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Based on random observation, during the survey walk-through, the building construction type does not comply with 19.1.6.2. including any exceptions. This condition may affect patients, staff, and visitors within the upper floors of the building during a fire event.

A. Morning of May 16th, Room # 8470 the surveyor observed exposed steel roof construction to determine that the building construction type is Type II (000). Although the building is sprinkler protected the building's story height does not allow for unprotected steel members.
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Based on random observation during the survey walk-through on May 15, 2012, not all interior finishes comply with applicable requirements of the Life Safety Code. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of compliance can expose occupants to harmful fire and smoke conditions.
Findings include:

A. Wood paneling wall finishes and framing was observed in the 1st floor St. Anthony's Shrine room that could not be confirmed to conform to Class A, B, or C in accordance with 19.1.6.3, 19.3.3.2 and 10.2.3. Although the room is sprinkler protected and the door to this room was observed to be a 'B' label fire door, the enclosing walls were not confirmed to provide a fire resistance rated assembly. (An access door in the corridor wall accesses areas behind the backlit stained glass.) The space was not provided with smoke detection as an additional protective feature.

B. CORRECTED 02/01/13

A. CORRECTED 02/01/13
B. CORRECTED 02/01/13


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Based on random observation, during the survey walk-through, use areas in corridors (or open to corridors) do not comply with 19.3.6.1. exception 1. This condition may affect patients, staff, and visitors within the adjacent egress corridor during a fire emergency.

C. May 15th at 11:10am 4th floor Work area 4314 (which is greater than 64 square feet) was observed open to the corridor further it is not located to permit direct observation by staff and is not smoke detected to comply with 19.3.6.1, Exception 1.

Based on random observation during the survey walk-through on May 16, 2012, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of protection could result in smoke compromising the facility's exit access corridors.

Findings include:

A. CORRECTED 01/31/13

B. The 2nd floor area containing the former Bone Scan 2022 room and the former Nuclear Med rooms 2024 & 2025 is not identified as a suite. These rooms are either provided with a curtain or an accordian door. The spaces are considered open to the corridor in non-compliance with 19.3.6.1.

C. CORRECTED 01/31/13

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.
Findings include:

A. CORRECTED 02/01/13


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B. CORRECTED 02/01/13

C. The east pair of doors from the Kitchen were not positive latching to comply with 19.3.6.3.2. (The doors were equipped with manual flush bolts and an astragal without a coordinator.)

D. The west pair of Kitchen doors (27209?) did not close to a latched condition under fire alarm testing.

Based on random observation during the survey walk-through on the morning of May 16, 2012, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. Corridor doors are not provided with positive latching hardware at the following locations:

1. CORRECTED 01/31/13

2. 3rd floor, the corridor doors to Neuro #20 room 3137 and #21 room 3138 are not positive latching.

3. 3rd floor corridor doors from the substerile alcove serving Neuro #20 and #21 are double acting without stops and not smoketight.

4. 2nd floor corridor doors at Radiology Recovery Suite 2150 were observed not to be positive latching when the auto opener drops out under fire alarm activation. The doors do not close far enough to latch.


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B. CORRECTED 01/31/13

A. CORRECTED 01/31/13


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Based on random observation during the survey walk-through, not all stair or shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 2000, 18.3.1.1 and 8.2.5. Findings include:
B. On 5/16/12 at 8:55AM, observations determined that Stair 8 - 2nd floor at the back of the shell / storage room contains a sign in the stairwell " system out of order " without identifying what system was not functioning. It was not obvious (no signs posted) if the stairs located in the new facility were designed to be an area of refuge in accordance with NFPA 101, 2000 7.2.12.3.1. The system that was not functional may be the 2 way communication as required by 7.2.12.2.6 or the communication to central control as required by 7.2.12.2.5.
UPDATE 01/31/13 hardware is being ordered for the new communication station located on the Main Level.

Based on random observation during the survey walk through not all vertical openings are protected to comply with 19.3.1 and 8.2.5.2. This could contribute to the lack of containment during a fire event. This condition could affect all patients, staff and visitors on two floor levels.


A. On the morning of May 15, 2012, the 8th floor Chute rooms 8498 and 8465 were observed to have both chute access doors in both rooms that did not latch to the closed position.


