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Based on observation and interview, the facility did not provide corridor double doors with an astragal seal. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 2:00 pm, observation revealed on the 2nd floor in the Post Anesthesia Care Unit Room 2501 in Smoke Compartment D, that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5 Exception 4.

2. On 03/09/2015 at 4:10 pm, observation revealed on the 1st floor in the Corridor 1412 in Smoke Compartment B, that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The bottom of the double doors were also greater than 1/8 inch opening. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5 Exception 4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated doors. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 6 inpatients, and an unknown number of staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 03/09/2015 at 11:00 am, observation revealed on the 3rd floor in the Door to Monumental Stairway 300 in Smoke Compartment F, that the door in the fire barrier wall could not be verified of having the required rating. This monumental stairway door had a label that stated it was designed for only 20 minutes, and was not a fire-rated door. Based on the fire-rating of this Building, Type II (111), the shaft door must meet a minimum of a 60 minute fire-rating. This door label with this door is non-compliant for its location. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 18.3.1.1, and 8.2.5.4, and 8.2.3.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with a readily understandable path of egress. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 03/09/2015 at 10:50 am, observation revealed on the 3rd floor in the Elevator Lobby & Hallway 3101 in Smoke Compartment F, that additional signage was installed in the exit pathway that conflicts with the proper egress direction from this area. The corridor starts beyond a double set of doors on the inpatient sleeping unit. This exit sign in the hallway and elevator lobby sends people in the wrong direction in a fire emergency. This signage is sending people towards a monumental stairway, not to be used in a fire emergency. The exit sign is pointing towards a monumental stairway, not allowed to be used as a required exit from this floor and area. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.2.10; sections 7.10.1.2 and 7.10.8.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with compliant smoke doors, smoke-tight seals at meeting edges, closers on smoke barrier doors, and smoke doors held-open with the required safe guards. This deficiency occurred in 5 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 2:46 pm, observation revealed on the 2nd floor in the Elevator Lobby 2220 & Corridor 2223 in Smoke Compartment D, that the smoke barrier door was not compliant. The smoke barrier door set was observed to have a greater than 1/8 opening between the bottom of the doors and the floor. This exceeded the minimum requirements for openings at bottom of smoke barrier doors within a 1-hour fire-rated smoke barrier to stop the spread of smoke and hot gases per section 8.3.4.1. The clearance for proper operation of smoke doors is defined as 1/8 inch. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 & 8.3.4.1.

2. On 03/09/2015 at 11:08 am, observation revealed on the 3rd floor in the Corridors 3116 & 3198 between Smoke Compartments E & F , that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. The meeting edges of the smoke barrier doors were not compliant with the Life Safety Code. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

3. On 03/09/2015 at 11:17 am, observation revealed on the 3rd floor in the Corridors 3148 & 3201 between Smoke Compartments F & E, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. The meeting edges of the smoke barrier doors were not compliant with the Life Safety Code. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

4. On 03/09/2015 at 11:54 am, observation revealed on the 2nd floor in the Corridors 2110 & 2400 between Smoke Compartments D & C, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. The meeting edges of the smoke barrier doors were not compliant with the Life Safety Code. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

5. On 03/09/2015 at 1:35 pm, observation revealed on the 2nd floor in the Corridors 2410 & 2313 and 2400 & 2300 between Smoke Compartments C & D, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

6. On 03/09/2015 at 2:31 pm, observation revealed on the 2nd floor in the Corridors 2410 & 2313 and 2400 & 2300 between Smoke Compartments C & D, that the smoke barrier door was not self-closing because the air differential between the two different smoke compartments was too strong for the doors to close properly. A strong air movement was observed and whistling sound heard when the doors were almost closed. Air grill testing and balance reports were not provided at time of survey. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 & HVAC Balance Requirements per 42 CFR 482.41(c)(4) where applicable.

7. On 03/09/2015 at 2:20 pm, observation revealed on the 2nd floor in the Surgery Corridor 2313 & Janitor Closet 2311 (Plan View) between Smoke Compartments C & D, that the smoke door was prevented from self-closing by a large piece of equipment pushed into the small space, identified as a Neptune by Stryker-Sterilizer Suction Machine. The space was not large enough to hold this piece of equipment and allow the smoke barrier door to close and latch to the frame in the event of a fire emergency. The Life Safety Plans given to the Survey Team for the survey, showed this door on the smoke barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

8. On 03/09/2015 at 10:27 am, observation revealed on the Penthouse floor in the Boiler Room 4103 in Smoke Compartment G, that the hazardous room door was prevented from self-closing by a door stopper. The door stopper was at the bottom of the door, holding the door open. The door was not tied to fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not enclose hazardous rooms with fire-sealed wall penetrations, rated wall construction and rated fire doors. These deficiencies occurred in 3 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 1:10 pm, observation revealed on the 2nd floor in the Consultation Room 2105 in Smoke Compartment D, that a door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The room was used for outside vendor storage. The door was not fire-rated for a hazardous space and the door was missing a closer. Observations revealed the walls were not fire-rated above the ceiling with proper fire caulking at all penetrations. This observed situation was non compliant with NFPA 101 (2000 ed.) section 18.3.6.3.4 and not compliant with NFPA 101 (2000 ed.), sections 18.3.2.1 & 8.4.

