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Based on observations, record review, and confirmed by staff, the facility failed to assure corridor walls are maintained as required.

THE FINDINGS INCLUDE:

On the morning of April 6, 2010, during record review and building tour, it was noted that corridor walls above the in-lay ceiling tiles have unsealed penetrations in the gypsum wallboard (GWB) throughout the facility. These holes are to abundant to note individually as they were noted on each floor surveyed in various locations. Using the Hospital Plan for Improvement report, a sample check was conducted to verifier the Plan for Improvement report. Automatic sprinkler protection is not fully provided thought out the Hospital.

This was confirmed and identified as a plan for improvement item by the facility's Director of Engineering.

Based on observations and confirmed by staff, corridor walls are not constructed as required. Section 19.3.6.2.3 states fixed fire window assemblies in accordance with 8.2.3.2.2 shall be permitted in corridor walls. Section 8.2.3.2.2 states fire window assemblies shall be permitted in fire barriers having a required fire resistance rating of 1 hour or less and shall be of an approved type with the appropriate fire protection rating for the location in which they are installed.

THE FINDINGS INCLUDE:

1) During the morning hours of April 6, 2010, while touring the North building, it was noted that plain glass vision panels are used in corridor walls and doors to the Radiology Suite in the North Building. The corridor walls to the room (two areas approximately 6 feet each) are constructed of plain glass. The smoke compartment in which this suite is located is not equipped with a complete automatic sprinkler system.

2) During the morning hours of April 6, 2010, while touring the Main building, it was noted that plain glass vision panels are used in the corridor wall to the Cashier Office. The cashier office has a unrated glass window in the corridor wall. The smoke compartment in which this office is located is not equipped with a complete automatic sprinkler system.

3) During the morning hours of April 5, 2010, while touring the Main building, it was noted that plain glass vision panels are used in the door to room 1004. The smoke compartment in which this door is located is not equipped with a complete automatic sprinkler system.

This was acknowledged by the Director of Engineering.

Based on observations and confirmed by staff, the facility failed to assure that all smoke compartments are designed as required and meet the proper size limitations.

THE FINDINGS INCLUDE:

- On the morning of April 6, 2010, after review facility floor plan and touring the facility it was noted that the first floor in the Main building and the Fowler building exceeded the maximum size for a single smoke compartment. The combined area is 35,780 square feet in size.

This was acknowledged by the Director of Engineering.

Based on observations and confirmed by staff, the hospital failed to assure that hazardous area's are separated as required.

THE FINDINGS INCLUDE:

- During the morning hours of April 6, 2010, while touring the Main building, it was noted that the corridor door to the file storage room located on the ground floor in the Fowler Building, did not self close. The door lacks a self closing device.

This was acknowledged by the Director of Engineering.

Based on observations and confirmed by staff, the facility failed to assure fire drills are conducted as required.

THE FINDINGS INCLUDE:

- On the morning of April 5, 2010, according to the documentation provided, the 2nd & 3rd shift fire drills were conducted at the following times:

Second Shift (3:00PM -11:00PM): 3/31/10 @ 9:30PM; 1/31/10 @ 4:40PM; 6/8/09 @ 8:30PM; 6/2/09 @ 3:00PM.

Third Shift (11:00PM-7:00AM) : 3/24/10 @ 6:00AM; 7/14/09 @ 5:15AM; 6/3009 @ 6:25AM; 6/2/09 @ 1:50AM

The following deficiency was noted:

1) There were no fire drills conducted for the second shift (3:00PM-11:00PM) in the 3rd and 4th quarters of 2009.

2) There was no fire drill conducted for the third shift (11:00PM-7:00AM) in the 4th quarter of 2009.

3) The fire drills conducted for the third shift between 11:00PM to 6:00AM were conducted with out an alarm signal or a code word. The facility conducted fire drill with a question and answering in-service.

This was acknowledged by the Director of Engineering.

Based on record review and confirmed by staff interview, the facility failed to assure that the automatic sprinkler system is maintained, tested and inspected as required by NFPA #25.
NFPA #25, Section 9.3.5 states the operating stems of outside screw and yoke (OS&Y) valves shall be lubricated annually. The valve then shall be completely closed and reopened to test its operation and distribute the lubricant.

THE FINDINGS INCLUDE:

While conducting the record review on the morning of April 5, 2010, it was found that the facility failed to provide the proper inspection for the buildings sprinkler sytem as required. Documents reviewed were the facility's vendor sprinkler testing and inspection forms dated 2/17/10; 11/23/09; 8/26/09; and 5/6/09. The following deficiency were noted.

There was no documentation indicating that the OS&Y valves were opened and closed, and lubricated as required.

This was acknowledged by the Director of Engineering.

The facility failed to ensure that the supply water pressure is being monitored as required. NFPA 13, section 4.1.1, states that a pressure gauge conforming to 5.15.3.2 shall be installed on each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.

THE FINDINGS INCLUDE:

- During the Hospital tour on the afternoon of April 6, 2010, it was found there is no pressure gauge located on the street side of the backflow preventer device (to monitor the city water pressure for the sprinkler system) on the sprinkler mains in the Fowler and Ambulatory Surgery building.

This was acknowledged by the Director of Engineering.

Based on observations and confirmed by staff, the facility failed to assure compliance with NFPA #90A. Section 3.3.4.4 states fire dampers shall be installed at each direct or ducted opening into or out of enclosures required by section 3.3.4.1.
Section 3.3.4.1 states air ducts that pass through the floors of buildings that require the protection of vertical openings shall be enclosed with partitions or walls constructed of materials as permitted by the building code of the authority having jurisdiction. The enclosure shall have a minimum fire resistance rating (based on possible fire exposure from either side of the partition or wall) of 1 hour where such air ducts are located in a building less than four stories in height and a minimum rating of 2 hours where such air ducts are located in a building four stories or more in height.
Section 2.3.4.1 states service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
Section 2.3.4.2 states service openings shall be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within.
Section 3.4.7 states that at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. NOTE: CMS issued a categorical waiver for Hospitals to operate under the (6-year) damper testing cycle of the NFPA 2007 edition without special application to CMS.

THE FINDINGS INCLUDE:

- During the record review on the morning of April 5, 2010, and as stated in the Fire Damper report provided by the hospital, 11 ducts which penetrate fire rated shaft walls were deemed inaccessible, therefore the required 6-year inspection/service was not preformed.
Note, the facility has schedule the inspection/service to be preformed.

This was acknowledged by the Director of Engineering.