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Based on random observation during the survey walk-through on May 15, 2012, not all stairs ventilation shafts and/or pipe shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

B. Based on random observation during the survey walk-through, not all stair or shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 2000, 19.3.1.1 and 8.2.5.
1. On 5/15/12 at 11:10 AM, observations determined that the Storage Room (2301 B), contains a 2 hour rated shaft. The door to the shaft was not self closing to a latched position.


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C. The access door for the dumbwaiter shaft located in the Ground floor Kitchen was observed not to be self-closing to a latch condition and was left open. The door did not maintain the required fire resistive rating for the shaft to comply with 19.3.1.1.


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D. At 1:21 PM on May 15, 2012, a series of pipe penetrations through the 2 hour fire rated floor assembly, in the pipe chase between Fifth Floor Soiled utility Room 5409 and Women's Toilet room 5450, were observed to not be sealed against the passage of fire in accordance with 8.2.3.2.4.2.


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E. CORRECTED 02/01/13

F. Main Building - 3rd Floor, Shaft T3066- A duct located in the corner of this shaft is partially engaged in the wall construction. A fire barrier to properly separate the shaft to comply with 19.3.1.1 and 8.2.5.4 could not be confirmed.

G. Main Building - 3rd Floor. Dutwork was observed located in the Mechanical Room 3451 which appears to penetrate uppers floors and below and not provided with fire dampers to comply with 8.2.3.2.4.1. NFPA 90A 1999 3-3.1.1. The Life Safety drawings do not indicate a fire separation in this Room. It was also observed that this same room is being used to store paint materials, etc.
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Based on random observation, during the survey walk-through, exit discharge signage is not present within the stairways. This condition may affect patients, staff, and visitors for a safe means of egress to a discharge during a fire emergency.

A. May 16th at 9:10am Surveyor was unable to locate signage within a stair enclosure that identifies the story, the top and bottom terminus, and the stair enclosure identification to comply with19.2.10.1, 7.10 and 7.2. Location observed: 4th floor landing of Stair 4022.
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Based on random observation during the survey walk through, not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1. Sprinklered Hazardous Areas are not properly separated in accordance with 8.4.1. This condition may prevent staff and visitors within the means of egress against safe passage to an exit discharge.
Findings include:
A. CORRECTED 02/01/13
B. CORRECTED 02/01/13


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C. CORRECTED 02/01/13


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D. Main Building - On 05/17/12 1:30PM, 3rd Floor : Designated Storage Room T3077 is not separated from the corridor. Life safety drawings do not indicate this storage to be a hazardous area but it is not separated from the corridor due to the opening by the Work Area T3074 and Nurse Station T3072. This room contains shelves with equipment and other materials and does not comply with 19.3.2.1 (7) and 8.4.


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E. On May 16th 8:15am, the 4th floor room 4519 corridor door of a deemed hazardous area (life safety floor plan reads classroom however being used as equipment storage) contains a manual hold open device which prevents the door from being self closing and does not comply with 19.3.2.1

F. On May 16th 9:15am, the 4th floor storage room 4501 corridor door contains a manual hold open device which prevents the doors from being self closing and does not comply with 19.3.2.1

A. CORRECTED 02/01/13
B. CORRECTED 02/01/13
C. CORRECTED 02/01/13
D. CORRECTED 02/01/13.


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Based on random observation during the survey walk through, not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1. Hazardous areas (sprinkler protected) are not separated from exit access corridors. This condition may prevent staff and visitors within the means of egress against safe passage to an exit discharge.

E. CORRECTED 02/01/13

F. May 16th 9:15am 4th floor storage room # 4501 corridor door contains a manual hold open device which prevents the doors from being self closing and does not comply with 19.3.2.1

G. May 16th 9:30am 4th floor (Children's Hospital building) ISO room # 4269A is currently being used as storage for staff gowns, contains doors which are not self closing and does not comply with 19.3.2.1

Based on random observation during the survey walkthrough not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.

A. On 05/15/12 at 2:00pm 3rd floor West Stair C3100, The Life Safety plans indicate that the identified Shaft T3160 is part of the 2-hour stair enclosure and not separated from the stair and does not comply with 19.3.1.1.
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Based on random observation during the survey walkthrough not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.


