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Based on observation and interview, the facility did not provide a common Separation Barrier with doors of positive-latching hardware, sealed wall penetrations and fire-rated wall construction. These deficiencies occurred in 9 of the 74 smoke compartments for the entire health care campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/20/2015 at 10:22 am, observation revealed on the 4th floor in the Corridor outside of room 4101 at Separation Barrier between SC-4F & 4B, that the separation doors would not positively self-latch when released because the closer would not pull the doors tight to the door frame. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.1.1.4.

2. On 04/20/2015 at 10:29 am, observation revealed on the 4th floor in 4126-Corridor at Separation Barrier between SC-4F & 4G, that the separation doors 2-hour fire-rated, would not positively self-latch to the door frame, when released, because of the deficient door closers. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.1.1.4.

3. On 04/20/2015 at 1:40 pm, observation revealed on the 4th floor in 4301B-Storage Room, that penetrations were not sealed according to an approved method. The deficiencies included multiple penetrations of pipes, conduits, and wires through a 2-hour Separation Barrier above the ceiling at the double door set going into the Storage Room. A patch 4" x 4" was also observed without having any of the screws double mudded or seams taped per the fire barrier assembly. These observed situations were not compliant with NFPA 101 (2000 ed.), sections 18.1.1.4 & 8.2.3.2.4.

4. On 04/21/2015 at 1:08 pm, observation revealed on the 3rd floor in 3101-Corridor between SC-3D & SC-3B/3F, that penetrations were not sealed according to an approved method. The deficiencies included multiple penetrations of pipes, conduits, and wires not properly fire-sealed through a 2-hour Separation Barrier above the ceiling at the double door set and adjoining wall next to Children/Parents Lounge Room 3216. Observed metal screws not all double mudded or gypsum wallboard seams taped. These observed situations were not compliant with NFPA 101 (2000 ed.), sections 18.1.1.4 & 8.2.3.2.4.

5. On 04/21/2015 at 9:42 am, observation revealed on the 4th floor in 4126-Corridor at 2-hour Separation Barrier between CMS Buildings #02 & #01 at SC-4E & SC-4G, that penetrations were not sealed according to a UL approved method. These deficiencies included the horizontal lid of the 2-hour deck that was not properly fire-sealed where it met the vertical wall above the ceiling. Also observed 5 pipes not properly fire-sealed though the 2-hour Separation Barrier (masonry construction) used between two different buildings. These observed situations were not compliant with NFPA 101 (2000 ed.), sections 18.1.1.4 & 8.2.3.2.4.

6. On 04/21/2015 at 1:21 pm, observation revealed on the 3rd floor where a Separation Barrier should have been placed between the Hospital (I-2 Occupancy) and the Ronald McDonald House (R-2 Occupancy) at SC-3D, per observation, the Separation Barrier was missing and the existing wall not constructed to a 2-hour fire-rating. The Life Safety Plans did not call out for this Separation Barrier, where two separate entices control the spaces. On one side of a recently renovated wall is St. Mary's Hospital (I-2 Occupancy) and the other side is the Ronald McDonald House (R-2 Occupancy). This condition requires a 2-hour Separation Barrier between the two occupancies. These observed situations were not compliant with NFPA 101 (2000 ed.), section 18.1.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not provide and maintain the required building construction type, Type II (222), with support steel covered with 2-hour rated fire-proofing, matching the same construction type on all floors of the CMS Building #02. These deficiencies occurred in 3 of the 74 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/20/2015 at 1:30 pm, observation revealed on the 4th floor in the 4301-Pre-Op & Post-Op Suite in SC-4-I, that fire-proofing was missing from the structural steel beam. The steel beam or steel lintel holding up several floors of shaft wall is exposed near the North end of the North Wing addition. It is required to be fire-protected to the minimum 2-hours meeting the Building Type II (222) of this building. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.1.6.2.

2. On 04/21/2015 at 2:40 pm, observation revealed that one building construction type was "stacked" above a different type of construction on the next lower floor, which may affect the structural fire-resistance and stability of the North Wing component of CMS Building #02. The 4-Story Shaft was missing the proper fire-proofing due to the metal lath and plaster having been removed that provided the 2-hour fire-protection for this 4-Story Building, Type II (222), built in 1926. All floors need to be verified they are built to the required Type II (222) construction, where shaft metal lath and plaster was removed in past renovations. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.1.6.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor, and compliant corridor wall construction at highrise elevator lobbies. These deficiencies occurred in 5 of the 74 smoke compartments at this hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 9:25 am, observation revealed on the 5th floor in the 4'x10' Open Alcove, that the area was not separated from the exit egress corridor by smoke-tight wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector, as an alternative, and was not fully-observable from a 24-hour occupied location. These observed situations were not compliant with NFPA 101 (2000 ed.), section 18.3.6.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/21/2015 at 10:45 am, observation revealed on the 5th floor in the Vending Machine Alcove 5602, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector, as an alternative, and was not fully-observable from a 24-hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

