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Based on observation and staff interview, it was determined that the facility failed to arrange and maintain access to another smoke compartment in accordance with Life Safety Code Section 18.3.7.1 and Chapter 7. This was evidenced by the following:


During the course of a walkthrough of the addition of the new emergency department it was noted that the doors from the entryway vestibule, waiting room, and visitor bathrooms to the Emergency Department had been locked without provision of the delayed egress device that had been agreed to during construction by the hospital ' s design team in consultation with CDPHE staff. By locking these doors the facility prevents access to a smoke barrier and separate smoke compartment as required by of LSC Chapter 18, New Health Care Occupancies, Section 18.3.7.1. The facility is citing security needs as the purpose for locking these doors. Under the currently adopted edition of the LSC the " clinical needs of the patient " is an allowable condition under which a facility may lock doors in the means of egress however security is not recognized as acceptable justification to lock doors. The facility contends that the entry spaces and corridor within the addition will meet equivalency when evaluated through NFPA 101A Alternative Approaches to Life Safety.


The reduction in the egress capacity has the potential to affect all occupants in the rooms from which egress is obstructed who would use this door as a means of accessing a smoke barrier.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on observation during the survey, it was determined that the facility failed to maintain hazardous area enclosures in accordance with the Life Safety Code Section 19.3.2.1 and Section 8.4. This was evidenced by the following:

Hazardous area enclosure doors were not provided with a self-closing device and positively latching and there were unsealed penetrations in smoke resistant wall, as required at the following locations:
a. Vacant sleeping room number 110 used as storage
b. Vacant sleeping room number 111 used as storage
c. Storage room 114

The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 19.3.2.1 and Section 8.4. Section 19.3.2.1 requires that hazardous area enclosures in (within fully sprinklered buildings) be smoke resistant and that the doors be self-closing or automatic closing.
The diminishment of the functionality of this fire containment around hazardous areas has the potential to affect all patients, staff , and visitor occupants in the rooms within the smoke compartment in the event of a fire at this location.

The deficiency items were discussed during the survey with the facility maintenance staff and again during the exit conference with the hospital administrator.

Based on observation, it was determined that the facility failed to arrange and maintain the travel distance along the means of egress within a suite of rooms in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:
A shelving unit had been placed in front of the door from the surgical central storeroom to the main corridor. This created a travel distance from surgical managers office through two intervening rooms to an exit access door of greater than 50 feet in violation of the Life Safety Code Section 19.2.5.8. The shelving unit was moved out of the way of the means of egress during the course of the inspection.
The reduction in the egress capacity has the potential to affect all staff in the surgical managers office who would use this door as an alternate means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2.1 and Chapter 7. This was evidenced by the following:

A) Access controlled corridor doors from the current emergency department suite to the exit corridor were not arranged in accordance with Life Safety Code Section 7.2.1.6.2, as required. The doors had magnetic holds installed which did not meet the following provisions of Life Safety Code 7.2.1.6.2:
a) " A sensor shall be provided on the egress side and
arranged to detect an occupant approaching the doors, and
the doors shall be arranged to unlock in the direction of
egress upon detection of an approaching occupant or loss of
power to the sensor. " . . .

c) " The doors shall be arranged to unlock in the direction
of egress from a manual release device located 40 in. to 48 in.
(102 cm to 122 cm) vertically above the floor and within 5 ft
(1.5 m) of the secured doors. The manual release device shall
be readily accessible and clearly identified by a sign that reads
as follows:
PUSH TO EXIT
When operated, the manual release device shall result in
direct interruption of power to the lock - independent of the
access control system electronics - and the doors shall
remain unlocked for not less than 30 seconds. "
B) The set of doors from the surgical suite to the post acute care unit had a hasp and lock arrangement which, if locked would prevent free egress from the surgical suite through this required means of egress. This arrangement is in violation of the provisions of Life Safety Code section 7.2.1.5.1 which requires doors to be arranged to be readily opened from the egress side without the use of a key, tool, or special knowledge.
C) The set of doors from the post acute care unit to the corridor had a thumbscrew lock arrangement which, if locked would require two releasing actions to egress from the pacu through this required means of egress. This arrangement is in violation of the provisions of Life Safety Code section 7.2.1.5.4 which requires doors to be arranged to be " operable with not more than one releasing operation " .