A. May 16th at 2:30pm 1st floor Stair S1001, The Life Safety plans indicate that Corridor T1243 is part of the 2-hour stair enclosure. A through wall transfer grille is directly connected to a vertical duct within a shaft. The shaft contains multiple ductwork that does not serve the stair enclosure. Therefore, the shaft is open to the stair and does not comply with 19.3.1.1.

Based on observation during the Federal Monitoring survey walk through not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.
The findings are:

A. On 02/01/13, The West exit stair (Stair X701), discharges into a corridor. There is no separation between the stair and the corridor. (The corridor is located on the Ground floor level between Forest Park and Radioation/Oncology). This does not comply with 19.3.1.1

B. On 02/01/13, The West exit stair (Stair X701) does not appear to comply with 7.7.2 for a minimum of 50% of the exit stairs to discharge directly to the exterior. This stair appears to discharge internally to a corridor.

C. On 02/01/13, The west corridor wall (between Forest Park and Radiation/Oncology) on the Ground floor discharge level contains an insulated pipe (on the Radiation/Oncology side of the wall) within the required 2-hour fire resistant building separation which does not comply with 19.1.2.3.

Based on random observation during the survey walk-through on May 15, 2012, exit access was not readily accessible at all times in accordance with 7.1 and 19.2.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.
Findings include:

A. Door hardware is provided on exit access doors which may require a second operation to open the door or will prevent egress in noncompliance with 7.2.1.5.4. Conditions observed include:

1. CORRECTED 02/01/13

2. The Ground floor corridor area TG101 directs exiting thru the 2-hour barrier into the CH building. The cross corridor door within the CH building at corridor TG113 is provided with a magnetic locking device without delayed egress function in non-compliance with 19.2.2.2.4 Exception No. 2 and 7.2.1.6.1. The corridors constitute a dead end condition.

3. CORRECTED 02/01/13
4. CORRECTED 02/01/13

Based on observation during the Federal Monitoring survey walk through while accompanied by the facility representatives, doors in exit access corridors were observed which do not comply with 7.2.1.4.4. This deficiency could affect all patients, visitors and staff by compromising the prompt care and movement of occupants during a fire/smoke emergency.
The finding is:

A. On 02/01/13 the surveyor observed patient room doors which extended into the required 8 foot width of the corridor a minimum of 11inches on both sides of the corridor. This was observed for every patient room on the second floor corridor. An example location is room # 2200.


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Based on random observation during the survey walk through, exit access is not accessible at all times to comply with 19.2.1. Designated egress doors were observed in the locked position. This condition may delay staff from gaining access to a means of egress during a fire event.

A. Main Building - The 3rd Floor Office Room T3277 has a corridor door with a dead bolt lock and a lockset. This condition requires more than 1 releasing operation for egress and does not comply with 7.2.1.5.4.


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B. May 16th at 9:40am, 4th floor Room # 4265 contains a corridor access door secured against egress which does not comply with 7.2.1.5.1.
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All inside stairs serving as an exit or exit component shall be enclosed in accordance with NFPA 101, 2000, 7.1.3.2.
Findings include:
A. On 5/15/12 at 11:00 AM, observations determined that the window from the South Stair (by turret)is exposed by other parts of the building at an angle of less than 180 degrees that are non-rated and within 10 ' -0 " which is not permitted based on NFPA 101, 7.2.2.5.2.


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Fire separation barriers are not maintained in accordance with 19.1.2.3 and 8.2.3. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the different occupancies.

Findings include:

B. The 1st floor 2-hour barrier doors 27215 between the Main Hospital building and the Chapel building were observed to have a pair of doors which could be opened in a sequence that would not allow them to return to the closed and latched condition due to the latch bolt and strike plate arrangement provided on the doors. An arrangement similar to the doors at Stair T1031 appeared to be required.

C. The Ground floor 2-hour barrier doors 72172 which access the Tunnel did not close to a latched condition.

Based upon review of the facility's life safety plans and observation during the survey walk-through, horizontal exits do not comply with 19.2.2.5 and 7.2.4. This deficiency could delay the access to an exit and the activation of the fire alarm in multiple fire/smoke compartments and affect patients, staff and visitors.