2. On 03/09/2015 at 2:47 pm, observation revealed on the 1st floor in the Elevator Equipment Room 1110 & Mechanical Equipment Room 1519 in Smoke Compartment B, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The fire door was observed to have an acoustic material attached to the door surface for sound absorption. Fire doors are not allowed to have anything attached unless approved by the door manufacturer and it meets NFPA 80 Standard for Fire Doors and Fire Windows and Chapter 2 of NFPA 101, Mandatory References. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 & 8.4.

3. On 03/09/2015 at 3:12 pm, observation revealed on the 1st floor in the Food Service Storage Room 1503 in Smoke Compartment A, that penetrations were not sealed according to an approved method. The deficiency included a sleeve not fire caulked through the wall above the ceiling. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

4. On 03/09/2015 at 3:27 pm, observation revealed on the 1st floor in the Materials Management Supplies Room 1524 in Smoke Compartment A, that penetrations were not sealed according to an approved method. The deficiency included a 5/8 inch diameter flex electrical conduit penetrating the wall above the ceiling and was not fire caulked. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

5. On 03/09/2015 at 3:01 pm, observation revealed on the 1st floor in the Rehabilitation Equipment Storage Room 1604 in Smoke Compartment A, that the enclosing walls were not constructed to a 1-hour fire resistance rating. The room had numerous combustible items throughout the room. The original Life Safety Plans did not show this room to be a hazardous room. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

6. On 03/09/2015 at 3:06 pm, observation revealed on the 1st floor in the Cart Wash Room 1502 in Smoke Compartment A, that the enclosing walls were not constructed to a 1-hour fire resistance rating. The room had two large 32+ gallon waste containers within the room. The original Life Safety Plans did not show this room to be a hazardous room. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation, interview and review of life safety plans, the facility did not provide egress paths at all times with no obstructions in the path of egress, egress paths with sufficient headroom, and egress without passing through intervening hazardous rooms. These deficiencies occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 3:50 pm, observation revealed on the 1st floor in the Emergency Electrical Room 1518A in Smoke Compartment B, that the exit path was not readily accessible because a mechanic cart was placed in front of the the egress door of this Emergency Electrical Room (having greater than 1200 amps of service) preventing it from opening to its required egress width. This is a hazardous situation should someone be within this room under a hazardous and emergency condition and need to egress immediately to safety. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

2. On 03/10/2015 at 12:06 pm, observation revealed on the 1st floor in the Kitchen Prep Room 1122B in Smoke Compartment B, that the headroom was only 6'-0" at the bulkhead. The function of the room was changed and the bulkhead height was not changed. The distance from the ceiling to the floor in new construction must be at least 7-feet 6-inches with no projections below 6-feet 8-inches. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.5.

3. On 03/09/2015 at 2:11 pm, observation revealed on the 2nd floor in the Exit Passageway 2431 in Smoke Compartment C, that an intervening room in the means of egress was hazardous. Exit Passageway was used for storage and this is not permitted by the life safety code since it ' s a room used as part of the exit pathway to an exit. Stored items included: 2 linen carts 48"w x 24"d x 60"h, 1 soiled hamper 24"w x 24' d x 36"h and one large surgical piece of equipment.
This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.5 & 18.3.6.1 Exception No. 1(a).

4. On 03/09/2015 at 2:14 pm, observation revealed on the 2nd floor in the Surgery Corridors 2430 & 2415 in Smoke Compartment C, that an intervening room in the means of egress was hazardous. Egress Corridor was used for storage and this is not permitted by the 2000 edition of the Life Safety Code, since it ' s a room used as part of the exit pathway to an exit or exit passageway. Stored items included: 7 linen carts 48"w x 24"d x 60"h, 2 soiled hampers 24"w x 24"d x 36"h, two large surgical pieces of equipment and 2 E-cylinders of oxygen. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.5 & 18.3.6.1 Exception No. 1(a).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on document review and interview, the facility did not conduct fire drills as required by the Code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. These deficiencies occurred in all of the 7 smoke compartments, and had the potential to affect all patients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/10/2015 at 11:30 am, record review of the facility fire drill records for the past 12 Months revealed that fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. During a review of the fire drills it was observed the facility was not varying the times sufficiently. The fire drill record showed the fire drill testing times were less than 1-hour on several occasions including during the 3rd Shift in the last 12 Months, between the 3rd and 4th quarters, these drills were held at 5:45 AM in the 3rd quarter and at 5:30 AM in the 4th quarter. A similar situation showed on the 1st Shift fire drills in the last 12 months, between the 2nd and 3rd quarters, these drills were held at 8:00 AM and 8:45 AM (less than the allowed 1-hour separation requirement for fire drills). This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on document review and interview, the facility did not maintain the fire alarm system according to NFPA 70 and NFPA 72 requirements. Deficiencies included compliant fire alarm testing and complete inspection documentation. These deficiencies occurred in all of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/10/2015 at 10:30 am, document record review revealed that the annual visual inspections and performance tests of the fire alarm system were not conducted as required by the code. The Annual Fire Alarm Inspection, dated June 23, 2014, by Grunau Fire Protection, for Orthopaedic Hospital, 475 W. River Woods Pkwy, Milwaukee, WI 53212, was missing documentation within the report that the transmission equipment was tested to verify the trouble feature sent back an alert to the facility within 4 minutes of being sent to the Central Monitoring Station, per NFPA 72 (1999 edition), section 7-2.2 requirements. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2.

