HospitalInspections.org

Based on observation and facility staff interview. the facility failed to maintain one of seven designated exit stairwells free of obstructions. Failure to maintain designated exit stairwells free of obstructions has the potential to affect all patients, staff and visitors . This deficient practice could prevent prompt evacuation from the facility in an emergency. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


Observation on 1/05/2018 at 11:24 A.M., of the designated exit stairwell 5A serving the second floor NICU and the outpatient pharmacy on the first floor showed 15 cardboard boxes, one plastic storage tub, one swivel office chair and metal shelving stored in the stairwell access alcove between the pharmacy exit stairwell access door and the stairwell landing. During an interview upon the observation staff II confirmed the findings.


NFPA 101, 2012 edition, section 19.2.1 states:
19.2.1 General. Every aisle, passageway, corridor, exit discharge,
exit location, and access shall be in accordance with Chapter 7,
unless otherwise modified by 19.2.2 through 19.2.11.

NFPA 101, 2012 edition, section 7.1.10.1 states:
7.1.10.1* General. Means of egress shall be continuously
maintained free of all obstructions or impediments to full instant
use in the case of fire or other emergency.

Based on observation, record review and facility staff interview, facility staff failed to provide the required complete sprinkler system per NFPA 13 requirements and complete smoke detection system in compliance with NFPA 72 to allow special locking arrangements in the building. This deficient practice has the potential to affect patients, staff and visitors by delaying notification of the building occupants and delaying sprinkler response in the event of a fire. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


Observations on 1/02/2017, 1/03/2017, 1/04/2017 and 1/05/2017 during the facility tour, showed seven of seven designated exit stairwell access doors contained card activated magnetic controlled access locks and key operated locks. Additional observation showed each floor of the hospital contained both card activated magnetic locks and key operated locks which subdivided the floors. Observation showed the 4th floor elevator lobby access door contained both both card activated magnetic locks and key operated locks. During an interview upon the observation staff II confirmed the findings.


Observation on 1/03/18, of the third floor nurse's station showed the area open to the corridor without smoke detector coverage. Observation showed the space open to the corridor measured approximately 20 feet by 22 feet.
During an interview upon the observation staff II confirmed the findings.

Observation during all days of survey did not show complete sprinkler coverage in the following locations:

-2nd floor sterilizer mechanical room# 2150
-Stairwell #1 bottom landing & adjacent hallway with door removed
-Stairwell #2 bottom landing
-Stairwell #4 bottom landing
-Stairwell #5 top and bottom landing
-Stairwell #5A bottom landing
-Elevator #7 pit (hydraulic)
-electrical closet #2190
-2nd floor radiology MRI janitor's closet
-plumbing pit room# 1007 (contained piped in medical gasses)
-radiology electrical closet #1025
--Janitor's closet #1013
-1st floor 3 closets #1268
-X-ray room # 1026
-X-ray room #1035
-X-ray room #1031
-X-ray room #1032
-room #1259
-Telecom closet#1238
-Specimen freezer in lab #1174
-Lab telephone room #1158
-electrical equipment room #1055
-one-half of mechanical room #1056
During an interview upon the observation staff II confirmed the findings.


19.2.2.2.5.1* Door-locking arrangements shall be permitted
where the clinical needs of patients require specialized security
measures or where patients pose a security threat, provided
that staff can readily unlock doors at all times in accordance
with 19.2.2.2.6.

19.2.2.2.5.2* Door-locking arrangements shall be permitted
where patient special needs require specialized protective measures
for their safety, provided that all of the following are met:
(1) Staff can readily unlock doors at all times in accordance
with 19.2.2.2.6.
(2) A total (complete) smoke detection system is provided
throughout the locked space in accordance with 9.6.2.9, or
locked doors can be remotely unlocked at an approved, constantly
attended location within the locked space.
(3)*The building is protected throughout by an approved,
supervised automatic sprinkler system in accordance with
19.3.5.1.
(4) The locks are electrical locks that fail safely so as to release
upon loss of power to the device.
(5) The locks release by independent activation of each of the
following:
(a) Activation of the smoke detection system required by
19.2.2.2.5.2(2)
(b) Waterflow in the automatic sprinkler system required
by 19.2.2.2.5.2(3)

19.2.2.2.6 Doors that are located in the means of egress and are
permitted to be locked under other provisions of 19.2.2.2.5 shall
comply with all of the following:
(1) Provisions shall be made for the rapid removal of occupants
by means of one of the following:
(a) Remote control of locks
(b) Keying of all locks to keys carried by staff at all times
(c) Other such reliable means available to the staff at all
times
(2) Only one locking device shall be permitted on each door.
(3) More than one lock shall be permitted on each door, subject
to approval of the authority having jurisdiction.