Findings include:

D. The plans indicate that a horizontal exit exists on the Ground floor between the Main Hospital building and the CH building. However, horizontal exits do not exist on other floors of the building which provide a separation continuous to ground in accordance with 7.2.4.3.1.

E. The plans do not indicate and it was not observed that manual fire alarm pull stations exist on each side of all designated double egress horizontal exits (or designated 2-hour fire barriers which could be considered as meeting the horizontal exit requirements) to comply with NFPA 101, 9.6.2.3 and NFPA 72, 2-8.2.2.

1. Main Building - 3rd Floor - Designated 2-hour fire rated occupancy separation exit doors between Corridor T3048 and Corridor T3047 lack a manual pull device on the Business Occupancy side to comply with 9.6.2.3 and NFPA 72, 2-8.2.2.


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Based on random observation during the survey walk through not all exits contain a manually operated fire alarm box to comply with 9.6.2.3. This condition may affect all patients staff and visitors within in smoke/fire compartments and delay the notification of a fire condition.

Findings include:

F. May 15th 1:30pm 4th floor The designated 2-hour fire barrier separation between Childrens Hospital Building and the Main Building at a pair of cross corridor doors lack manually operated pull stations.
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Horizontal exits serving as an exit or exit component shall terminate at an outside wall. Where the outside walls are at an angle less than 180 degrees, protection must be provided for a distance of 10 ' on each side of the horizontal exit as specified in NFPA 101, 2000, 7.2.4.3.2. Findings include:
A. On 5/16/12 observations determined that the exit route from the Administrative suite (1st floor) is through a horizontal exit. The South corridor contains windows and access to the exterior. The glass corridor wall intersects the 2 hour rated horizontal exit wall at 90 degrees on the Southwest corner. It is not clear how this arrangement meets with NFPA 101, 7.2.4.3.2.

Based upon review of the facility's life safety plans and observation during the survey walk-through, horizontal exits do not comply with 19.2.2.5 and 7.2.4. This deficiency could delay the access to an exit and the activation of the fire alarm in multiple fire/smoke compartments and affect patients, staff and visitors.

A. The plans indicate that a horizontal exit exists on the 3rd floor between the Gerlach building and the Milestone building. However, horizontal exits do not exist on other floors of the Gerlach building which provide a separation continuous to ground in accordance with 7.2.4.3.1.

B. The plans do not indicate and it was not observed that manual fire alarm pull stations exist on each side of all designated double egress horizontal exits (or designated 2-hour fire barriers which could be considered as meeting the horizontal exit requirements) to comply with NFPA 101, 9.6.2.3 and NFPA 72, 2-8.2.2.

1. May 17th 8:15am 4th floor ICU, The designated 2-hour fire barrier separation lacks manually operated pull stations on both sides of the barrier at the pair of cross corridor doors.

2. The designated horizontal exit at the 3rd floor lacks a manual pull station on both sides of the fire barrier between the Gerlach building and the Milestone building. .

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 18.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. Exit discharge from all exits use HID type light fixtures that require a warmup period before the lights operate which does not meet the requirements of NFPA-101, Section 7.9.1.2, for lighting to be of instantaneous operation so as not to leave the exit path in darkness.


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Based on random observation during the survey walk through, light switches within the exit enclosure provided a manual means to discontinue illumination within a means of egress and do not comply with 7.8.1.2. This condition may prevent staff and visitors, within the exit stair, from a safe passage to an exit discharge

B. On May 15th, 2:50pm, at the 4th floor exit Stair T4022, the flipping of the switch turned off the light at the 4th and 3rd floor landings.
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Based on random observation during the survey walk-through on May 15, 2012, exit signs were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.
Findings include:

A. UPDATE 02/01/13 The exit signage has been corrected for this item, therefore, a portion of this deficiency has been corrected.

B. CORRECTED 02/01/13.
C. CORRECTED 02/01/13.
D. CORRECTED 02/01/13
E. CORRECTED 02/01/13
F. CORRECTED 02/01/13
G. CORRECTED 02/01/13
H. CORRECTED 02/01/13
I. CORRECTED 02/01/13

Based on random observation during the survey walk-through on May 16, 2012, exit signs were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. The southwest corner of the 3rd floor Surgery area lacked exit signage at the corridor intersection to identify an exit access in that direction.