2. On 03/10/2015 at 10:15 am, document record review revealed that the quarterly visual inspections and performance tests of the fire alarm system were not conducted as required by the code. The following Fire Alarm Reports were available for review in the last 12 months: June 23, 2014 (Annual); September 11,2015 (quarterly); December 2, 2014 (quarterly). Missing was the 1st Quarter Report in 2014. Title: Quarterly or Annual Fire Alarm Inspection by Grunau Fire Protection for Orthopaedic Hospital, 475 W. River Woods Pkwy, Milwaukee, WI 53212 This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-5.2.2.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on document review and interview the facility did not inspect and test smoke detectors in accordance with the manufacturer's specifications specific to a complete smoke detector sensitivity test record. This deficiency occurred in all of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/10/2015 at 10:45 am, document record review revealed that the smoke detector sensitivity tests did not contain all the required information. The Annual Fire Alarm Inspection report, dated June 23, 2014, completed by a 3rd party fire protection company, was missing both the manufacturer acceptable range for each device tested and each device's current reading at the testing. It was also observed during the documentation review that the number of devices changed from one year to the next. The May 28, 2013 Report showed 229 devices reviewed and the June 23, 2014 report showed 227 devices reviewed. In review of the fire alarm records, with the facility personnel, only one device (Sterilizer Duct Detector) was approved to be removed by the State and Municipal (AHJ) Authority Having Jurisdiction, due to constant alerts. The other tested device could not be accounted for. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.3.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The Wisconsin Department of Health Services and Centers for Medicare Services (CMS) have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The Authority Having Jurisdiction (AHJ) considers any non-compliance a distinct hazard to life in hospital facilities, since patients are incapable of self-preservation and rely on a highly reliable sprinkler system to defend in-place. This is consistent with NFPA 13 (1999 edition) section 1-3, which notes that while NFPA 13 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a sprinkler system with sealed ceilings above the sprinklers to collect heat. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 10:40 am, observation revealed on the 3rd floor in the Storage Room 3225 in Smoke Compartment E, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. There was a 1 inch diameter hole around one of the sprinkler heads within the room. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

2. On 03/09/2015 at 11:19 am, observation revealed on the 3rd floor in the Corridor 3201 in Smoke Compartment E, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. There was a gap greater than 1/8 inch around the escutcheon ring in the wood cabinet used for storing linens between inpatient sleeping rooms 311 & 312. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

3. On 03/09/2015 at 11:40 am, observation revealed on the 3rd floor in the Corridor 3201 in Smoke Compartment E, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. The escutcheon ring was missing in the wood cabinet used for storing linens between inpatient sleeping rooms 319 & 320. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

4. On 03/09/2015 at 1:06 pm, observation revealed on the 2nd floor in the Registration Area 2102 in Smoke Compartment D, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. There was an opening around the escutcheon ring. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

5. On 03/09/2015 at 3:17 pm, observation revealed on the 1st floor in the Medical Gas Storage Room 1526 in Smoke Compartment A, that there was one or more unsealed holes near the ceiling. The holes included several pieces of acoustical ceiling tile missing at corners of tiles. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat, sprinklers free of lint and dust, and sprinkler heads protected from foreign objects. These deficiencies occurred in 3 of the 7 smoke compartments, plus outside the building under the main canopy. These deficiencies had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 2:25 pm, observation revealed on the 2nd floor in the Sterile Pack Processing Area & Storage 2406 in Smoke Compartment C, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. The four sprinkler heads within this room were observed to have excessive amounts of lint and dust on the sprinkler heads. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

2. On 03/09/2015 at 2:36 pm, observation revealed on the 2nd floor in the Decontamination Room 2405 in Smoke Compartment C, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. The three sprinkler heads within this room were observed to have excessive amounts of lint and dust on the heads. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

3. On 03/09/2015 at 2:37 pm, observation revealed on the 2nd floor in the Trash, Bio-Hazard & Soiled Linen Room 1314 in Smoke Compartment C, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. A sprinkler head above the large waste bags hamper cart (larger than 32 gals.) was observed to have black plastic bag parts wrapped around a sprinkler head. The bags in the large waste carts were of the same material and color as that of the material around the sprinkler head. The sprinkler head did not have a shield to protect it. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