3. On 04/20/2015 at 10:17 am, observation revealed on the 4th floor in the 4106A-Highrise Elevator Lobby in SC-4B, that the corridor wall was not compliant because the Elevator Lobby walls must be smoke-tight for high-rise construction. This building added 2-Floors (Inpatient Units) with a Elevator Mechanical Penthouse in 2004 that pushed the height of the tallest floor above 75'-0" above grade, requiring all elevator lobbies to be enclosed and smoke-tight. Above the ceiling the walls were not smoke-tight with numerous penetrations of pipes, conduits, wires and ducts not properly smoke-sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

4. On 04/21/2015 at 12:11 pm, observation revealed on the 3rd floor at the 3601A-Highrise Elevator Lobby in SC-3B, that the corridor wall was not compliant because the wall must be smoke-tight for high-rise construction. This building added 2 Floors (Inpatient Units) with a Elevator Mechanical Penthouse in 2004 that pushed the height of the tallest floor above 75'-0" above grade, requiring all elevator lobbies to be enclosed and smoke-tight. Above the ceiling the walls were not smoke-tight with numerous penetrations of pipes, conduits, wires and ducts not properly smoke-sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

5. On 04/22/2015 at 11:00 am, observation revealed on the 2nd floor at the 2601A- Highrise Elevator Lobby in SC-2B, that the corridor wall was not compliant because the wall must be smoke-tight for high-rise construction. This building added 2 Floors (Inpatient Units) with a Elevator Mechanical Penthouse in 2004 that pushed the height of the tallest floor above 75'-0" above grade, requiring all elevator lobbies to be enclosed and smoke-tight. Above the ceiling the walls were not smoke-tight with numerous penetrations of pipes, conduits, wires and ducts not properly smoke-sealed. Based on the cummulative observations from these three floor elevator lobbies in the Southwest Wing, all the lobbies in this addition need to be verified to be smoke-tight. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

6. On 04/22/2015 at 9:57 am, observation revealed on the 3rd floor in the Pediatric Procedure Suite (2,669 SF) in SC-3C, that the corridor wall was not compliant because the suite was required to be smoke-tight to the corridor and numerous penetrations were observed from sprinkler pipes, drywall patches not taped and screws not mudded. This area was recently remodeled to new construction. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).
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29942

Based on observation and interview, the facility did not provide corridor separation doors with code compliant corridor doors. These deficiencies occurred in 4 of the 74 smoke compartments within this hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 2:30 pm, observation revealed on the 3rd floor in the SC-SI, North Wing, built in 1926, that the corridor was not compliant. During the survey tour it was explained that this wall of the office was on a smoke barrier between SC-3I & SC-3G. However, the Life Safety Plans did not show it this way. As a wall to the corridor this wall still had to be smoke-tight, which it was not. Observed a three (3") inch diameter sleeve not sealed smoke-tight and 1" diameter copper pipe not sealed smoke-tight. Cummulatively these observed situations were not compliant with NFPA 101 (2000 ed.), section 18.3.6.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

2. On 04/21/2015 at 3:43 pm, observation revealed on the 3rd floor in the 3501C-Newborn Nursery Suite, Soiled Utility Room in SC-3G, that the corridor wall was not compliant. Duct tape was used to close the 6" diameter opening in the wall above the ceiling. The duct tape does not meet 'Limited-Combustible' requirements per NFPA 101 (2000 ed.), section 3.3.118 for a hospital. This room was not correctly identified in the Life Safety Plans. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.6.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with doors with positive-latching hardware, sealed wall penetrations, fire-rated wall construction, and taped joints on fire-rated walls. These deficiencies occurred in 13 of the 74 smoke compartments in this hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/20/2015 at 11:50 am, observation revealed on the 4th floor in the 4627-South Exit Stairs in SC-4A, that the door was in a vertical shaft opening and would not positively self-latch because the closer would not pull the door tight to the door frame and the door was missing a fire-rated bottom door sweep. These observed situations were not compliant with NFPA 101 (2000 ed.), 18.3.1.1, and 8.2.5.4, and 8.2.3.2.

2. On 04/20/2015 at 2:42 pm, observation revealed on the 4th floor in the 4415-Equipment Room adjacent to a 2-hour fire-rated shaft off Corridor 4431 in SC-4H, that penetrations were not fire-sealed according to an approved method. The deficiencies included openings around the ducts penetrating the floor assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

3. On 04/21/2015 at 8:55 am, observation revealed on the 4th floor in the 4539A-Electrical Room in SC-4C, that a penetration was not sealed according to an approved method. The deficiency included a 18" x 4" electrical bus way not properly fire-caulked in a 2-hour fire barrier. This space was next to the vertical chase and exit stairs. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

4. On 04/21/2015 at 10:02 am, observation revealed on the 4th floor in the 4126B-South Wing Stairwell in SC-4F, that penetrations were not sealed according to an approved method. The deficiencies included three penetrations caused by two anchors not properly fire-sealed from a vertical ladder in a 2-hour shaft assembly, and one plaster patch coming off from wear and tear. We also saw a plumbing vent pipe passing through the exit stair, which is not permitted. These observed situations were not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