B. The 2nd floor corridor serving the CT rooms lacks exit signage to identify the 2nd exit path.

C. The 2nd floor corridor C2105 leading toward the bridge from the cross corridor doors at corridor C2009 is not provided with visible exit signage until at the cross corridor doors leading to corridor C2107. The bridge is not identified as an exit path and may be considered an allowable dead end.
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Based on random observation during the survey walk through failure to maintain a central station for the reporting of emergency situations does not comply with NFPA 72. This condition could result in the delayed response to an emergency rescue situation during a fire event. This condition may affect all patients staff and visitors.

A. Morning of May 16th, Level H (Helipad) Stair 8, the rescue assistance intercom does not report to a 24 hour location. It was determined that there was no active, dedicated central station assigned for rescue assistance. Therefore the intercom system in all stairs did not report to a central station. Signs were posted within the stairwells which read that the intercom was out of service. This does not comply with 18.2.2.10 and 7.2.12.2.5.


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B. CORRECTED 01/31/13
C. CORRECTED 01/31/13
D. CORRECTED 01/31/13

A fire alarm system with approved components, devices or equipment is not installed according to NFPA 72, National Fire Alarm Code, to provide effective warning and to direct staff to the source of the fire.

Findings include:

A. On 5/17/12 during the fire alarm tests locations were observed at the 2nd floor nurse station where the flash from more than two strobes are visible and not synchronized in accordance with NFPA 72, 1999, 4-4.4.2.3.


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B. CORRECTED 01/31/13.

The fire alarm system with approved components, devices or equipment is not installed according to NFPA 72, National Fire Alarm Code, to provide effective warning and to direct staff to the source of the fire.

Findings include:

A. CORRECTED 02/01/13

B. On 5/17/12 during the fire alarm tests locations were observed where more than 2 strobes are visible and not synchronized in accordance with NFPA 72, 1999, 4-4.4.2.3. Locations include:

1. Main - 8th floor
2. Main - 7th floor


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Based on random observation during the survey walk-through on May 15, 2012, not all portions of the building fire alarm system are maintained in accordance with 19.3.4 and NFPA 72.
Findings include:

C. CORRECTED 02/01/13

D. The strobes in the Kitchen were not syncronized to comply with NFPA 72-1999, 4-4.4.2.3.


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E. CORRECTED 02/01/13


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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This condition may affect all patients, staff and visitors within a fire/smoke compartment adjacent to the compartment of fire origin.

F. On May 16th at 10:00am, a visual alarm notification device was not observed to be installed in the Mens toilet/shower room #4047. This does not comply with NFPA 72, 4-4.4.3.2.
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A. CORRECTED 02/01/13
B. CORRECTED 02/01/13
C. CORRECTED 02/01/13


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Based on random observation during the survey walk-through on the morning of May 15, 2012, not all portions of the facility's fire alarm system are installed in accordance with NFPA 72 1999.
Findings include;

A. During the survey tour of the south stairway on 4th floor a side wall smoke detector was observed to be more than 12" below the ceiling and not in accordance with 2-3.4.3.1.

B. CORRECTED 02/01/13

Based on document review, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency could affect any patients, staff, or visitors in the building because fire alarm system components may not be operational.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 Table 7-3.2. During the review of records in the Milestone Building First Floor Gandhi Meeting Room on the morning of May 17, 2012, it was determined that a smoke detector in Patient Sleeping Room 7341 in the Main Hospital Building was not tested by the outside vendor during the system test conducted on December 30, 2011. No records were available which indicated that the device had been subsequently tested.
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Based on document review, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency could affect any patients, staff, or visitors in the building because fire alarm system components may not be operational.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 Table 7-3.2. During the review of records in the Milestone Building First Floor Gandhi Meeting Room on the morning of May 17, 2012, it was determined that the smoke detectors listed below were not tested by the outside vendor during the system test conducted on September 30, 2011. No records were available which indicated that the device had been subsequently tested. Devices include:

1. Smoke detector 4146.

2. Smoke detector 1043.
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Based on random observation during the survey walk through the failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed action during a fire event. The sprinkler system is not installed to comply with NFPA 13. This condition may delay activation of the fire alarm system and affect all patients, staff and visitors.