4. On 03/09/2015 at 3:15 pm, observation revealed on the 1st floor in the Loading Dock Room 1525 in Smoke Compartment A, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

5. On 03/09/2015 at 3:16 pm, observation revealed on the 1st floor in the Soiled Holding Room 1527 in Smoke Compartment A, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

6. On 03/09/2015 at 3:57 pm, observation revealed on the 1st floor in the Male and Female Staff Locker Rooms 1513 & 1516 in Smoke Compartment B, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

7. On 03/10/2015 at 12:07 pm, observation revealed on the 1st floor in the Kitchen Pots and Pans & Dish Cleaning Room 1122A in Smoke Compartment B, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

8. On 03/10/2015 at 12:15 pm, observation revealed at the exterior of the building at the Exterior Main Canopy, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on document review and interview, the facility did not provide and maintain portable fire extinguishers as required by the Codes with complete inspection documentation. This deficiency involved all of the 7 smoke compartments, plus outside the building on the parking lot. This deficiency had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.


FINDINGS INCLUDED:

On 03/10/2015 at 11:00 am, record review revealed that fire extinguishers were not inspected annually for expelled extinguisher agent process. Surveyor was told the company expelling the agents bring a truck to the site and remove all the agents onsite and then reload the extinguishers. Currently no policies and procedures exist for this 'expelling process' on the site of these chemicals within the extinguishers. No current policies include letter approvals from the Village of Glendale Fire Department or Village of Glendale Building Inspection Department for allowing expelling of the extinguisher agents into the ground water environment. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.6, 9.7.4.1 and NFPA 10.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/09/2015 at 12:02 pm, observation revealed on the 2nd floor in the Oxygen Storage Room 2607 in Smoke Compartment D, that combustible materials were stored within 5' of a storage site of cylinders of oxygen. Stored within this distance was combustible cushions and linens. It was also observed that the door had a grille within the door, also not compliant, for a hazardous space used to store numerous oxygen cylinders. This observed situation was not compliant with NFPA 99 (1999 ed.), 4.3.1.1.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/09/2015 at 1:33 pm, observation revealed on the 2nd floor in the Corridor outside Operating Rooms 4, 7 & 8 in Smoke Compartment C, that medical gas piping gauges were not installed according to the requirements of the code. The piping and pressure gauge installation included vacuum system gauges at shut-off boxes #ZVB4, #ZVB7 & #ZVB8. These pressurized vacuum gauges showed the vacuum pressure between 29 to 30 inches Hg (vacuum), which is outside the required range for vacuum line pressure in a hospital surgery room & surgical operating department. Per NFPA 99, section 4-3.2.2.10 (b) Area Vacuum System Gauges, the "normal range" display shall indicate normal only between 12 and 19 inches Hg (vacuum). These observed situations were not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), section 4-3.2.2.10.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, proper use of extension cords, and electrical panels with complete directories. This deficiency occurred in 5 of the 7 smoke compartments, and had the potential to affect 49 inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 2:28 pm, observation revealed on the 2nd floor in the Sterilizer Equipment Room 2409 in Smoke Compartment C, that clearance in front of electrical equipment was less than 3'-0". The Electrical Panel 2EH was blocked by equipment within the room, preventing emergency access. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-26.

2. On 03/09/2015 at 11:11 am, observation revealed on the 3rd floor in the Clean Workroom 3174 in Smoke Compartment F, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to Power Clips used for patient monitoring. This observed situation was not compliant with NFPA 70 (1999 ed.), article 400-8.

3. On 03/09/2015 at 10:19 am, observation revealed on the Penthouse floor in the Mechanical & Water Softener Room in Smoke Compartment G, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel PEQL, at breaker #31 was in the 'ON' position and was marked as a spare. At time of survey it could not be determined what it served. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-22.

4. On 03/09/2015 at 11:05 am, observation revealed on the 3rd floor in the IDF Electrical Closet Room 3103 in Smoke Compartment F, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #CBPA was found to have Breaker #14 in a 'ON' position, but was marked as a spare. Its source could not be identified at time of the survey. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-22.

5. On 03/09/2015 at 11:49 am, observation revealed on the 2nd floor in the Electrical Room 2103 in Smoke Compartment D, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #2A was found to have Breakers #12, #31, #32, #34 & #36 in a 'ON' position, but were marked as spares. There sources could not be identified at time of the survey. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-22.

6. On 03/09/2015 at 3:48 pm, observation revealed on the 1st floor in the Emergency Electrical Room 1518A in Smoke Compartment B, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #LSL, breakers #7 & #9 and Panel #EQL, breaker #21, where found in the 'ON' position and were not identified to what they served. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-22.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation and interview, the facility did not provide corridor double doors with an astragal seal. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 2:00 pm, observation revealed on the 2nd floor in the Post Anesthesia Care Unit Room 2501 in Smoke Compartment D, that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5 Exception 4.