5. On 04/21/2015 at 10:10 am, observation revealed on the 4th floor in the 4112-Corridor Alcove at Sub-Waiting next to a shaft in SC-4F, that penetrations were not fire-sealed according to an approved method. The deficiencies included multiple fire-seals missing around ducts, pipes and conduits in fire barrier wall assemblies above ceiling at shaft. These observed situations were not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

6. On 04/21/2015 at 11:35 am, observation revealed on the 4th floor in the 4612-Southwest Wing, North Exit Stairs in SC-4B, that a penetration was not sealed according to an approved method. The deficiency included a 45 degree angle metal conduit running through the corner wall of the exit stairs (fire-rated to 2-hour construction). Only items specific to exit stairs support and operation are allowed to enter and leave exit stairs. This is non-compliant to NFPA 101 (2000 ed.), section 4.6.7 of the Life Safety Code. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

7. On 04/21/2015 at 1:35 pm, observation revealed on the 3rd floor in the 3116E-South Wing Exit Stairs in SC-3D, that penetrations were not sealed according to an approved method. The deficiencies included two shut-off valves penetrating the 2-hour vertical fire rating. Could not verify the construction of shaft wall assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

8. On 04/21/2015 at 3:05 pm, observation revealed on the 3rd floor in the 3428-Northwest Wing Stairwell in SC-3G, that a penetrations was not sealed according to an approved method. The deficiency included a three inch diameter sprinkler pipe penetration that was not fire-sealed to the required 2-hour rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

9. On 04/20/2015 at 10:15 am, observation revealed on the 4th floor in the 4107-Stress Testing Lab Room at SC-4F, that the shaft wall was not constructed to the required fire resistance rating because the construction joint was not fire-sealed where the wall met the deck above. Fire caulking was also missing at side walls and multiple pipe and mechanical duct penetrations were not properly fire-sealed. These observed situations were not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

10. On 04/20/2015 at 11:47 am, observation revealed on the 4th floor in the 4627-South Exit Stairs in SC-4A, that the shaft wall was not constructed to the required fire resistance rating because construction joints were not sealed where the wall met the deck above. The drywall seams were observed not taped in all locations and non-compliant fire caulk was used to seal penetrations in the shaft wall construction. At time of discovery the Owner's Representative could not provide documentation of the fire caulk used. These observed situations were not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

11. On 04/20/2015 at 11:48 am, observation revealed on the 4th floor in the 4612-Southwest Wing North Exit Stairs in SC-4B, that the shaft wall was not constructed to the required fire resistance rating because the construction joints were not sealed where the wall met the deck above. The drywall seams were observed not taped in all locations and non-compliant fire caulk was used to seal penetrations in the shaft wall construction. At time of discovery the Owner's Representative could not provide documentation of the fire caulk used. These observed situations were not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

12. On 04/20/2015 at 1:50 pm, observation revealed on the 4th floor in the 4301-North Wing Suite in SC-4-I, that the shaft wall was not constructed to the required fire resistance rating because the construction joint was not sealed where the wall met the deck above. The upper corrugated metal decking was not properly fire caulked or fire sealed. Their was no intumescent fire material to stop the spread of smoke. The insulation stuffed between the metal deck and wall could not be verified it met all the requirements of a 2-hour shaft assembly against a 2-hour floor deck. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

13. On 04/21/2015 at 2:46 pm, observation revealed on the 3rd floor in the Corridor outside of North Stairwell 3311E of the North Wing at SC-3I, that the shaft wall was not constructed to the required fire resistance rating because the construction joint was not sealed where the wall met the deck above. Top-of-deck at shaft next to North Stairwell was not fire caulked and one conduit was not fire-caulked through 2-hour fire-rated assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

14. On 04/21/2015 at 3:30 pm, observation revealed on the 3rd floor in the 3444-Corridor next to far Northwest Stairwell in SC-3H, that the enclosing wall was not constructed to a 2-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. Shaft wall above ceiling was not fully taped and screws mudded and penetrations fire-sealed per an approved assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

15. On 04/22/2015 at 9:53 am, observation revealed on the 3rd floor in the Electrical Closet #3548 in SC-3C, that the shaft wall was not constructed to the required fire resistance rating because the construction joint was not sealed where the wall met the deck above. This Pediatric Inpatient Sleeping Unit (3C) was recently remodeled and the top-of-wall at vertical shaft within the electrical room was not properly fire-sealed along with seams & penetrations. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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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 exit signs when the egress path is not readily apparent, and "no-exit" signs may be confused as exits. This deficiency occurred in 1 of the 74 smoke compartments within the hospital campus and had the potential to affect 2 of the staff that were working.

FINDINGS INCLUDE:

1. On 4-20-2015 at 3:47 pm, it was observed in the 6E smoke compartment on the 6th floor in the Penthouse #6403, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Power Plant Manager).