A. Afternoon of May 15th, Ground level room G004, surveyor was not able to view sprinkler heads within this room. There does not appear to be adequate sprinkler coverage for this area.

B. Afternoon of May 15th, Ground level inspector test room (across from G004) is not sprinkler protected.


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C. CORRECTED 02/01/13


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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999), NFPA-20(1999), and NFPA-70(1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

D. CORRECTED 02/01/13

E. CORRECTED 02/01/13


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F. UPDATE 02/01/13 Mechanical room # 4029 has additional sprinkler heads added to the underside of ductwork which is greater than 48 inches in width. Therefore, a portion of this deficiency has been corrected.


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G. UPDATE 02/01/13 The stand pipe in the South stair on the 5th floor has a listed pressure guage, therefore, a portion of this deficiency has been corrected.

A. CORRECTED 02/01/13
B. CORRECTED 02/01/13


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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA 13-1999.
Findings include:

C. The 1st floor Data room 1423 had ceiling tile displaced and openings to chase areas not provided with sprinkler protection.

D. CORRECTED 02/01/13


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Building C: 5th Floor

E. Based on direct observation the surveyor finds the facility failed to provide dedicated automatic sprinkler protection for patient room wardrobes. Sprinkler heads were installed more than 3 feet from the face of the wardrobes. (NFPA 13, 1999 & CMS Life Safety Regional Program Letter No. 93-12)

F. Base on direct observation the surveyor finds side wall sprinkler heads are obstructed by the patient privacy curtains when in the parked position.


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Based on random observation during the survey walk through the failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed action during a fire event. The sprinkler system is not installed to comply with NFPA 13. This condition may affect all patients, staff and visitors on the upper floor levels.

G. The facility failed to provide fire suppression for the following areas:

1. May 16th 10:30am 4th floor, data room (listed as mech room 4477 on faciity life safety plan) lacks sprinker protection.

2. May 16th 10:45am 4th floor, storage room (listed as mech room 4449 on faciity life safety plan) contains a mezzanine within the area which is 55 inches deep. The area below lacks sprinkler protection.

Based on observation the facility failed to ensure all areas of the facility were provided with complete coverage by the automatic sprinkler system in accordance with NFPA 101, 2000 Edition, Section 19.3.5 as well as NFPA 13. The findings include:
A. On 5/16/12 at approximately 9:45 AM during the tour by the " North Parking deck" informational sign, the corridor contains unprotected niches. Sprinkler heads are provided in the corridor; however the sprinkler coverage is obstructed by the wall columns in providing coverage of the floor plant niche.
B. CORRECTED 01/31/13
C. On 5/16/12 Electrical Closet, in the lab (G1252) was not provided with sprinkler protection.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999), NFPA-20(1999), and NFPA-70(1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

1. All four required alarm points for each fire pump are not monitored at a constantly attended location as required by NFPA 20-7-4.7.
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Based on direct observation and document review and staff interview, the facility failed to provide:

a. The four required alarm points for 4 of 4 fire pumps on the remote alarm annunciators at a point of constant attendance. (NFPA 20, 1999, 7-4.7)

b. Indication that alarm conditions were simulated at the time of the annual fire pump test. (NFPA 25, 1998, 5-3.3.3)

c. Indication that the annual flow tests for 4 of 4 fire pump were conducted under emergency power. (NFPA 25, 1998, 5-3.3.4)
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Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A 1999. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

Findings include:

A. At 11:15 AM on May 15, 2012, a duct was observed, which penetrates the floor in Fifth Floor Mechanical Room 5241, for which the fire damper is not in the plane of the floor as required by NFPA 90A 1999 3-3.2.

B. At 11:19 AM on May 15, 2012, the following conditions were observed relative to a duct which penetrates the 2 hour fire rated wall between Fifth Floor Mechanical Room 5241 and Corridor T5602:
1. The duct penetration was observed to lack a fire damper required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1.

2. The duct penetration was observed to not be sealed against the passage of fire in accordance with a tested design as required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. because a large gap exists between the duct and the wall.