2. On 03/09/2015 at 4:10 pm, observation revealed on the 1st floor in the Corridor 1412 in Smoke Compartment B, that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The bottom of the double doors were also greater than 1/8 inch opening. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5 Exception 4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated doors. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 6 inpatients, and an unknown number of staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 03/09/2015 at 11:00 am, observation revealed on the 3rd floor in the Door to Monumental Stairway 300 in Smoke Compartment F, that the door in the fire barrier wall could not be verified of having the required rating. This monumental stairway door had a label that stated it was designed for only 20 minutes, and was not a fire-rated door. Based on the fire-rating of this Building, Type II (111), the shaft door must meet a minimum of a 60 minute fire-rating. This door label with this door is non-compliant for its location. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 18.3.1.1, and 8.2.5.4, and 8.2.3.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with a readily understandable path of egress. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 03/09/2015 at 10:50 am, observation revealed on the 3rd floor in the Elevator Lobby & Hallway 3101 in Smoke Compartment F, that additional signage was installed in the exit pathway that conflicts with the proper egress direction from this area. The corridor starts beyond a double set of doors on the inpatient sleeping unit. This exit sign in the hallway and elevator lobby sends people in the wrong direction in a fire emergency. This signage is sending people towards a monumental stairway, not to be used in a fire emergency. The exit sign is pointing towards a monumental stairway, not allowed to be used as a required exit from this floor and area. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.2.10; sections 7.10.1.2 and 7.10.8.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with compliant smoke doors, smoke-tight seals at meeting edges, closers on smoke barrier doors, and smoke doors held-open with the required safe guards. This deficiency occurred in 5 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 2:46 pm, observation revealed on the 2nd floor in the Elevator Lobby 2220 & Corridor 2223 in Smoke Compartment D, that the smoke barrier door was not compliant. The smoke barrier door set was observed to have a greater than 1/8 opening between the bottom of the doors and the floor. This exceeded the minimum requirements for openings at bottom of smoke barrier doors within a 1-hour fire-rated smoke barrier to stop the spread of smoke and hot gases per section 8.3.4.1. The clearance for proper operation of smoke doors is defined as 1/8 inch. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 & 8.3.4.1.

2. On 03/09/2015 at 11:08 am, observation revealed on the 3rd floor in the Corridors 3116 & 3198 between Smoke Compartments E & F , that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. The meeting edges of the smoke barrier doors were not compliant with the Life Safety Code. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

3. On 03/09/2015 at 11:17 am, observation revealed on the 3rd floor in the Corridors 3148 & 3201 between Smoke Compartments F & E, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. The meeting edges of the smoke barrier doors were not compliant with the Life Safety Code. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

4. On 03/09/2015 at 11:54 am, observation revealed on the 2nd floor in the Corridors 2110 & 2400 between Smoke Compartments D & C, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. The meeting edges of the smoke barrier doors were not compliant with the Life Safety Code. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

5. On 03/09/2015 at 1:35 pm, observation revealed on the 2nd floor in the Corridors 2410 & 2313 and 2400 & 2300 between Smoke Compartments C & D, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

6. On 03/09/2015 at 2:31 pm, observation revealed on the 2nd floor in the Corridors 2410 & 2313 and 2400 & 2300 between Smoke Compartments C & D, that the smoke barrier door was not self-closing because the air differential between the two different smoke compartments was too strong for the doors to close properly. A strong air movement was observed and whistling sound heard when the doors were almost closed. Air grill testing and balance reports were not provided at time of survey. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 & HVAC Balance Requirements per 42 CFR 482.41(c)(4) where applicable.

7. On 03/09/2015 at 2:20 pm, observation revealed on the 2nd floor in the Surgery Corridor 2313 & Janitor Closet 2311 (Plan View) between Smoke Compartments C & D, that the smoke door was prevented from self-closing by a large piece of equipment pushed into the small space, identified as a Neptune by Stryker-Sterilizer Suction Machine. The space was not large enough to hold this piece of equipment and allow the smoke barrier door to close and latch to the frame in the event of a fire emergency. The Life Safety Plans given to the Survey Team for the survey, showed this door on the smoke barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

8. On 03/09/2015 at 10:27 am, observation revealed on the Penthouse floor in the Boiler Room 4103 in Smoke Compartment G, that the hazardous room door was prevented from self-closing by a door stopper. The door stopper was at the bottom of the door, holding the door open. The door was not tied to fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with fire-sealed wall penetrations, rated wall construction and rated fire doors. These deficiencies occurred in 3 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 1:10 pm, observation revealed on the 2nd floor in the Consultation Room 2105 in Smoke Compartment D, that a door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The room was used for outside vendor storage. The door was not fire-rated for a hazardous space and the door was missing a closer. Observations revealed the walls were not fire-rated above the ceiling with proper fire caulking at all penetrations. This observed situation was non compliant with NFPA 101 (2000 ed.) section 18.3.6.3.4 and not compliant with NFPA 101 (2000 ed.), sections 18.3.2.1 & 8.4.