The reduction in the egress capacity has the potential to affect all patients and staff in the rooms from which egress is obstructed who would use this door as a means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on observation during the survey, it was determined that the facility failed to maintain egress corridors subject to use by patients of the facility that were of the required 8 foot width (in the portions of the building were new construction took place and hence subject to the "New" chapter 18 of the Life Safety Code) in accordance with Life Safety Code Section 18.2.3.3. This was evidenced by the following:

New construction of the CICP registration offices in the former waiting area open to the corridor have reduced the corridor width to 7 feet 6 inches in one location and to 7 feet 2 inches in another.

The reduction in the egress capacity has the potential to affect all patients, staff, and other occupants of the first floor who would use this corridor as an alternate means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

It was determined through record review during the survey that the facility failed to maintain a fire safety plan in accordance with the Life Safety Code, Section 19.7.2.2. This was evidenced by:

At the time of the survey, the facility failed to provide documentation to reflect that the required element of the facility ' s fire safety plan related to " Evacuation of smoke compartment " had been incorporated into the facility ' s plan and ongoing training for staff. NFPA 101 (2000 edition) states:

19.7.2.2 A written health care occupancy fire safety plan shall
provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

Failure of the staff to be familiar with the appropriate procedures in the event of a fire threatens all patients, staff, and other occupants of the entire building.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

A) Sprinkler heads were not maintained to be free of paint overspray, as required. One sprinkler head was observed to be painted in the bathroom of patient room 102.
B) Sprinkler heads were not maintained to be free of loading, as required. Sprinkler heads were observed to be loaded with material in the following locations:
a. Laboratory by back window
b. Room 103
c. Room 104
d. Room 105
e. Room 106
f. Room 107
g. Room 108
h. Room 111
i. Room 115
j. Room 122
k. Room 123
C) Sprinkler heads were not maintained to be free of leaking and corrosion, as required. Sprinkler heads were observed to be leaking and corroded in the following locations:
a. clean linen room on the 2nd floor
b. Room 103
c. Room 104
d. Room 115
e. Room 118
f. Room 119
g. Room 122
h. Room 123
i. Room 124

The diminishment of the functionality of this fire suppression system has the potential to affect all occupants in the rooms from which egress would be obstructed in the event of a fire at this location which the sprinkler would suppress as well as delaying notification to all occupants of the fire zone of the presence of a fire through fire alarm activation of the water flow switch.

The deficiency items were discussed during the survey with the facility maintenance staff and again during the exit conference with the hospital administrator.

Based on observation during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10 and 7.3.2. This was evidenced by the following:

Designated egress corridors were not continuously maintained free of obstructions and impediments to full instant use, as required. Egress corridors were observed to be obstructed in the following location: The administrative corridor to the surgery locker-rooms was obstructed by mobile shelving units reducing the corridor width to 24 inches.
The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

The reduction in the egress capacity has the potential to affect all staff in the locker rooms who would use this corridor as an alternate means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 99-Health Care Facilities and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

A) Level 1 Emergency Power Supplies were not installed within a room having emergency lighting charging served by the load side of the transfer switch, as required. The main generator enclosure was observed to have emergency lighting devices served by the city supplied power circuit without provisions for charging of the emergency lighting batteries by the load side of the transfer switch as required by NFPA 110.

NFPA 110 Section 5-3.1 requires:
" The Level 1 or Level 2 EPS equipment location shall be
provided with battery-powered emergency lighting. The emergency
lighting charging system and the normal service room
lighting shall be supplied from the load side of the transfer
switch. "

The diminishment of the ability to troubleshoot a problem with the generator during a power outage has the potential to affect all patients, staff , and visitor occupants ability to safely egress the facility through loss of emergency lighting and egress path marking in the event of a fire at this location.

The deficiency items were discussed during the survey with the facility maintenance staff and again during the exit conference with the hospital administrator.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 18.2.5.10 and Chapter 7. This was evidenced by the following:

During the course of a walkthrough of the addition of the new emergency department it was noted that the doors from the entryway vestibule, waiting room, and visitor bathrooms to the Emergency Department had been locked without provision of the delayed egress device that had been agreed to during construction by the hospital ' s design team in consultation with CDPHE staff. The locking of these doors creates a " dead-end " corridor of greater than 30 feet in violation of LSC Chapter 18, New Health Care Occupancies, Section 18.2.5.10. The facility is citing security needs as the purpose for locking these doors. Under the currently adopted edition of the LSC the " clinical needs of the patient " is an allowable condition under which a facility may lock doors in the means of egress however security is not recognized as acceptable justification to lock doors. The facility contends that the entry spaces and corridor within the addition will meet equivalency when evaluated through NFPA 101A Alternative Approaches to Life Safety.

