticker on them read, " in case of emergency push to open. "
Staff E5 and F6 were observed to do this. They had difficulty pushing the doors open, taking several minutes to do so. Each door in the accordion had to be pushed out and then laterally toward the wall. The accordion door was not observed to push out as a single door in one smooth motion.
During the tour, Staff E5 and F6 confirmed the observations in an interview.

Based on observation, interview, and review of schematics, the facility failed to ensure all suites on the sixth, fifth, and third floor that were greater than 1,000 square feet in area had two remote exit access doors. This has the potential to affect all patients, staff, and visitors on the sixth, fifth, and third floors.
Findings include:
Tour of the sixth floor was conducted on 11/05/12 at 12:10 P.M. with Staff E5 and F6. Observation and review of the schematic revealed the south end of the floor to contain a suite of 1,400 square feet, containing space for sleeping patients, and one exit.
During the tour of the sixth floor, Staff E5 confirmed the finding.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Observation of the floor and review of the schematic revealed wing A and wing D to be suites. Review of the schematic revealed wing A to have 1800 square feet area and wing D to have 1435 square feet area.. Observation of both the suites did not reveal two remote exits.
During the tour of the fifth floor, Staff E5 confirmed the finding.
Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. Observation during the tour and review of the floor ' s schematic revealed a 1600 square foot suite in wing C. The suite contained sleeping patients. The suite was not observed to have more than one remote exit.
During the tour of the third floor, Staff E5 confirmed the finding.

Based on observation during tour, review of the floor plans and staff verification it was determined this facility failed to ensure suites of greater than 1000 sq. ft. had two exit accesses remotely located from each other. This had the potential to affect all those who were utilizing this area of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the second floor suite located adjacent to stairwell A observation was made of only one exit access from the suite. Review of the floor plans reveals this suite is approximately 1,800 sq. ft. and this finding was verified by staff members A1 and D4 on 11/06/12.

Based on observation during tour and staff verification it was determined this facility failed to ensure all sprinkler heads were continuously maintained in reliable operating condition. This had the potential to affect all those who were utilizing these areas of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the first and second floors observation was made of sprinkler heads which had dirt, dust and/or debris on them in the following locations:
First floor:
*Within room 1179 of the vascular ultrasound department.
*Within rooms 1302, 1285, 1276 and 1278 of the emergency department.
*Multiple dirty sprinkler heads were observed in the cafeteria area.

Second floor:
*Multiple dirty sprinkler heads located in the men's surgical locker room.

These findings were verified by staff members present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the medical gas storage rooms were protected with at least a one hour fire rated construction and all switches and receptacles were located at the proper distance from the floor. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 170.

Findings include:

Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the medical gas room number 0108 located in the lower level lab area, observation was made of an unrated door. This medical gas room had three H tanks of nitrogen, one H tank of argon and one small tank of argon.

During tour of the medical gas room number 136 located on the first floor adjacent to the hyperbaric room, observation was made of a light switch mounted less than five feet from the floor and a ventilation system that appeared to be tied into the hospital ventilation system due to the fact that it had a supply and return diffuser. This system was not able to be verified by this writer as a dedicated ventilation system as required.

These findings were verified by all staff present during tour. Staff A1 stated on 11/06/12 at approximately 11:15 AM that they will check to see if this ventilation system was a dedicated system. No verification was obtained by the end of the survey process.