8.15.3.2 Noncombustible Construction.
8.15.3.2.1 In noncombustible stair shafts having noncombustible
stairs with noncombustible or limited-combustible
finishes, sprinklers shall be installed at the top of the shaft
and under the first accessible landing above the bottom of
the shaft.


7.2.1.6.3 Elevator Lobby Exit Access Door Assemblies Locking.
Where permitted in Chapters 11 through 43, door assemblies
separating the elevator lobby from the exit access required by
7.4.1.6.1 shall be permitted to be electrically locked, provided
that all the following criteria are met:
(1) The lock is listed in accordance with ANSI/UL 294, Standard
for Access Control System Units.
(2) The building is protected throughout by a fire alarm
system in accordance with Section 9.6.
(3) The building is protected throughout by an approved,
supervised automatic sprinkler system in accordance
with Section 9.7.
(4) Waterflow in the sprinkler system required by 7.2.1.6.3(3) is
arranged to initiate the building fire alarm system.
(5) The elevator lobby is protected by an approved, supervised
smoke detection system in accordance with Section 9.6.
(6) Detection of smoke by the detection system required by
7.2.1.6.3(5) is arranged to initiate the building fire alarm
system and notify building occupants.
(7) Initiation of the building fire alarm system by other than
manual fire alarm boxes unlocks the elevator lobby door
assembly.
(8) Loss of power to the elevator lobby electronic lock system
unlocks the elevator lobby door assemblies.
(9) Once unlocked, the elevator lobby door assemblies remain
unlocked until the building fire alarm system has
been manually reset.
(10) Where the elevator lobby door assemblies remain latched
after being unlocked, latch-releasing hardware in accordance
with 7.2.1.5.10 is affixed to the door leaves.
(11) A two-way communication system is provided for communication
between the elevator lobby and a central
control point that is constantly staffed.
(12) The central control point staff required by 7.2.1.6.3(11)
is capable, trained, and authorized to provide emergency
assistance.
(13) The provisions of 7.2.1.6.1 for delayed-egress locking systems
are not applied to the elevator lobby door assemblies.
(14)*The provisions of 7.2.1.6.2 for access-controlled egress
door assemblies are not applied to the elevator lobby
door assemblies.

Based on record review, observation, and interview, the facility failed to provide emergency task illumination that would operate automatically in all the medication preparation rooms. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.

Findings included:

1. Review of the 2012 National Fire Protection Association (NFPA) 99 showed:
- Section 3.3.30 Critical Branch. system of feeders and branch circuits supplying power for task illumination, fixed equipment, select receptacles, and select power circuits serving areas and functions related to patient care that are automatically connected to alternate power sources by one or more transfer switches during interruption of the normal power source;
- Section 3.3.173 Task Illumination. Provisions for the minimum lighting required to carry out necessary tasks in the areas described in Chapter 6, including safe access to supplies and equipment and access to exits;
- Section 6.4.2.2.3.2 The life safety branch shall supply power for lighting,
receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code
(3) Hospital communications systems, where used for issuing instruction during emergency conditions
(4) Generator set location as follows:
(a) Task illumination
(b) Battery charger for emergency battery-powered lighting unit(s)
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations; and
- Section 6.4.2.2.4.2 The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases, task illumination, select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected acute nursing areas, psychiatric bed areas (omit receptacles), and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires).

2. Review of 2012 NFPA 101, Life Safety Code Section 7.9.2.3 showed the emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting.

3. Observation on 01/02/18 - 01/03/18 during the tour of the main hospital building including the Psychiatric Center and the Ellis Fischel Cancer Center showed the medication preparation room lights, that were marked (red) as being on the emergency generator circuit, were able to be shut off by a switch.