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C. CORRECTED 01/31/13

D. During the record review process it was discovered the facility did not have building ventilation drawings to show the location of fire and smoke dampers in accordance with 3-4.6.1.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

Findings include:

A. Duct penetrations through the walls of 2 hour fire rated ventilation shafts were observed which lack fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. Locations observed include (all Fifth Floor):

1. 11:48 AM, May 15, 2012: 1 duct at Shaft T5052 into Office 5301.

2. 11:53 AM on May 15, 2012: 1 duct at Shaft T5021 into Waiting Room 5480.

B. At 11:53 AM on May 15, 2012, a duct penetration, in the 2 hour fire rated shaft wall between Fifth Floor Shaft T5021 and Patient Sleeping room 5474, was observed to not be sealed against the passage of fire in accordance with a tested design as required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. because a large gap exists between the duct and the wall.

C. At 1:08 PM on May 15, 2012, a ventilation shaft was observed, between Fifth Floor Patient Sleeping Room 5319 and Nurses' Station T5050, which does not carry a fire resistance rating because it is constructed of metal studs and 1 layer of drywall outboard only, as prohibited by NFPA 90A 1999 3-3.4.1. The number of building stories connected by this shaft could not be determined.

D. At 1:33 PM on May 15, 2012, a duct was observed, which penetrates the floor in Fifth Floor Mechanical Room 5501, for which the fire damper is not in the plane of the floor as required by NFPA 90A 1999 3-3.2.
.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

Findings include:

A. Duct penetrations through the walls of 2 hour fire rated ventilation shafts were observed which lack fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. Locations observed include:

1. 9:02 AM May 16, 2012: 2 ducts through the floor of Fourth Floor Mechanical Room 4714.
2. 9:06 AM May 16, 2012: 2 ducts from Fourth Floor Mechanical Room 4714 to Convenience Stair S4702.

3. 9:22 AM May 16, 2012: 2 ducts at shaft in Third Floor Nurses' Station T3026.

4. 9:45 AM May 16, 2012: 2 ducts at Medication Room 3746.

5. 10:08 AM May 16, 2012: 2 ducts at Pump Room 2748.
.

During the record review process it was discovered the facility did not have building ventilation drawings to show the location of fire and smoke dampers in accordance with 3-4.6.1.

This deficiency could cause injury to patients and staff during an emergency situation to isolate part of the building.
.

Based on random observation during the survey walk through not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

A. 6th floor, Bridge contain multiple beds, one gurney and one reclining chair stored in this location.
.

Based on random observation during the survey walk through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

A. May 15th 2:15pm 4th floor, ICU Corridors contain numerous mobile nurse computer stations - located one between every second room. Each station contained one to two chairs located in front of them. The corridor exceeded 8 feet in width, however, the depth of the station alone exceeded the 7 inch distance of intrusion allowed by the life safety code.
.

Based on random observation during the survey walk through, not all portable medical gases are stored in accordance with NFPA 99.
Findings include:

A. On 5/16/12 during the walk-through of the surgery suite (G9456) Medical gas tanks were observed being stored in a sprinkler protected room. The size and number of tanks in this room may exceed 3000 cu ft, the room does not meet storage requirements of NFPA 99, 1999, 4-3.1.1.2 and / or 8.3.1.11.1.


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Based on random observation during the survey walk-through on May 16, 2012, not all portable medical gases are stored in accordance with NFPA 99. This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials.
Findings include:

B. The 3rd floor Medical Gas storage room 3-9453 was observed to have the automatic flush bolts on the 45 minute rated inactive corridor door leaf not engaging.

Based on random observation during the survey walk-through on May 15, 2012, not all portable medical gases are stored in accordance with NFPA 99. This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials.
Findings include:

A. CORRECTED 02/01/13


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B. CORRECTED 02/01/13
C. CORRECTED 02/01/13


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D. At 1:43 PM on May 15, 2012, 7 medical gas tanks were observed being stored, in Fifth Floor Clean Utility Room 5400, that are less than 5'-0" from combustibles not in accordance with NFPA 99 1999 8-3.1.11.2(c)(2).