Based on facility tour, staff interview, review of operating room relative humidity (RH) levels and verification it was determined this facility failed to ensure the relative humidity in all operating rooms was maintained to at least 35% or greater according to the National Fire Protection Association (NFPA) 99 Chapter 5.4.1.1. This had the potential to affect all those utilizing this area of the facility. The facility census was 170 at the beginning of the survey.
Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the operating rooms a question was proposed to staff A1 regarding how and what relative humidity levels are to be maintained. Staff A1 stated they are maintaining RH levels according to the ASHRAE standard which promotes 20-60% RH levels and not the NFPA standards which require a minimum of 35% RH levels in anesthetizing locations.
Documentation review of the operating room RH levels for 2012 took place on 11/07/12. It was noted that RH levels in every operating room was consistently below the required 35% level for the months of January through March. Also noted was RH levels sporadically below the required 35% in different operating rooms on varying months beyond March of 2012.
Additional documentation was provided on 11/08/12 regarding an incident in operating room # 8 on 05/16/12. This documentation revealed a reported fire during a procedure which was found to be initiated in an electrical unit for the operating table. Documentation revealed this to be smoke and not an active fire and in which no harm came to the patient or staff. Interview with staff E5 on 11/08/12 at approximately 1:15 PM reveals the unit was immediately removed and replaced and the procedure was completed without incident. This writer also reviewed the humidity level of operating room # 8 on the day of the incident 05/16/12, and was found to be documented at 25.4%, well below the required 35%. Interview with E5 on 11/08/12 at approximately 1:40 PM reveals the sensor for operating room # 8 had not been functioning correctly and felt the RH level was truly greater than what the sensor was reading. Further interview reveals this sensor had not functioned properly for at least two months prior to the incident and was not corrected until 09/16/12, four months after the incident.

These findings were verified by all staff present during interview and documentation review of operating room RH levels on 11/08/12.

LIFE SAFETY CODE 101, 2000 edition, 7.2.1.5.4: Doors shall be operable with not more than one releasing operation.
Based on observation and interview, the facility failed to ensure each door was operable with not more than one releasing operation, specifically the door on a seclusion room. This has the potential to affect any patient placed in the seclusion room.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Observation of the facility revealed a room 1113. The room was observed to have two locks. One was a sliding deadbolt, and the other was a locking latch. The sliding deadbolt was observed to have holes in its frame as well as in the bolt itself. Therefore, the bolt could be held in place with both a pin in a hole as well as when the bolt is latched.
During the tour, Staff Z1, a member of nursing administration, explained the room was used as a seclusion room. He/she explained a staff member is always outside the room when a patient is inside. He/she stated sometimes both the deadbolt and the locking latch are used.

LIFE SAFETY CODE 101, 2000 edition, 19.2.2.2.5: Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

Based on observation and interview, the facility failed to ensure each door located in the means of egress, as defined by LIFE SAFETY CODE 101, 2000 edition, 3.3.121, had one locking device, specifically the door on the seclusion room. This has the potential to affect any patient placed in the seclusion room.

Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Observation of the facility revealed a room 1113. The room was observed to have two locks. One was a sliding deadbolt, and the other was a locking latch.
During the tour, Staff Z1, a member of nursing administration, explained the room was used as a seclusion room. He/she explained a staff member is always outside the room when a patient is inside. He/she stated sometimes both the deadbolt and the locking latch are used.