4. During an interview on 01/03/18, at 4:00 PM, Staff AA, Executive Director, Support Services, stated that all the lights in the medication preparation rooms are not automatically on and could be shut off with a switch.

5. Observation on 01/03/18 at 10:30 AM during the tour of the main hospital building showed the medication preparation room (T3203) lights, were able to be shut off by a switch.

6. During an interview on 01/03/18, 10:30 AM , Staff FF confirmed that all the lights in the medication preparation rooms could be shut off with a switch.

Based on observation and facility staff interview, the facility staff failed to ensure all designated exit corridors are illuminated with emergency egress lights not controlled by a light switch. One designated exit corridor contained switches controlling the emergency egress lighting fixtures. Failure to provide emergency egress lighting fixtures not controlled by a light switch has the potential to affect all patients and staff within the corridor. This deficient practice could delay the safe evacuation of patients, staff and visitors in the event of an emergency.The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.



1. Observation on 1/03/18, during the building tour, showed the second floor surgical sterile designated exit hallway contained switches controlling the emergency egress lighting fixtures. During an interview upon the observation staff II confirmed the findings.




19.2.8 Illumination of Means of Egress. Means of egress shall
be illuminated in accordance with Section 7.8.


7.8.1.2 Illumination of means of egress shall be continuous
during the time that the conditions of occupancy require that
the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside medication rooms. This deficient practice has the potential to affect all patients within the nursing unit served by the medication room. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss.The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.

1. Observations on all days of survey, during the Life Safety Code (LCS) tour, showed the following medication rooms equipped with switch controlled lights:

-NICU Level II 3rd floor medication room
-Emergency Department 1st floor medication room #1222
-NICU 2nd floor medication room #2219C
-5th floor medication room #5201G
-5th floor medication room #5105
-4th floor PICU medication room

During an interview upon the observation staff II confirmed the findings.



NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) 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, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation during the life safety code tour at the Missouri Orthopedic Institute hospital, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and one designated exit corridor in the facility per NFPA (National Fire Protection Association) requirements. Failure to provide a storage room door equipped with positive latching puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.

1. Observation on 1/2/18, during the facility tour, showed the pharmacy with a separate room. Observation showed the room contained excessive amounts of combustible material . Observation showed the room measured 231 square feet. The room did not have one hour separation from the pharmacy. Observation showed the pharmacy open to the corridor.

2, During an interview on 1/2/18 at 2:20 P.M., the pharmacist said that pharmacy staff use the room for storage.

3. Observation on 01/03/2018 , during the facility tour, showed the older operating rooms restricted service corridor had been converted to a storage room approximately 800 sq/ft containing a large quantity of combustible materials. Observation showed seven of the operating room corridor doors and both entrance doors did not have a positive latch.

4. On 01/03/2018 at 11:30 AM in interview staff RN MM stated the corridor was used for storage for the seven operating rooms.

19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on observation, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and one designated exit corridor in the facility per NFPA (National Fire Protection Association) requirements. Failure to provide a storage room door equipped with positive latching puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.



1. Observation on 01/03/2018, during the facility tour, showed operating room #10 converted to a storage room containing a large quantity of combustible materials. Observation showed the operating room #10 corridor door did not have a positive latch, the room measured over 100 square feet and the room contained piped in medical gas outlets. During an interview upon the observation staff II confirmed the findings.



19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on observation and interview during the life safety code tour at the Main hospital, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and one designated exit corridor in the facility per NFPA (National Fire Protection Association) requirements. Failure to provide a storage room door equipped with positive latching puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


1. Observation on 01/02/18 at 3:10 PM of the ground floor corridor showed a door to a large janitor closet, where the eye wash station and cleaning equipment is stored, had a self-closure on the door but the self-closing device had been disabled and the door did not automatically close upon release.
During an interview upon the observation , maintenance staff stated that the self-closing arm had been removed from the door.

2. Observation on 1/04/18 at 11:15 AM during the facility tour on the third floor showed the storage room on hallway TH-3EN had approximately 900 sq/ft of combustible supplies. The automatic closure was removed from the door and the door was propped open. During an interview upon the observation staff FF stated they were not aware the door closure had been removed.