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed and maintained in accordance with NFPA 99-1999.
Findings include:

A. During the survey of the 2nd floor Radiology area, the medical gas zone valves serving the former Bone Scan 2022 space and the former Nuclear Med rooms 2024 & 2025 was not separated from the spaces by an intervening wall to comply with NFPA 99-1999, 4-3.1.2.3(d).


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B. CORRECTED 02/01/13
C. CORRECTED 02/01/13
D. CORRECTED 02/01/13

Based upon random observation during the survey walk-thru on the morning of May 16, 2012, the emergency power system is not installed in accordance with NFPA 70 and NFPA 99. Non-compliance could result in inability to identify the location of system components to diagnose failures of the emergency power when required.

Findings include:

A. Emergency power electrical receptacles located in the 3rd floor typical Operating Rooms (#12 & #14 observed) are not labeled to identify the circuit and panel from which they are fed to comply with NFPA 70-1999, 517-19a.

B. CORRECTED 02/01/13

Based on random observationduring the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

1. The annunciators for the seven generators were not monitored at a 24 hour staffed location and did not meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

2. Both power plants need receptacles from the life safety branch of power at the generator set locations to meet the requirements of NFPA-70, Section 517-32(e).
.

A. CORRECTED 01/31/13


13755


Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.
Findings include:

B. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. CORRECTED 02/01/13


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A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. CORRECTED 02/01/13
.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.
.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. Examples include the elevator room panel EPA, (equipment branch?), serves all of the cab lighting that should be served from the life safety panel, and panel L1A a life safety panel serves the security camera and receptacles that should be fed from a critical panel. These examples and other locations throughout the building do not meet the requirements of NFPA-70, Section 517-31 thru 35.
.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. In several locations the critical panels are serving exit signs, stairwell lighting, elevator lights, and med gas alarms that should be served from the life safety panels which does not meet the requirements of NFPA-70, Section 517-31 thru 35.
.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. In several locations, life safety panels are serving items such as nurse's stations that should be served by the critical panel, and the critical panels are serving fire alarm and med gas panels that should be served from the life safety panels which does not meet the requirements of NFPA-70, Section 517-31 thru 35.


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Based on random observation during the document review process on the morning of May 17, 2012, not all portions of the facility's records for emergency electrical components are in accordance with NFPA 99 1999.

Findings include;

B. During the record review documents for the monthly Line Isolation Monitors were not available in accordance with 3-3.3.4.2 ( b ). This deficiency could cause injury to patients due to electrical shock during procedures.
.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. In several locations, life safety panels are serving items such as nurse's stations that should be served by the critical panel, and the critical panels are serving fire alarm and med gas panels that should be served from the life safety panels which does not meet the requirements of NFPA-70, Section 517-31 thru 35.
.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Panel schedules throughout all buildings other than Milestone were not accurate, circuit breakers in several panels were marked as spare and were in the on position. This does not meet the requirements of NFPA-70, Section 110-22.
.

Existing elevators are not confirmed to be equipped with Firefighter's Service in accordance with ASME/ANSI A17.3 - 3.11.3 and A17.1 - 211.3. Failure to provide required services could endanger occupants of the elevator and prevent firefighters' use of the elevator(s) when needed.

Findings include:

A. The Ground floor level of Elevator #16 was not confirmed to have smoke detection provided for the elevator recall system. Detection was provided in the corridor, but not near the elevator door and not confirmed to interface with the elevator recall system.
.

Based on random observation during the survey walk-through on the morning of May 16, 2012, not all portions of the facility's elevator penthouse installation are in accordance with NFPA 101 2000 and NFPA 13 1999. These deficiencies could cause injury to patients or staff while moving from floor to floor.

Findings include;

A. During the survey tour of the penthouse electronic elevator controllers were observed without provisions for the cooling of the controllers according to the manufacture's guidelines in accordance with NFPA 101 2000 9.4.5.

B. CORRECTED 01/31/13

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor did not find a single disconnect on elevator 30 and 31 for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.
.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor observed that the elevator machine rooms for all elevators were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.
.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor observed that the elevator machine rooms for elevators 1, 2, 3, 4, 5, 6, and 7 were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.
.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor observed that the elevator machine rooms for elevators 20, 21, 22, and 23 were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.
.