The reduction in the egress capacity has the potential to affect all occupants in the rooms from which egress is obstructed who would use this door as a second means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on record review during the course of the survey, it was determined that the facility failed to install and maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This was evidenced by the following:

A review of panelboard branch circuit index cards noted the following deficiencies:

The Critical Branch of the essential electrical system was supplying branch circuits that were not related to patient care in accordance with Section 3-4.2.2.2 (c).
The following circuit breakers related to the new construction within the hospital, as identified on the panelboard index card, were not related to patient care and/or exceeded the allowed motor size:

1) Panelboard ECL1A2: " Copying "
2) Panelboard ECL1A2: " Registration CICP "
3) Panelboard ECL1A: " Time Clock "

NFPA 99 Section 3-4.2.2.2 (c) Critical Branch.: The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation.
10. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Failure of the essential electrical system due to overloading of the generator and failure of the ability to load shed during peak demand periods could result in a generator failure and thereby threatens all patients, staff, and other occupants of the entire building.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

It was determined through record review during the survey that the facility failed to document that it was conducting periodic testing of emergency Lighting Equipment in accordance with the Life Safety Code, Section 7.9.3. This was evidenced by:

At the time of the survey, the facility failed to provide documentation to reflect that the facility was testing its emergency lighting equipment every 30 days for a period of no less than 30 seconds and every year for a period of no less than 90 minutes as required by Life Safety Code , Section 7.9.3. According to the facility maintenance director the records were maintained on a computer which lost its hardrive in January of 2013 and hence he could not produce the documentation of the testing that the facility had been doing for the past four years.

The diminishment of the ability to ensure the functioning of the emergency egress lighting in the event of an emergency has the potential to affect all patients, staff , and visitor occupant ' s ability to safely egress the facility.

The deficiency items were discussed during the survey with the facility maintenance staff and again during the exit conference with the hospital administrator.

It was determined through observation during the survey that the facility failed to install Alcohol Based Hand Rub Dispensers in a safe and appropriate manner. This was evidenced by:

The following alcohol-based hand sanitizer dispensers were located above an electrical device:
a. Next to the main entrance door in the laboratory.

The dispenser unit was moved away from the electrical device during the course of the inspection.
The added potential for a fire presented by this source of fuel in close proximity to a heat source has the potential to affect all occupants in the rooms from which egress would be obstructed in the event of a fire at this location who would use this door as a means of egress.

The deficiency items were discussed during the survey with the facility maintenance staff and again during the exit conference with the hospital administrator.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain access to another smoke compartment in accordance with Life Safety Code Section 18.3.7.1 and Chapter 7. This was evidenced by the following:


During the course of a walkthrough of the addition of the new emergency department it was noted that the doors from the entryway vestibule, waiting room, and visitor bathrooms to the Emergency Department had been locked without provision of the delayed egress device that had been agreed to during construction by the hospital ' s design team in consultation with CDPHE staff. By locking these doors the facility prevents access to a smoke barrier and separate smoke compartment as required by of LSC Chapter 18, New Health Care Occupancies, Section 18.3.7.1. The facility is citing security needs as the purpose for locking these doors. Under the currently adopted edition of the LSC the " clinical needs of the patient " is an allowable condition under which a facility may lock doors in the means of egress however security is not recognized as acceptable justification to lock doors. The facility contends that the entry spaces and corridor within the addition will meet equivalency when evaluated through NFPA 101A Alternative Approaches to Life Safety.


The reduction in the egress capacity has the potential to affect all occupants in the rooms from which egress is obstructed who would use this door as a means of accessing a smoke barrier.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on observation during the survey, it was determined that the facility failed to maintain hazardous area enclosures in accordance with the Life Safety Code Section 19.3.2.1 and Section 8.4. This was evidenced by the following:

Hazardous area enclosure doors were not provided with a self-closing device and positively latching and there were unsealed penetrations in smoke resistant wall, as required at the following locations:
a. Vacant sleeping room number 110 used as storage
b. Vacant sleeping room number 111 used as storage
c. Storage room 114

The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 19.3.2.1 and Section 8.4. Section 19.3.2.1 requires that hazardous area enclosures in (within fully sprinklered buildings) be smoke resistant and that the doors be self-closing or automatic closing.
The diminishment of the functionality of this fire containment around hazardous areas has the potential to affect all patients, staff , and visitor occupants in the rooms within the smoke compartment in the event of a fire at this location.