3. Observation on 1/04/18 at 11:00 AM during the afternoon facility tour on the third floor showed an old operating room across from the central corridor for the operating suites had been converted into a storage room approximately 192 sq/ft containing eight large racks of combustible Styrofoam cushions. The room did not have a one hour rated construction separating the storage room from the corridor. During an interview upon the observation staff LL stated the room had been converted to temporary storage.

4. Observation on 01/04/2018 , during the facility tour, showed the operating rooms restricted service corridor had been converted to a storage room approximately 1,200 sq/ft containing a large quantity of combustible materials. Observation showed three of the operating room corridor doors and both entrance doors did not have a positive latch. During an interview upon the observation staff LL stated the corridor was used for storage for the nine operating rooms.

19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on observation and interview, the facility failed to insure that the cooking facility at the Missouri Orthopedic Hospital was not open to the designated exit corridor. Having the cooking facility open to the corridor puts patients, staff and visitors at risk of being harmed in a fire by not being able to exit through the corridor if there was a fire in the cooking facility and the corridor was full of smoke. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


1. On 1/02/2018 at 3:15 PM during the life safety code tour in the afternoon showed the cooking facility had two deep fat fryers with a grill and was cooking for the hospital staff and patients. The cooking facility was open to the exit corridor and there were no doors to separate it from exit corridor.

2. On 1/02/2018 at 3:15 PM in interview staff FF stated this area had just been remodeled in November of 2017 and the doors to the cooking facility had been removed.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Based on observation and interview the facility failed to ensure that pharmacy that was open to the corridor had smoke detectors installed. Failure to have areas open to corridor having smoke detection provided puts patients, staff and visitors at a potential risk of harm in a fire in the open area and not being notified of a fire in that area. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.

1. On 1/03/2018 at 4:10 PM, observation showed the pharmacy was open to the corridor and there was no smoke detection provided.

2. Interview with staff FF on 1/03/2108 at 4:10 PM confirmed there were no smoke detectors in the pharmacy and was not sure why one was not there.

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Based on observation and facility staff failed to ensure areas open to the corridor contain smoke detection
per NFPA 72, National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


Observation on 1/03/18, during the facility tour, of the third floor nurse's station showed the area open to the designated exit corridor without smoke detector coverage. Observation showed the space open to the corridor measured approximately 20 feet by 22 feet. During an interview upon the observation staff II confirmed the findings.



19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

19.3.4.5.2 Detection in Spaces Open to Corridors. See 19.3.6.1.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on record review, observation, and interview, the facility failed to ensure that two waiting rooms, that are open to the corridor, were provided with smoke detection. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.

Findings included:

1. Review of the 2012 National Fire Protection Association 101, Life Safety Code showed:
- Section 19.3.6.1 Corridor Separation. Corridors shall be separated from all other areas by one of the following:
(1) Smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met:
(a)*The spaces are not used for patient sleeping rooms,
treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8, waiting areas shall be permitted to be
open to the corridor, provided that all of the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 ft2 (55.7 m2).
(b) Each area is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.

2. Observation on 01/03/18 at 3:50 PM on the 7th floor west, showed a family and visitor lounge that was open to the corridor and did not have smoke detection.

3. Observation on 01/03/18 at 4:40 PM on the 5th floor near the purple elevators showed a waiting room was open to the corridor and did not have smoke detection.

3. During an interview on 01/03/18 at 4:40 PM, Staff AA, Executive Director, Support Services, confirmed these rooms did not have smoke detection.

Based on observation, record review and facility staff interview, the facility staff failed to ensure the sprinkler supervisory alarms were installed and monitored per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition.The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


Observations on 1/05/2018 at 1:30 P.M., during the facility tour, showed a sprinkler system Post Indicator Valve (PIV) connected to the facility sprinkler system water supply in a parking lot behind the hospital. Observation showed the wires disconnected from the electronic supervising device and the PIV. During an interview upon the observation staff II confirmed the findings.


Record review of the annual fire alarm inspection dated 02/20-24/2017 did not show a connection function test for the sprinkler system Post Indicator Valve (PIV).


NFPA 101, 2012 edition, Section 9.7.2 states:

"9.7.2 Supervision.