Based on observation during tour and staff interview it was determined this facility failed to ensure temporary fire pull station devices and exit signs were posted in areas under construction for the safety of construction crews. This facility failed to ensure exits signs were temporarily modified to direct occupant flow to proper exit accesses when current exit accesses were temporarily not available due to construction according to the National Fire Protection Association (NFPA) 101 Chapters 20.2.10, 7.10, 4.6.10.1 and 4.6.10.2.
This facility failed to ensure the medical gas room was protected with construction having a fire resistance rating of at least one hour and that the light switch was located at least five feet from the floor according to NFPA 99 Chapter 4-3.1.1.2.
This facility failed to ensure the occupancy separation between the main hospital building and the building housing the ASC was separated with at least a one hour fire rated construction as required by NFPA 101 20.3.7.1.
This facility failed to ensure the smoke barrier separating the ASC into two smoke compartments was constructed with at least a one hour fire resistance rating according to NFPA 101 Chapter 20.3.7.3.
This facility failed to ensure all anesthetizing locations maintained a relative humidity (RH) reading of at 35% or greater in all operating rooms according to NFPA 99 5.4.1.1.
This had the potential to affect all occupants utilizing this facility. The patient census at the beginning of the survey was 170.
Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of level zero near the outpatient rehabilitation area, observation was made near elevators 0501 and 0502 of an exit sign displayed directing occupant flow to the stairwell near the elevators. When this writer approached the door to the stairwell observation was made of a sign posted on the door stating " First floor access closed. " No direction was posted as an alternative exit access for occupants.
Additionally, just outside of the outpatient rehabilitation department in the corridor and near room 0060, observation was made of an exit sign posted directing occupant flow toward an open staircase. Directly in front of the staircase another exit sign was posted directing occupant flow up the stairs. The staircase was observed to be closed off due to construction. Again, no direction was posted as an alternative exit access for occupants.
During tour of level one and specifically adjacent to the construction area, observation was made of temporary walls and partitions placed in such a manner as to provide access to occupants to and from the surgery center. It was also observed by this writer of construction persons and visitors utilizing these temporary means of egress. From within the construction area, observation was made by this writer that this construction area lacked any temporary exit signs and fire pull station devices in order to provide safety measures for the construction crew and occupants outside of the construction area.
The medical gas room # 1552 located on level one was observed to have a non-fire rated door and the light switch located within the room was mounted less than five feet from the floor. This room contained four H-tanks of carbon dioxide, five E-tanks of oxygen, two E-tanks of compressed air and one E-tank of nitrous oxide.
During tour of level one occupancy separation located in the northeast section of the building and within corridor 1001, observation was made above the ceiling tiles located above the double fire rated doors of three unsealed conduits and a bundle of unsealed wires passing through the three hour fire rated construction.
During tour of level one smoke barrier located within the ASC, observation was made of penetrations above the ceiling tiles and above the smoke barrier doors between room numbers 1517 and 1554. The penetrations consisted of one open end conduit, unsealed electrical junction box and two flex conduits passing through holes approximately one and a half inches round.
These findings were verified by staff members present during tour.
A phone call was placed by this writer to staff C3 on 11/14/12 at 11:57 AM regarding maintaining RH levels within the ASC operating rooms and if they were maintained by the same heating ventilation air conditioning units as those in the main hospital building. Staff C3 stated they probably were but would have staff E5 call in order to verify this. This writer also requested a faxed copy of the ASC operating room humidity level readings for the months of January, February and March of 2010. Staff C3 stated he/she would make sure to pass the message on to the right person.
At 2:00 PM this writer received a telephone call from staff A1 who verified the parameters of RH in the ASC operating rooms are the same as those in the main building which is 20% -60% RH although the systems are separate. A request was made from staff A1 for a faxed copy of the humidity reading from January through March of 2012. Staff A1 stated he/she will fax them as soon as he/she has them. At 3:15 PM staff A1 called again and asked if there was a problem with the RH in the ASC operating rooms and this writer explained it is possible if the RH is less than 35%. This writer then asked staff A1 if he/she had faxed the information yet and staff A1 replied, "no, I'm still waiting on the information."
By the end of the day at approximately 4:00 PM this writer received an email from Staff A1 stating: "We did not track the Outpatient Surgery rooms during these months the same that was presented for the Main ORs during your visit." A call was place to staff A1 at 4:00 PM and discussion took place about whether the RH levels could be obtained from January 2012 or not. Staff A1 stated not being sure and the call ended with the discussion of; if the reports from January through March are able to be obtained later, and they do reveal RH levels greater than 35%, they could include the reports as verification in their plan of correction.
No faxed information was available in order to verify this facility maintains the RH levels at 35% or greater in all of the ASC's operating rooms.

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 occupants utilizing these areas of the facility. The facility census was 170 at the beginning of the survey.

Findings include:

Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the first floor emergency department observation was made of smoke detectors located near air flow devices in room number 1253 and in the corridor just outside of room number 1254.
Tour of the radiology department finds a smoke detector located near an air flow device in room 1221A.
Tour of the corridor near the gift shop reveals a smoke detector located near an air flow device.
Tour of the second floor operating room suites reveals a smoke detector located near an air flow device across from room 2266.

These findings were verified by all staff present during tour.