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Based on facility tour and observation, review of facility documentation and staff interview and verification, the facility failed to ensure the building construction type and height met an approved construction type for the height, composition and use of the building. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 01/31/11 construction information was provided by the Staff T of the facility. Review of the information revealed the West building was first constructed in early 1900s and was added onto several times. Construction type included load bearing masonry, to steel post and beam, bar joists and some wood floor joist and wood roof joists. Attic spaces with exposed wood joists housed both mechanical and storage areas on two southerly wings. The West building was noted be approximately sixty percent sprinklered.

On 02/03/11 between 9:45 A.M. and 5:00 P.M., tour of the West building was conducted with Staff W and V. Located on the fourth floor were two wings. One wing was identified to be storage and the other was a mechanical area. Observation of both areas revealed an attic type appearance with exposed wood construction at the roof and at the walls. The areas were provided automatic sprinkler protection and smoke detection. The floors were noted to be concrete.

Review of the facility schematic indicated there was a 2 hour fire rated building separation between the mechanical room and the storage room and the reminder of the fourth floor. Observation above the ceiling tiles at the entrance to the mechanical room revealed a small space for visibility, approximately 4 inches in height by 5 feet in width. Exposed wood was visible above the door frame. Observation inside the mechanical room of the same 2 hour barrier wall revealed that due to pipes and other mechanical items access and visibility of the the two hour fire barrier was very limited. Staff V present verified that visibility of the fire wall from inside the mechanical room was very limited. Staff V and W verified that exposed wood was visible above the door frame outside the mechanical room. Staff V and W also verified that due to the limited space available for observation, it was not possible to determine if the 2 hour fire wall was intact.

Further observation of the fourth floor revealed the presence of a locked geriatric psychiatric unit located between the two wings that were used as the mechanical room and and storage. Staff present on tour observed and verified the observations.

Continued observation of the West building did not reveal further observation of exposed wood in the construction of the building.

Based on facility tour and staff verification it was determined this facility failed to ensure all doors located within smoke/fire barriers were held open with devices that would automatically close all such doors upon activation of the fire alarm, sprinkler or smoke detection system. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings include:

Tour of the south portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the third level locked psychiatric unit observation was made of the smoke barrier door equipped with an automatic closing device, bordering the west end of the break room. This door was held open using a rubber wedge placed between the bottom of the door and the floor which essentially disarmed the self closing device.

During tour of the forth level cardiac cath lab, observation was made of the smoke barrier door of the south end bio-hazard room which was equipped with an automatic closing device. This door was held open using a wood wedge placed between the bottom of the door and the floor which essentially disarmed the self closing device.

These findings were verified by Staff T and U during tour.

Based on facility observation and staff interview and verification the facility failed the ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Potentially all persons who utilized the Sleep Center could be affected.

Findings included:

On 02/04/11 between the hours of 8:45 A.M. and 9:15 A.M. observation of the facility was completed with Staff W, Staff CC and Staff DD. Staff CC indicated the Sleep Center had two smoke barrier walls at each end of the corridor where the Sleep Center was coated. Observation of the smoke barrier walls above the ceiling tiles in patient rooms 1208 and 1209 revealed penetrations.

In room 1208 a penetration estimated to be approximately six inches by eight inches was observed. In room 1209 another penetration was located. The penetration in room 1209 was noted to be approximately six inches by eight inches. Staff present on tour observed and verified the penetrations in the smoke barrier walls.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke/fire barriers were constructed to provide at least a one half hour fire resistance rating. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings included:

1. On 02/01/11 at 11:50 A.M., tour of the seventh floor of the East building was conducted with Staff T and Staff V. Observation of the seventh floor revealed the floor was unoccupied and closed. Staff T stated the floor was to closed and not used for patient care as renovation was planned in the near future.