9.7.2.1* Supervisory Signals. Where supervised automatic
sprinkler systems are required by another section of this Code,
supervisory attachments shall be installed and monitored for
integrity in accordance with NFPA 72, National Fire Alarm and
Signaling Code, and a distinctive supervisory signal shall be provided
to indicate a condition that would impair the satisfactory
operation of the sprinkler system. Supervisory signals shall
sound and shall be displayed either at a location within the
protected building that is constantly attended by qualified personnel
or at an approved, remotely located receiving facility."


Please refer to NFPA 72, 2010 ed. Table 14.4.5 (15L), Table 14.4.2.2 (14I) for testing requirements.

Based on record review and interview for the main hospital, facility staff failed to inspect the sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


1. Record review on 01/05/2018 did not show the following inspections:

-five (5) year internal pipe inspections/testing for the sprinkler systems (Chapter 14)

-five year check valve interior inspections

2. On 01/05/2018 during the record review, interview with staff CC confirmed the facility did not conduct the five year internal pipe and five year check valve interior inspections.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.


5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected
monthly to ensure that they are in good condition and
that normal water supply pressure is being maintained.

5.2.4.2 Gauges on dry, preaction, and deluge systems shall be
inspected weekly to ensure that normal air and water pressures
are being maintained.

5.2.4.3 Where air pressure supervision is connected to a constantly
attended location, gauges shall be inspected monthly.

5.3.2* Gauges.
5.3.2.1 Gauges shall be replaced every 5 years or tested every
5 years by comparison with a calibrated gauge.

5.3.2.2 Gauges not accurate to within 3 percent of the full
scale shall be recalibrated or replaced.

13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.

13.6.2 Testing.
13.6.2.1* All backflow preventers installed in fire protection
system piping shall be tested annually by conducting a forward
flow test of the system at the designed flow rate, including hose
stream demand, where hydrants or inside hose stations are
located downstream of the backflow preventer.

13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected
as described in 13.4.1.1 and 13.4.1.2.

13.4.1.1* Alarm valves and system riser check valves shall be
externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being
maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.4.1.2* Alarm valves and their associated strainers, filters,
and restriction orifices shall be inspected internally every
5 years unless tests indicate a greater frequency is necessary.

5.2* Inspection.
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level
annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be
free of corrosion, foreign materials, paint, and physical damage;
and shall be installed in the correct orientation (e.g., upright,
pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following
shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer

Based on record review, facility staff failed to inspect the one wet & three dry sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. Additionally, facility staff failed to ensure sprinkler heads were kept clean of buildup. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


1) Record review on 01/05/2018 did not show the following inspections:

- three (3) year dry system full trip test for 3 of 3 dry sprinkler systems

- weekly dry system gauge inspections for 3 of 3 dry sprinkler systems

- monthly system gauge inspections for the one wet and three dry sprinkler systems

-five (5) year internal pipe inspections/testing for the one wet and three dry sprinkler systems (Chapter 14)

-five year gauge replacement/calibration records for the one wet and three dry sprinkler systems

-annual backflow inspections for the one wet and three dry sprinkler systems

-five year check valve interior inspections

2) Observation on 1/05/2018, during the facility tour, showed standard response sprinkler heads in the kitchen covered with a lint like material. During an interview upon the observation staff II confirmed the findings.


Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.


5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected
monthly to ensure that they are in good condition and
that normal water supply pressure is being maintained.

5.2.4.2 Gauges on dry, preaction, and deluge systems shall be
inspected weekly to ensure that normal air and water pressures
are being maintained.

5.2.4.3 Where air pressure supervision is connected to a constantly
attended location, gauges shall be inspected monthly.

5.3.2* Gauges.
5.3.2.1 Gauges shall be replaced every 5 years or tested every
5 years by comparison with a calibrated gauge.

5.3.2.2 Gauges not accurate to within 3 percent of the full
scale shall be recalibrated or replaced.

13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.

13.6.2 Testing.
13.6.2.1* All backflow preventers installed in fire protection
system piping shall be tested annually by conducting a forward
flow test of the system at the designed flow rate, including hose
stream demand, where hydrants or inside hose stations are
located downstream of the backflow preventer.

13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected
as described in 13.4.1.1 and 13.4.1.2.