2. On 4-20-2015 at 3:55 pm, it was observed in the 6E smoke compartment on the 6th floor in the Penthouse #6403, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Power Plant Manager).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction, and sealed wall penetrations. This deficiency occurred in 2 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/20/2015 at 12:26 pm, observation revealed on the 4th floor in the 4968-Corridor area at Smoke Barrier in 4J & 4K, that the smoke barrier wall was not compliant. The fire/smoke barrier stenciling shows 2-hour fire barrier, but the facility Life Safety Plans show 1-hour fire/smoke barrier. This is confusing and incorrect. Verification must be undertaken to verify the real condition at the smoke barrier construction and correctly identify it on the Life Safety Plans. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.7.3. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

2. On 04/20/2015 at 1:00 pm, observation revealed on the 4th floor in the 4929-West Corridor at North Wall of Smoke Barrier 4K & 4J, that penetrations were not sealed according to an approved method. These deficiencies included multiple pipe and conduits of 1/2" to 2" in diameter. These observed situations were not compliant with NFPA 101 (2000 ed.), section 18.3.7.3. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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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 smoke-tight seals at meeting edges, and pairs of opposite-swinging cross-corridor doors. This deficiency occurred in 5 of the 74 smoke compartments within this hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 11:40 am, observation revealed on the 3rd floor in the 3610 & 3611-Corridors at smoke barrier doors in SC-3B & 3A, 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 (brushes) to resist the passage of smoke. The corridor smoke barrier doors had attached vertical astragals that were non-compliant fire rated astragals. Documentation was not provided at time of survey to show they met the approved assembly or the door manufacturer fire tested requirements. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

2. On 04/21/2015 at 1:46 pm, observation revealed on the 3rd floor in the 3231-Separation Wall Barrier between Bldg. #02 & Bldg. #01, that the pair of cross-corridor smoke barrier doors did not swing in opposite directions. These doors are both Separation Barrier doors and Smoke Barrier doors, requiring the double-egress swing in new construction. Surveyor was told these Pediatric spaces were renovated in 2012. Life Safety Plans are showing double egress swinging doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.5 .

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not enclose hazardous rooms with doors with positive-latching hardware and fire-seal walls with UL approved systems. These deficiencies occurred in 3 of the 74 smoke compartments, and had the potential to affect 19 of the 440 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 4-20-2015 at 1:45 pm it was observed in the 7A smoke compartment on the 7th floor in the Equipment Storage Room #53, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Power Plant Manager).

2. On 4-20-2015 at 3:16 pm it was observed in the 6C smoke compartment on the 6th floor in the Dictation Room #6505, that the door would not self-close because the door hardware did not include a closer. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Power Plant Manager).

3. On 04/20/2015 at 10:33 am, observation revealed on the 4th floor in the Center Wing - Hazardous spaces, that the hazardous rooms were not compliant. Several of the spaces holding materials considered hazardous, were not identified on the Life Safety Plan. This was compounded by some of the rooms also located on the Separation Wall barrier. Observed several spaces with penetrations not properly fire-sealed at hazardous spaces. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. These observed situations were not compliant with NFPA 101 (2000 ed.), 19.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

4. On 04/21/2015 at 1:55 pm, observation revealed on the 3rd floor in the 3207, 3203 & 3204-Hazardous Spaces at Center Wing in SC-3F, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. The walls were not properly completed to the required fire-rating for hazardous spaces, where seams are taped and mudded and screws double mudded per their UL assembly. Also found drywall patches were not properly taped and fire-sealed. Some of the patches were 18" x 18". The room was considered hazardous because it exceeded 50 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 LL (Director Project Mgmt.).
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28616

Based on observation and interview, the facility did not provide and maintain all exit stairs with door assemblies and to meet code requirements for exits free-of-storage. This deficiency occurred in 1 of the 74 smoke compartments within the hospital campus and had the potential to affect all the staff and outside vendors that might be working at this level in a fire emergency.

FINDINGS INCLUDE:
On 4-20-2015 at 12:49 pm it was observed in the Center & North Wing Penthouses leading from the Penthouse area in the North Wing Stair Enclosure, that a portion of the stair enclosure was being used as usable space. During the survey, two (2) brooms and spare elevator doors were observed in the fire-rated North Wing Stair Enclosure. Note: The only way to get off this roof from North, Center & South Wing Penthouses is through this North Wing Stair Enclosure. The code requires that "there shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential of interfering with egress." This is the only exit off the Roof and from Penthouses at 5th Floor according to the Life Safety Plans. This observed situation was not compliant with NFPA 101 (2000 edition), sections 19.2.2.3 and 7.2.2.5.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Power Plant Manager).
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Based on observation and interview, the facility did not ensure that corridors did not have excessively long dead-ends as permitted by the code with too long of dead end corridors. This deficiency occurred in 1 of the 74 smoke compartments withn the hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/22/2015 at 11:15 am, observation revealed on the 2nd floor in the Main Entry Corridor into Psych Unit in SC-2B, that a dead-end corridor of 41+ feet was observed and the maximum allowed by code is 30'-0". This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.10. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).
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Based on observation and interview, the facility did not provide egress paths at all times with doors that swing in the direction of egress and door hardware that operated with a single release motion. These deficiencies occurred in 3 of the 74 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 2:00 pm, observation revealed on the 5th floor in the Room number 5414, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt near the door handle. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/21/2015 at 2:00 pm, observation revealed on the 2nd floor in the Room number 2983, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt near the door handle. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