2. On 03/09/2015 at 2:47 pm, observation revealed on the 1st floor in the Elevator Equipment Room 1110 & Mechanical Equipment Room 1519 in Smoke Compartment B, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The fire door was observed to have an acoustic material attached to the door surface for sound absorption. Fire doors are not allowed to have anything attached unless approved by the door manufacturer and it meets NFPA 80 Standard for Fire Doors and Fire Windows and Chapter 2 of NFPA 101, Mandatory References. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 & 8.4.

3. On 03/09/2015 at 3:12 pm, observation revealed on the 1st floor in the Food Service Storage Room 1503 in Smoke Compartment A, that penetrations were not sealed according to an approved method. The deficiency included a sleeve not fire caulked through the wall above the ceiling. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

4. On 03/09/2015 at 3:27 pm, observation revealed on the 1st floor in the Materials Management Supplies Room 1524 in Smoke Compartment A, that penetrations were not sealed according to an approved method. The deficiency included a 5/8 inch diameter flex electrical conduit penetrating the wall above the ceiling and was not fire caulked. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

5. On 03/09/2015 at 3:01 pm, observation revealed on the 1st floor in the Rehabilitation Equipment Storage Room 1604 in Smoke Compartment A, that the enclosing walls were not constructed to a 1-hour fire resistance rating. The room had numerous combustible items throughout the room. The original Life Safety Plans did not show this room to be a hazardous room. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

6. On 03/09/2015 at 3:06 pm, observation revealed on the 1st floor in the Cart Wash Room 1502 in Smoke Compartment A, that the enclosing walls were not constructed to a 1-hour fire resistance rating. The room had two large 32+ gallon waste containers within the room. The original Life Safety Plans did not show this room to be a hazardous room. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation, interview and review of life safety plans, the facility did not provide egress paths at all times with no obstructions in the path of egress, egress paths with sufficient headroom, and egress without passing through intervening hazardous rooms. These deficiencies occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 3:50 pm, observation revealed on the 1st floor in the Emergency Electrical Room 1518A in Smoke Compartment B, that the exit path was not readily accessible because a mechanic cart was placed in front of the the egress door of this Emergency Electrical Room (having greater than 1200 amps of service) preventing it from opening to its required egress width. This is a hazardous situation should someone be within this room under a hazardous and emergency condition and need to egress immediately to safety. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

2. On 03/10/2015 at 12:06 pm, observation revealed on the 1st floor in the Kitchen Prep Room 1122B in Smoke Compartment B, that the headroom was only 6'-0" at the bulkhead. The function of the room was changed and the bulkhead height was not changed. The distance from the ceiling to the floor in new construction must be at least 7-feet 6-inches with no projections below 6-feet 8-inches. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.5.

3. On 03/09/2015 at 2:11 pm, observation revealed on the 2nd floor in the Exit Passageway 2431 in Smoke Compartment C, that an intervening room in the means of egress was hazardous. Exit Passageway was used for storage and this is not permitted by the life safety code since it ' s a room used as part of the exit pathway to an exit. Stored items included: 2 linen carts 48"w x 24"d x 60"h, 1 soiled hamper 24"w x 24' d x 36"h and one large surgical piece of equipment.
This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.5 & 18.3.6.1 Exception No. 1(a).

4. On 03/09/2015 at 2:14 pm, observation revealed on the 2nd floor in the Surgery Corridors 2430 & 2415 in Smoke Compartment C, that an intervening room in the means of egress was hazardous. Egress Corridor was used for storage and this is not permitted by the 2000 edition of the Life Safety Code, since it ' s a room used as part of the exit pathway to an exit or exit passageway. Stored items included: 7 linen carts 48"w x 24"d x 60"h, 2 soiled hampers 24"w x 24"d x 36"h, two large surgical pieces of equipment and 2 E-cylinders of oxygen. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.5 & 18.3.6.1 Exception No. 1(a).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on document review and interview, the facility did not conduct fire drills as required by the Code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. These deficiencies occurred in all of the 7 smoke compartments, and had the potential to affect all patients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/10/2015 at 11:30 am, record review of the facility fire drill records for the past 12 Months revealed that fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. During a review of the fire drills it was observed the facility was not varying the times sufficiently. The fire drill record showed the fire drill testing times were less than 1-hour on several occasions including during the 3rd Shift in the last 12 Months, between the 3rd and 4th quarters, these drills were held at 5:45 AM in the 3rd quarter and at 5:30 AM in the 4th quarter. A similar situation showed on the 1st Shift fire drills in the last 12 months, between the 2nd and 3rd quarters, these drills were held at 8:00 AM and 8:45 AM (less than the allowed 1-hour separation requirement for fire drills). This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on document review and interview, the facility did not maintain the fire alarm system according to NFPA 70 and NFPA 72 requirements. Deficiencies included compliant fire alarm testing and complete inspection documentation. These deficiencies occurred in all of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/10/2015 at 10:30 am, document record review revealed that the annual visual inspections and performance tests of the fire alarm system were not conducted as required by the code. The Annual Fire Alarm Inspection, dated June 23, 2014, by Grunau Fire Protection, for Orthopaedic Hospital, 475 W. River Woods Pkwy, Milwaukee, WI 53212, was missing documentation within the report that the transmission equipment was tested to verify the trouble feature sent back an alert to the facility within 4 minutes of being sent to the Central Monitoring Station, per NFPA 72 (1999 edition), section 7-2.2 requirements. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2.