The deficiency items were discussed during the survey with the facility maintenance staff and again during the exit conference with the hospital administrator.

Based on observation, it was determined that the facility failed to arrange and maintain the travel distance along the means of egress within a suite of rooms in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:
A shelving unit had been placed in front of the door from the surgical central storeroom to the main corridor. This created a travel distance from surgical managers office through two intervening rooms to an exit access door of greater than 50 feet in violation of the Life Safety Code Section 19.2.5.8. The shelving unit was moved out of the way of the means of egress during the course of the inspection.
The reduction in the egress capacity has the potential to affect all staff in the surgical managers office who would use this door as an alternate means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2.1 and Chapter 7. This was evidenced by the following:

A) Access controlled corridor doors from the current emergency department suite to the exit corridor were not arranged in accordance with Life Safety Code Section 7.2.1.6.2, as required. The doors had magnetic holds installed which did not meet the following provisions of Life Safety Code 7.2.1.6.2:
a) " A sensor shall be provided on the egress side and
arranged to detect an occupant approaching the doors, and
the doors shall be arranged to unlock in the direction of
egress upon detection of an approaching occupant or loss of
power to the sensor. " . . .

c) " The doors shall be arranged to unlock in the direction
of egress from a manual release device located 40 in. to 48 in.
(102 cm to 122 cm) vertically above the floor and within 5 ft
(1.5 m) of the secured doors. The manual release device shall
be readily accessible and clearly identified by a sign that reads
as follows:
PUSH TO EXIT
When operated, the manual release device shall result in
direct interruption of power to the lock - independent of the
access control system electronics - and the doors shall
remain unlocked for not less than 30 seconds. "
B) The set of doors from the surgical suite to the post acute care unit had a hasp and lock arrangement which, if locked would prevent free egress from the surgical suite through this required means of egress. This arrangement is in violation of the provisions of Life Safety Code section 7.2.1.5.1 which requires doors to be arranged to be readily opened from the egress side without the use of a key, tool, or special knowledge.
C) The set of doors from the post acute care unit to the corridor had a thumbscrew lock arrangement which, if locked would require two releasing actions to egress from the pacu through this required means of egress. This arrangement is in violation of the provisions of Life Safety Code section 7.2.1.5.4 which requires doors to be arranged to be " operable with not more than one releasing operation " .

The reduction in the egress capacity has the potential to affect all patients and staff in the rooms from which egress is obstructed who would use this door as a means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on observation during the survey, it was determined that the facility failed to maintain egress corridors subject to use by patients of the facility that were of the required 8 foot width (in the portions of the building were new construction took place and hence subject to the "New" chapter 18 of the Life Safety Code) in accordance with Life Safety Code Section 18.2.3.3. This was evidenced by the following:

New construction of the CICP registration offices in the former waiting area open to the corridor have reduced the corridor width to 7 feet 6 inches in one location and to 7 feet 2 inches in another.

The reduction in the egress capacity has the potential to affect all patients, staff, and other occupants of the first floor who would use this corridor as an alternate means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

It was determined through record review during the survey that the facility failed to maintain a fire safety plan in accordance with the Life Safety Code, Section 19.7.2.2. This was evidenced by:

At the time of the survey, the facility failed to provide documentation to reflect that the required element of the facility ' s fire safety plan related to " Evacuation of smoke compartment " had been incorporated into the facility ' s plan and ongoing training for staff. NFPA 101 (2000 edition) states:

19.7.2.2 A written health care occupancy fire safety plan shall
provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

Failure of the staff to be familiar with the appropriate procedures in the event of a fire threatens all patients, staff, and other occupants of the entire building.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

A) Sprinkler heads were not maintained to be free of paint overspray, as required. One sprinkler head was observed to be painted in the bathroom of patient room 102.
B) Sprinkler heads were not maintained to be free of loading, as required. Sprinkler heads were observed to be loaded with material in the following locations:
a. Laboratory by back window
b. Room 103
c. Room 104
d. Room 105
e. Room 106
f. Room 107
g. Room 108
h. Room 111
i. Room 115
j. Room 122
k. Room 123
C) Sprinkler heads were not maintained to be free of leaking and corrosion, as required. Sprinkler heads were observed to be leaking and corroded in the following locations:
a. clean linen room on the 2nd floor
b. Room 103
c. Room 104
d. Room 115
e. Room 118
f. Room 119
g. Room 122
h. Room 123
i. Room 124

The diminishment of the functionality of this fire suppression system has the potential to affect all occupants in the rooms from which egress would be obstructed in the event of a fire at this location which the sprinkler would suppress as well as delaying notification to all occupants of the fire zone of the presence of a fire through fire alarm activation of the water flow switch.