3. On 04/21/2015 at 2:10 pm, observation revealed on the 5th floor in the Room number 5410, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt near the door handle. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

4. On 04/21/2015 at 2:15 pm, observation revealed on the 5th floor in the Room number 5408, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a separate dead bolt near the door handle. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

5. On 04/21/2015 at 1:46 pm, observation revealed on the 3rd floor at the 3230 & 3231-Center Wing Corridors in SC-3F, that the door in the path of egress did not swing in the direction of egress travel. This Center Wing for Pediatrics was recently renovated in 2012. The Life Safety Plans (completed in January 2015) were incorrect on double doors at the corridor. Plans showed 3231 & 3230 as double egress doors, when in fact they were one-directional doors connecting to a continuous corridor on the other side of these doors at a 2-hour smoke barrier. These should have been double-egress doors for a new renovation project per NFPA 101, section 18.3.7.5. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

6. On 04/21/2015 at 1:48 pm, observation revealed on the 3rd floor at the 3260 & 3261-Center Wing Corridors in SC-3F, that the door in the path of egress did not swing in the direction of egress travel. This Center Wing for Pediatrics was recently renovated in 2012. The Life Safety Plans (completed in January 2015) were incorrect on double doors at the corridors. Plans showed 3260 & 3261 as one-directional doors, when in fact they were double-egress doors connecting to a continuous corridor on the other side of these doors at a 2-hour smoke barrier. These should have been identified in the Life Safety Plans as double-egress doors for a new renovation project per NFPA 101, section 18.3.7.5. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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29942

Based on observation and interview, the facility did not provide and maintain corridor widths that were at least the minimal clear width required by the code. The proper width of corridors is 8'-0" fornew construction. This deficiency occurred in 1 of the 74 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 04/21/2015 at 1:49 pm, observation revealed on the 3rd floor in the 3260 & 3261-Center Wing Corridors in SC-3F, that the clear and unobstructed width of the corridor was less than 8'-0" for new construction or renovation. These corridors were observed to have bed traffic coming from the Elevator Lobby & the Pediatrics West Wing SC-3C/3E Inpatient Unit. 8'-0" wide Corridors were observed on the other side of the 2-hour smoke barrier & separation wall barrier. You cannot diminish the corridor width in a fire emergency. The double-egress requirement comes from NFPA 101, section 18.2.3.3, New Health Care Occupancies, to provide emergency patient movement in opposite directions in a fire emergency. This Center Wing Pediatrics area was renovated in 2012, as new. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. Corridors used by patients are required to be at least 8'-0" wide. Corridors used only by others (staff) must be at least 44" wide. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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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. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 04/20/2015 at 1:30 PM, during review of facility fire drill records for the past 12 months it was discovered 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. The facility's fire drill records from May 2014 to April 2015 indicated that, four (1st, 2nd, 3rd & 4th quarter) of four third-shift drills were held between 5:53 am and 6:53 am. This 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 JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).


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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with smoke detectors at required locations. This deficiency occurred in 2 of the 74 smoke compartments within the hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/22/2015 at 9:34 am, observation revealed on the 3rd floor in the Corridor Alcove #3531 in SC-3C, that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was 'missing' in the alcove not monitored 24 hours a day & 7 days a week. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).

2. On 04/21/2015 at 11:33 am surveyor observed in the 1C smoke compartment on the First Floor in the Corridor, the smoke detectors were not located in accordance with NFPA 72 requirements. Only 1 smoke detector was located in the entire corridor. This observed situation was not compliant with NFPA 101 (2000 edition), section 9.6.1.4 and NFPA 72 (1999 edition), section 2-2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (V-P Operations), staff MM (Maintenance Mechanic) and staff KK (Power Plant Manager).
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32724

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required fully-sprinkled. This deficiency occurred in 2 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 1:35 pm, observation revealed on the 5th floor in the Electrical Room #5457 (cannot find on Life Safety Plans), that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.6.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 4-22-2015 at 12:36 pm, it was observed in the 2A smoke compartment on the 2nd floor in the Activity Room #2658, that the sprinkler was placed farther than 22" below the ceiling. This situation would delay the release of water and does not satisfy listing requirements. This observed situation was not compliant with NFPA 13 (1999 edition), 5-5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Power Plant Manager).
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Based on observation, interview and a review of documents, 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 sprinklers free of lint. This deficiency occurred in 74 of the 74 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/20/2015 at 10:30 am, during a review of facility documents, it was discovered that the monthly wet sprinkler inspections did not include the gauge inspections required by the code. This situation was not compliant with NFPA 25 (1998 ed.), 2-2., 2-2.4.1 and Table 2-1. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/20/2015 at 10:45 am, during a review of facility documents, the facility could not verify that the sprinkler water pressure gauges had been replaced or calibrated within the last 5 years. This situation was not compliant with NFPA 25 (1998 ed.), 2-3.2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