2. On 03/10/2015 at 10:15 am, document record review revealed that the quarterly visual inspections and performance tests of the fire alarm system were not conducted as required by the code. The following Fire Alarm Reports were available for review in the last 12 months: June 23, 2014 (Annual); September 11,2015 (quarterly); December 2, 2014 (quarterly). Missing was the 1st Quarter Report in 2014. Title: Quarterly or Annual Fire Alarm Inspection by Grunau Fire Protection for Orthopaedic Hospital, 475 W. River Woods Pkwy, Milwaukee, WI 53212 This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-5.2.2.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on document review and interview the facility did not inspect and test smoke detectors in accordance with the manufacturer's specifications specific to a complete smoke detector sensitivity test record. This deficiency occurred in all of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/10/2015 at 10:45 am, document record review revealed that the smoke detector sensitivity tests did not contain all the required information. The Annual Fire Alarm Inspection report, dated June 23, 2014, completed by a 3rd party fire protection company, was missing both the manufacturer acceptable range for each device tested and each device's current reading at the testing. It was also observed during the documentation review that the number of devices changed from one year to the next. The May 28, 2013 Report showed 229 devices reviewed and the June 23, 2014 report showed 227 devices reviewed. In review of the fire alarm records, with the facility personnel, only one device (Sterilizer Duct Detector) was approved to be removed by the State and Municipal (AHJ) Authority Having Jurisdiction, due to constant alerts. The other tested device could not be accounted for. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.3.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The Wisconsin Department of Health Services and Centers for Medicare Services (CMS) have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The Authority Having Jurisdiction (AHJ) considers any non-compliance a distinct hazard to life in hospital facilities, since patients are incapable of self-preservation and rely on a highly reliable sprinkler system to defend in-place. This is consistent with NFPA 13 (1999 edition) section 1-3, which notes that while NFPA 13 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a sprinkler system with sealed ceilings above the sprinklers to collect heat. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 10:40 am, observation revealed on the 3rd floor in the Storage Room 3225 in Smoke Compartment E, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. There was a 1 inch diameter hole around one of the sprinkler heads within the room. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

2. On 03/09/2015 at 11:19 am, observation revealed on the 3rd floor in the Corridor 3201 in Smoke Compartment E, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. There was a gap greater than 1/8 inch around the escutcheon ring in the wood cabinet used for storing linens between inpatient sleeping rooms 311 & 312. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

3. On 03/09/2015 at 11:40 am, observation revealed on the 3rd floor in the Corridor 3201 in Smoke Compartment E, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. The escutcheon ring was missing in the wood cabinet used for storing linens between inpatient sleeping rooms 319 & 320. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

4. On 03/09/2015 at 1:06 pm, observation revealed on the 2nd floor in the Registration Area 2102 in Smoke Compartment D, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. There was an opening around the escutcheon ring. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

5. On 03/09/2015 at 3:17 pm, observation revealed on the 1st floor in the Medical Gas Storage Room 1526 in Smoke Compartment A, that there was one or more unsealed holes near the ceiling. The holes included several pieces of acoustical ceiling tile missing at corners of tiles. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat, sprinklers free of lint and dust, and sprinkler heads protected from foreign objects. These deficiencies occurred in 3 of the 7 smoke compartments, plus outside the building under the main canopy. These deficiencies had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 2:25 pm, observation revealed on the 2nd floor in the Sterile Pack Processing Area & Storage 2406 in Smoke Compartment C, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. The four sprinkler heads within this room were observed to have excessive amounts of lint and dust on the sprinkler heads. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

2. On 03/09/2015 at 2:36 pm, observation revealed on the 2nd floor in the Decontamination Room 2405 in Smoke Compartment C, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. The three sprinkler heads within this room were observed to have excessive amounts of lint and dust on the heads. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

3. On 03/09/2015 at 2:37 pm, observation revealed on the 2nd floor in the Trash, Bio-Hazard & Soiled Linen Room 1314 in Smoke Compartment C, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. A sprinkler head above the large waste bags hamper cart (larger than 32 gals.) was observed to have black plastic bag parts wrapped around a sprinkler head. The bags in the large waste carts were of the same material and color as that of the material around the sprinkler head. The sprinkler head did not have a shield to protect it. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