13.4.1.1* Alarm valves and system riser check valves shall be
externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being
maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.4.1.2* Alarm valves and their associated strainers, filters,
and restriction orifices shall be inspected internally every
5 years unless tests indicate a greater frequency is necessary.

5.2* Inspection.
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level
annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be
free of corrosion, foreign materials, paint, and physical damage;
and shall be installed in the correct orientation (e.g., upright,
pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following
shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer

Based on record review and interview the facility failed to have fundamental risk assessments completed and formal documented risk assessment procedures for all building systems categories are determined by a performed by qualified personnel. Failure to have the building systems risk assessments completed puts patients at risk for a potential negative outcome if category one systems ( Category 1 system in which a failure of such equipment or system is likely to cause major injury or death of patients or caregivers) fail with no plan on how to respond if the system fails. The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


On 1/05/2018 in the AM record review showed the fundamental risk assessment had been started but had not been completed. Interview with Staff CC confirmed the reviews had not been completed at this time.

Based on observation, the facility staff failed to ensure extension cords were not used permanently, multi plug adaptors were not used and surge protectors met NFPA requirements.The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.


Observation on 1/03/2017, during the facility tour, showed two power taps without the correct rating and one multi plug adaptor at the 3rd floor nurse's station. Additional observation showed the power tap was not UL 1363, 1363A or 60601-1 rated.


Observation on 1/03/2017, during the facility tour, showed two power taps without the correct rating in the 4th floor PICU. Additional observation showed the power taps were not UL 1363, 1363A or 60601-1 rated. During an interview upon the observation staff II confirmed the findings.


Observation on 1/03/2017, during the facility tour, showed four power taps without the correct rating and two multi plug adaptors in the 4th floor offices. Additional observation showed a refrigerator connected to a power tap without the correct rating in office #442H. Additional observation showed the power taps were not UL 1363, 1363A or 60601-1 rated. During an interview upon the observation staff II confirmed the findings.


Observation on 1/04/2017, during the facility tour, showed one power tap without the correct rating at the 2nd floor pre-operation nurse's station. Additional observation showed the power tap was not UL 1363, 1363A or 60601-1 rated. During an interview upon the observation staff II confirmed the findings.


Observation on 1/04/2017, during the facility tour, showed one duplex receptacle in room #2127. Observation showed an extension cord connected the one duplex outlet to a work table with built in multi plug receptacles. Observation showed one power tap(#1) without the correct rating connected to one of the table built in multi plug receptacles. Additional observation showed power tap(#1) had a yellow colored extension connected to it. The yellow extension cord was connected to a second power tap which was connected to a third power tap. Observation showed the third power tap had a fan and a small refrigerator connected to it. Additional observation showed the power taps were not UL 1363, 1363A or 60601-1 rated. During an interview upon the observation staff II confirmed the findings.


Observation on 1/04/2017, during the facility tour, showed a duplex receptacle in room #2131 with one power tap without the correct rating connected to a second power tap connected to a third power tap connected to a fourth power tap connected to a fifth power tap. Observation showed five laptop computers each connected to one of the five power taps. Additional observation showed the power taps were not UL 1363, 1363A or 60601-1 rated. During an interview upon the observation staff II confirmed the findings.


Refer to NFPA 70, National Electrical Code, 2011 edition, Article 400.8 for additional information.

Based on interview and lack of policy and procedures to review, the facility failed to have periodic evaluations that are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers:
* packaging is non-flammable
* applicators are in unit doses
* Preoperative "time-out" is conducted prior the initiation of any surgical procedure to verify:
o application site is dry prior to draping and use of surgical equipment
o pooling of solution has not occurred or has been corrected
o solution-soaked materials have been removed from the OR prior to draping and use of surgical devices
o policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use
Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. Failure to provide the evaluations and time outs puts surgical patients as risk from operating fires.
The facility census was 397 patients at the main campus, four patients at the Missouri Orthopedic Institute with 101 patients at the Women's and Children's hospital.

During an interview on 01/03/18 at 1:50 PM, Staff LL, OR Manager, stated that personnel in the surgical department had no documentation or process for assessing the risk of fire to the patient based on specific risk factors that may occur during surgery. They were working with another department to develop a computer program that would add that risk assessment to the patient's medical record.