3. On 04/20/2015 at 10:50 am, during a review of facility documents, the facility could not verify the sprinkler water check valves had been internally inspected within the last 5 years. This situation was not compliant with NFPA 25 (1998 ed.), 9-4.2.1. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

4. On 04/20/2015 at 11:00 am, during a review of facility documents, the facility could not verify the sprinkler water pipes had been investigated internally for obstruction within the last 5 years. This situation was not compliant with NFPA 25 (1998 ed.), Table 2-1 and section 10-2.2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

5. On 04/21/2015 at 1:30 pm, observation revealed on the 5th floor in the Storage Room #5561, that there was one or more holes near the ceiling. The holes included four 2'x2' missing ceiling 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. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

6. On 04/21/2015 at 2:20 pm, observation revealed on the 5th floor in the Room #5411A, that there was one or more holes near the ceiling. The holes included two 2'x2' missing ceiling tiles. These holes would reduce the response time of the sprinklers in the rooms and did not duplicate the tight conditions that were used in the sprinkler UL certification test. These observed situations were not compliant with NFPA 25 (1998 ed.), 1-11.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

7. On 04/21/2015 at 2:30 pm, observation revealed on the 5th floor in the Room #5409, that there was one hole near the ceiling. The hole included a 2'x2' missing ceiling tile. This hole 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 JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

8. On 4-20-2015 at 3:25 pm it was observed in the 6C smoke compartment on the 6th floor in the Toilet Room #6501, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Power Plant Manager).

9. On 04/20/2015 at 10:31 am, observation revealed on the 4th floor in the 4226 & 4227A-Center Wing Corridor, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully-operable as designed. Some of the sprinkler heads were observed to be dirty and dusty. Could not determine on-going maintenance and cleaning of sprinklers in these corridors. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

10. On 04/21/2015 at 2:58 pm surveyor observed in the 2D smoke compartment on the Second Floor floor in the Server Room, 2119, that there was one or more unsealed holes near the ceiling. The hole(s) included 6 bundles of wires that were penetrating the ceiling and the openings were not sealed. 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 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (V-P Operations) and staff KK (Power Plant Manager).

11. On 04/21/2015 at 3:02 pm surveyor observed in the 2D smoke compartment on the Second Floor floor in the Closet, 2118, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (V-P Operations) and staff KK (Power Plant Manager).

12. On 04/21/2015 at 11:46 am surveyor observed in the 1F smoke compartment on the First Floor floor in the Corridor, that the escutcheon ring on the sprinkler was a cap was falling off a sprinkler head. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (V-P Operations), staff MM (Maintenance Mechanic) and staff KK (Power Plant Manager).



29942

Based on document review and interview, the facility did not provide and implement smoking regulations that are code compliant with all the elements of a smoking program. This deficiency affects 74 of the 74 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 04/20/2015 at 2:30 pm, during a review of documents entitled "St. Mary's Hospital Tobacco Free Environment" dated February 1st, 2008, it was noted that the document did not prohibit non-responsible patients from smoking without direct supervision. This situation is not compliant with NFPA 101 (2000 ed.), section 18.7.4. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).
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Based on observation and interview, the facility did not provide a ventilation system in accordance with the manufacturer specifications and NFPA 90A (1999 ed.) with missing fire dampers, and missing fire/smoke dampers in new construction. This deficiency occurred in 5 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/20/2015 at 2:20 pm, observation revealed on the 4th floor in the 4407B-Northwest Wing at the IT Closet in SC-4D, that a fire damper was not installed in an air transfer duct that penetrated the 2-hour fire-rated wall assembly. The fire dampers were missing at both supply-air vent and return-air vent into the hazardous room because the duct-end stopped at the wall on one side and did not proceed into the room to take advantage of not having to damper a fully-ducted HVAC System in the hospital per the Building Code. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 and NFPA 90A (1999 ed.), 3-3.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

2. On 04/21/2015 at 1:25 pm, observation revealed on the 3rd floor in the Separation Wall Barrier between the Hospital (I-2 Occupancy) and the Ronald McDonald House (R-2 Occupancy) at SC-3D, that a fire/smoke damper was not installed in an air-transfer duct that penetrated the 2-hour fire-rated wall assembly. This was new construction requiring a fire/smoke damper. The required 2-hour fire-rated separation barrier was missing the combination fire/smoke dampers on the HVAC system (supply and return ducting) for new construction at Separation Barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 and NFPA 90A (1999 ed.), 3-3.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