4. On 03/09/2015 at 3:15 pm, observation revealed on the 1st floor in the Loading Dock Room 1525 in Smoke Compartment A, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

5. On 03/09/2015 at 3:16 pm, observation revealed on the 1st floor in the Soiled Holding Room 1527 in Smoke Compartment A, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

6. On 03/09/2015 at 3:57 pm, observation revealed on the 1st floor in the Male and Female Staff Locker Rooms 1513 & 1516 in Smoke Compartment B, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

7. On 03/10/2015 at 12:07 pm, observation revealed on the 1st floor in the Kitchen Pots and Pans & Dish Cleaning Room 1122A in Smoke Compartment B, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

8. On 03/10/2015 at 12:15 pm, observation revealed at the exterior of the building at the Exterior Main Canopy, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on document review and interview, the facility did not provide and maintain portable fire extinguishers as required by the Codes with complete inspection documentation. This deficiency involved all of the 7 smoke compartments, plus outside the building on the parking lot. This deficiency had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.


FINDINGS INCLUDED:

On 03/10/2015 at 11:00 am, record review revealed that fire extinguishers were not inspected annually for expelled extinguisher agent process. Surveyor was told the company expelling the agents bring a truck to the site and remove all the agents onsite and then reload the extinguishers. Currently no policies and procedures exist for this 'expelling process' on the site of these chemicals within the extinguishers. No current policies include letter approvals from the Village of Glendale Fire Department or Village of Glendale Building Inspection Department for allowing expelling of the extinguisher agents into the ground water environment. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.6, 9.7.4.1 and NFPA 10.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/09/2015 at 12:02 pm, observation revealed on the 2nd floor in the Oxygen Storage Room 2607 in Smoke Compartment D, that combustible materials were stored within 5' of a storage site of cylinders of oxygen. Stored within this distance was combustible cushions and linens. It was also observed that the door had a grille within the door, also not compliant, for a hazardous space used to store numerous oxygen cylinders. This observed situation was not compliant with NFPA 99 (1999 ed.), 4.3.1.1.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
______________________________________

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/09/2015 at 1:33 pm, observation revealed on the 2nd floor in the Corridor outside Operating Rooms 4, 7 & 8 in Smoke Compartment C, that medical gas piping gauges were not installed according to the requirements of the code. The piping and pressure gauge installation included vacuum system gauges at shut-off boxes #ZVB4, #ZVB7 & #ZVB8. These pressurized vacuum gauges showed the vacuum pressure between 29 to 30 inches Hg (vacuum), which is outside the required range for vacuum line pressure in a hospital surgery room & surgical operating department. Per NFPA 99, section 4-3.2.2.10 (b) Area Vacuum System Gauges, the "normal range" display shall indicate normal only between 12 and 19 inches Hg (vacuum). These observed situations were not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), section 4-3.2.2.10.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, proper use of extension cords, and electrical panels with complete directories. This deficiency occurred in 5 of the 7 smoke compartments, and had the potential to affect 49 inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/09/2015 at 2:28 pm, observation revealed on the 2nd floor in the Sterilizer Equipment Room 2409 in Smoke Compartment C, that clearance in front of electrical equipment was less than 3'-0". The Electrical Panel 2EH was blocked by equipment within the room, preventing emergency access. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-26.

2. On 03/09/2015 at 11:11 am, observation revealed on the 3rd floor in the Clean Workroom 3174 in Smoke Compartment F, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to Power Clips used for patient monitoring. This observed situation was not compliant with NFPA 70 (1999 ed.), article 400-8.

3. On 03/09/2015 at 10:19 am, observation revealed on the Penthouse floor in the Mechanical & Water Softener Room in Smoke Compartment G, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel PEQL, at breaker #31 was in the 'ON' position and was marked as a spare. At time of survey it could not be determined what it served. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-22.

4. On 03/09/2015 at 11:05 am, observation revealed on the 3rd floor in the IDF Electrical Closet Room 3103 in Smoke Compartment F, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #CBPA was found to have Breaker #14 in a 'ON' position, but was marked as a spare. Its source could not be identified at time of the survey. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-22.

5. On 03/09/2015 at 11:49 am, observation revealed on the 2nd floor in the Electrical Room 2103 in Smoke Compartment D, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #2A was found to have Breakers #12, #31, #32, #34 & #36 in a 'ON' position, but were marked as spares. There sources could not be identified at time of the survey. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-22.

6. On 03/09/2015 at 3:48 pm, observation revealed on the 1st floor in the Emergency Electrical Room 1518A in Smoke Compartment B, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #LSL, breakers #7 & #9 and Panel #EQL, breaker #21, where found in the 'ON' position and were not identified to what they served. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-22.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Mgr. Facilities & Maintenance) and staff C (Maintenance Mechanic).
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