The deficiency items were discussed during the survey with the facility maintenance staff and again during the exit conference with the hospital administrator.

Based on observation during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10 and 7.3.2. This was evidenced by the following:

Designated egress corridors were not continuously maintained free of obstructions and impediments to full instant use, as required. Egress corridors were observed to be obstructed in the following location: The administrative corridor to the surgery locker-rooms was obstructed by mobile shelving units reducing the corridor width to 24 inches.
The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

The reduction in the egress capacity has the potential to affect all staff in the locker rooms who would use this corridor as an alternate means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 99-Health Care Facilities and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

A) Level 1 Emergency Power Supplies were not installed within a room having emergency lighting charging served by the load side of the transfer switch, as required. The main generator enclosure was observed to have emergency lighting devices served by the city supplied power circuit without provisions for charging of the emergency lighting batteries by the load side of the transfer switch as required by NFPA 110.

NFPA 110 Section 5-3.1 requires:
" The Level 1 or Level 2 EPS equipment location shall be
provided with battery-powered emergency lighting. The emergency
lighting charging system and the normal service room
lighting shall be supplied from the load side of the transfer
switch. "

The diminishment of the ability to troubleshoot a problem with the generator during a power outage has the potential to affect all patients, staff , and visitor occupants ability to safely egress the facility through loss of emergency lighting and egress path marking in the event of a fire at this location.

The deficiency items were discussed during the survey with the facility maintenance staff and again during the exit conference with the hospital administrator.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 18.2.5.10 and Chapter 7. This was evidenced by the following:

During the course of a walkthrough of the addition of the new emergency department it was noted that the doors from the entryway vestibule, waiting room, and visitor bathrooms to the Emergency Department had been locked without provision of the delayed egress device that had been agreed to during construction by the hospital ' s design team in consultation with CDPHE staff. The locking of these doors creates a " dead-end " corridor of greater than 30 feet in violation of LSC Chapter 18, New Health Care Occupancies, Section 18.2.5.10. The facility is citing security needs as the purpose for locking these doors. Under the currently adopted edition of the LSC the " clinical needs of the patient " is an allowable condition under which a facility may lock doors in the means of egress however security is not recognized as acceptable justification to lock doors. The facility contends that the entry spaces and corridor within the addition will meet equivalency when evaluated through NFPA 101A Alternative Approaches to Life Safety.

The reduction in the egress capacity has the potential to affect all occupants in the rooms from which egress is obstructed who would use this door as a second means of egress.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

Based on record review during the course of the survey, it was determined that the facility failed to install and maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This was evidenced by the following:

A review of panelboard branch circuit index cards noted the following deficiencies:

The Critical Branch of the essential electrical system was supplying branch circuits that were not related to patient care in accordance with Section 3-4.2.2.2 (c).
The following circuit breakers related to the new construction within the hospital, as identified on the panelboard index card, were not related to patient care and/or exceeded the allowed motor size:

1) Panelboard ECL1A2: " Copying "
2) Panelboard ECL1A2: " Registration CICP "
3) Panelboard ECL1A: " Time Clock "

NFPA 99 Section 3-4.2.2.2 (c) Critical Branch.: The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation.
10. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Failure of the essential electrical system due to overloading of the generator and failure of the ability to load shed during peak demand periods could result in a generator failure and thereby threatens all patients, staff, and other occupants of the entire building.

The deficiency item was discussed with facility maintenance staff during the survey and again during the exit conference with the facility administrator.

It was determined through record review during the survey that the facility failed to document that it was conducting periodic testing of emergency Lighting Equipment in accordance with the Life Safety Code, Section 7.9.3. This was evidenced by:

At the time of the survey, the facility failed to provide documentation to reflect that the facility was testing its emergency lighting equipment every 30 days for a period of no less than 30 seconds and every year for a period of no less than 90 minutes as required by Life Safety Code , Section 7.9.3. According to the facility maintenance director the records were maintained on a computer which lost its hardrive in January of 2013 and hence he could not produce the documentation of the testing that the facility had been doing for the past four years.

The diminishment of the ability to ensure the functioning of the emergency egress lighting in the event of an emergency has the potential to affect all patients, staff , and visitor occupant ' s ability to safely egress the facility.

The deficiency items were discussed during the survey with the facility maintenance staff and again during the exit conference with the hospital administrator.