3. On 04/20/2015 at 10:18 am, observation revealed on the 4th floor at the 4107-Stress Testing Lab Room in SC-4F, that a fire damper was not installed in an air duct that penetrated the fire-rated floor assembly. The new duct was missing both a fire and smoke damper required for a 2-hour shaft wall assembly to stop the spread of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.5.2.1 and NFPA 90A (1999 ed.), section 3-3.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based upon observation, the facility did not provide a properly enclosed linen or trash chute and appropriate collection rooms with compliant chutes. This deficiency occurred in 1 of the 74 smoke compartments within the hospital campus and had the potential to affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 04/21/2015 at 9:14 am surveyor observed in the SC-A11 smoke compartment on the Level A floor in the Dirty Linen Room, that the chute was not compliant. A laundry cart was under a chute blocking the shutter from closing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff MM (Maintenance Mechanic) and staff KK (Power Plant Manager).
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Based on observation and interview, the facility did not maintain an egress path that was free of obstructions or corridors free of materials that obstruct egress. This deficiency occurred in 1 of the 74 smoke compartments within the hospital campus and had the potential to affect all of the patients that the facility was licensed to serve in this smoke compartment, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 04/21/2015 at 10:06 am surveyor observed in the A9 smoke compartment on the Level A floor at the Corridor Doors, that items were stored in the exit access pathway, including a wheelchair that was parked in the corridor in a location that would prevent a smoke barrier door from closing. The wheelchair was stored in this location for greater than 30 minutes and was not attended by a staff person that was responsible for its use and relocation during a fire emergency. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6), and 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (V-P Operations), staff MM (Maintenance Mechanic) and staff KK (Power Plant Manager).
____________________________

Based on interview, observations and a review of facility flame spread documents, the facility did not provide hanging drapes or show curtains that met code requirements, such as; flammability or sprinkler obstructions at both cubical curtains and shower curtains. Some do not permit the designed distribution of sprinkler water. These deficiencies occurred in 3 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 2:51 pm, observation revealed on the 5th floor in the Shower Room #5967, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the shower curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/21/2015 at 3:35 pm, observation revealed on the 2nd floor in the Shower Room #2949, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the shower curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

3. On 04/21/2015 at 3:51 pm, observation revealed on the 2nd floor in the Women Locker Room #2988-Shower area, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the shower curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

4. On 04/20/2015 at 12:21 pm, observation revealed on the 4th floor in the 49B-Patient Toilet Room in SC-4J, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower stall. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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29942

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 04/22/2015 at 9:30 am, observation revealed on the 2nd floor in the Cardio OR number 4, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Three 32 gallon capacity trash containers were stored adjacent to each other in a very close proximity. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).


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Based on observation and interview, the facility did not provide the safe medical gas storage and administration areas at shut-off valve controls in accordance with NFPA 99 (1999 ed.), Standards for Health Care Facilities, with arrows indicating the flow of gas for proper signage and closers on all doors. This deficiency occurred in 5 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/20/2015 at 3:03 pm, observation revealed on the 4th floor at the 4445-Medical Gas Storage Room near Northwest Stair 4422 in SC-4H, that the door did not self-close because the door closer was removed from the door. The room was storing several different types of medical gas cylinders as follows: 11 (full) Oxygen 'E-Type' Cylinders; 1 (full) Nitrogen 'A-Type' Cylinder; 4 (empty) Oxygen 'E-Type' Cylinders; and 4 (full) Nitrous Oxide 'E-Type' Cylinders. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.2.4 and NFPA 99 (1999 ed.), section 8-3.1.11. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

2. On 04/21/2015 at 9:30 am, observation revealed on the 4th floor in the 4522-Linen Chute Room in SC-4E, that the room entry door did not have a sign with the words: "oxidizing gas stored within." No signage of oxygen trans-filling was present on the door or adjacent to the door. The space was identified as a Linen Chute Room and used as such besides also being used as a Oxygen Trans-filling Room. The room held 9 'K-Type' Cylinders, 2 large Liquid Oxygen Cylinders used for trans-filling and several 'A-Type' Oxygen Tanks. Sizes of the two Liquid Oxygen Tanks could not be determined at time of survey observation. Space for a person trans-filling and keeping the door closed during this operation is questionable. A low exhaust duct was not present in the room. This observed situation was not compliant with NFPA 99 (1999 ed.), 8-3.1.11.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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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 74 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 04/21/2015 at 2:21 pm, observation revealed on the 3rd floor in the Center Wing - Pediatric Inpatient Unit in SC-3F, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included gas movement was not identified on the pipe within the shut-off box. Gas direction is required to be shown on medical gas piping per NFPA 99 (1999 ed.), Chapter 4 and NFPA 101 (2000 ed.), Section 18.3.2.4. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), Chapter 4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility 'did not use' life support systems and did not provide an alternate and independent source of power in accordance with the Codes with adequate illumination of the egress path. This Emergency Department - Satellite location was granted full hospital prevailages with the understanding it would be operated as a Emergency Department of the Hospital.
This deficiency occurred in all of the 2 smoke compartments, and had the potential to affect all patients (when present) and an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 04/22/2015 at 9:00 am surveyor observed in the South smoke compartment on the First Floor in the Exam Room #6, that the battery back-up light did not light when tested. This observed situation was not compliant with NFPA 99 (1999 edition), sections 3.6.3.1.1, 13-3.3.2 and 3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff II (V-P Operations), staff KK (Power Plant Manager) and staff OO (Nurse Manager).
__________________________

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code, with proper use of extension cords and electrical panels with complete directories. These deficiencies occurred in 5 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 9:55 am, observation revealed on the 5th floor in the Storage Room #5607, that two strip-plug extension cords (temporary power tap) were used as a substitute for fixed wiring. One strip-plug extension cord was used to provide power to seven (7) communication equipment and in the same location, another a strip-plug extension cord was used to provide power to five (5) communication equipment. These observed situations were not compliant with NFPA 70 (1999 ed.), section 400-8. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/21/2015 at 10:25 am, observation revealed on the 5th floor in the Electrical Closet Room near Lobby 5601B, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers #34, #36, & #28 inside the Panel #CR-L-5SW-N did not have proper labeling to identify the loads they were feeding. These observed situations was not compliant with NFPA 70 (1999 ed.), Section 110-22. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

3. On 04/20/2015 at 2:50 pm, observation revealed on the 4th floor in the Corridor outside Old OR #4, currently used as a Conference Room in a SC-4H, that electrical panel breakers were not labeled to identify the loads they fed. Electrical Panel identification could not be verified at time of survey due to not having a key access to the electrical closet. The area is used for Cath Labs Procedures. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

4. On 04/20/2015 at 3:28 pm, observation revealed on the 4th floor in 4407-Electrical Service Room, that electrical panel breakers were not labeled to identify the loads they fed. Electrical Panel identification could not be verified at time of survey due to not having a key access. The area is used for Cath Labs Procedures. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

5. On 04/21/2015 at 9:00 am, observation revealed on the 4th floor in 4939B-Data Room within SC-4C, that electrical panel breakers were not labeled to identify the loads they fed. This room had a electrical Panel #B with a breaker #11 in the 'ON' position and the panel identification noted it as a spare. This electrical panel does not meet NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

6. On 04/21/2015 at 11:04 am, observation revealed on the 3rd floor in the 3601B-Highrise Elevator Lobby at Electrical Closet Room in SC-3B, that electrical panel breakers were not labeled to identify the loads they fed. Panel #CR-L-3SW-N, breakers #22 & #24 were in a 'ON' position and the breakers were identified as spares. These observed situations were not compliant with NFPA 70 (1999 ed.), Section 110-22. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

7. On 04/21/2015 at 11:08 am, observation revealed on the 3rd floor in the 3601B-Highrise Elevator Lobby at Electrical Closet Room in SC-3B, that electrical panel breakers were not labeled to identify the loads they fed. Panel #NOR-L-3SW-N, breakers #53, #55, #56, #57 & #58 were in a 'ON' position and the breakers were identified as spares. These observed situations was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

8. On 04/21/2015 at 11:10 am, observation revealed on the 3rd floor in the 3601B-Highrise Elevator Lobby at Electrical Closet Room in SC-3B, that a electrical panel breaker was not labeled to identify the loads they fed. Panel #NOR-L-3SW-N, breaker #14 was in a 'ON' position and the breaker was identified as a spare. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

9. On 04/22/2015 at 9:49 am, observation revealed on the 3rd floor in the Electrical Closet Room #3548 in SC-3C, that electrical panel breakers were not labeled to identify the loads they fed. Panel #L3WB-1, was missing the identification card for the entire electrical panel and could not be found anywhere on the Pediatric Inpatient Sleeping Unit, this area was recently remodeled with adjoining areas. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).

10. On 04/22/2015 at 10:48 am, observation revealed on the 2nd floor in the Electrical Closet Room #2601B in SC-2B, that electrical panel breakers were not labeled to identify the loads they fed. Electrical Panel #CR-L-2SW-N, breakers #21 & #23; Panel #LS-L-2-SW-N, breaker #12; and Panel #NOR-L-2SW-N, breaker #60 & #76 were found to have breakers in the 'ON' position and were marked as spares; Electrical Panel #NOR-L-2SW-N could not be closed and latched because the panel doors were broken. All of these electrical panels were near the Psychiatric Inpatient Sleeping Unit, recently remodeled with adjoining areas. These observed situations were not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).
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29942

Based on document review and interview, the facility did not provide and use a program to respond to outages of the automatic sprinkler system by having complete procedures for responding to outages. This deficiency would affect 74 of the 74 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 04/20/2015 at 4:15 pm, during a review of facility documents, the facility policy document entitled "Fire Watch Policy" dated April 26th, 2013 did not describe the actions to be taken if the automatic sprinkler systems were out-of-service for more than 4 hours in a 24-hour period. This situation was not compliant with NFPA 101 (2000 ed.), section 9.7.6.1. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).
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Based on document review and interview, the facility did not provide and use a program to respond to outages of the fire alarm system by having complete procedures for responding to outages. This deficiency occurred in 74 of the 74 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 04/20/2015 at 4:12 pm, during a review of facility documents the facility policy document entitled "Fire Watch Policy" dated April 26th, 2013 did not describe the actions to be taken if the fire alarm systems were out-of-service for more than 4 hours in a 24-hour period. This situation was not compliant with NFPA 101 (2000 ed.), section 9.6.1.8. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).
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