Observation of the smoke barrier wall that divided the seventh floor revealed multiple penetrations. The smoke barrier was identified to have extended from outside wall to outside wall which included between patient rooms 703 and 704. Observation above the ceiling tiles in rooms 703 and 704 revealed multiple penetrations in the smoke barrier wall. Observation above ceiling tiles in room 704 revealed the smoke barrier wall was not continuous and was open above the bathroom. Staff T and V observed and verified the penetrations in the smoke barrier wall in both patient rooms.

2. Tour of the South portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the smoke/fire rated walls observation was made of penetrations above the ceiling tile in the following locations:

Level Zero:
* At the west end of the half hour rated smoke barrier bordering the storage room and above the door and ceiling tile, observation was made of one 2 inch open end conduit and one 1 inch unsealed copper line.

Level One:
* At the west end of the 2 hour fire rated barrier bordering the physician's convenience center above the door to the left, observation was made of two 1 inch unsealed conduits.
* In the 2 hour fire rated barrier above the double doors of the radiology department waiting area, observation was made of one 1 inch open end conduit and one unsealed conduit.

Level Two:
* Above the double doors located in the 2 hour fire rated barrier between the main elevators, a one 1 inch unsealed conduit was observed.
* Around the corner of the main elevators near the snack area and above the TV, observation was made of two unsealed flex conduits penetrating the 2 hour fire rated barrier.

Level Three:
* Within the one half hour smoke barrier located at the back wall of the kitchen, observation was made of an approximate 2 foot by 4 inch unsealed area where the drywall meets the upper deck.
* Above the north end one half hour smoke barrier double doors, observation was made of penetrations around one conduit and a set of wires. Additionally, observation was made of one unsealed conduit.

Level Four:
* Near the center of the core just south of the stairs and behind the bio-hazard soiled room, observation was made of penetrations in the one half hour smoke barrier. Facing the back of the bio-hazard room and to the right, observation was made of a large portion of drywall missing within the smoke barrier. At each end an approximate 2-3 foot by 3 foot section was missing and an approximate 6 foot by 4 inch middle section was missing.
* Following the smoke barrier around the corner from the above description and across from cath lab number three. At the corner of the smoke barrier just prior to the double smoke barrier doors, observation was made of an approximate 6 foot section of unsealed groves where the drywall meets the corrugated steel upper deck.
* At the back smoke barrier wall of the kitchen in the center of the core observation was made of an approximate 7 foot long by 1 inch section of unsealed area where the drywall meets the corrugated upper steel deck.
* Observation was made of one flex and one straight unsealed conduit located above the smoke barrier door of the south end bio-hazard room.
* Within the storage room at the south end of the smoke barrier, observation was made of several inches of an unsealed area around a duct penetrating the smoke barrier. Six other penetrations were observed around six conduits. Additionally, observation was made of an approximate 16 foot by one inch section of unsealed area where the drywall meets the upper corrugated steel deck.

These findings were verified by staff T and U during tour on 02/03/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke/fire barriers were constructed to provide at least a one hour fire resistance rating, specifically in the one hour fire separation located between building one and three. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of building three took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the one hour fire rated wall located on level one separating building one and three, observation was made of three areas of penetrations above the ceiling tiles listed as:
* Six open end conduits and one open junction box observed at the back end of exam room number eleven.
* Above the south double leafed smoke barrier doors located between exam room eight and nine, observation was made of two one inch holes, one unsealed copper line and one unsealed 2.5 inch square conduit.
* One open end conduit located above the smoke barrier door within the nurse manager's room.

These findings were verified by staff T and U during tour on 02/03/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure all doors located in smoke barriers were equipped with an automatic or self-closing device and no gaps greater than one eighth inch existed between door leafs when in the closed position. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings include:

1. On 02/01/11 between 10:40 A.M. and 5:00 P.M. and on 02/02/11 between the hours of 9:30 A.M. and 2:30 P.M., tour of the East building was conducted with Staff T, U, V, and X.

The following smoke doors were observed to have gaps greater than one eighth inch at the edges of the doors when in the closed position;

Eighth Floor
* A smoke barrier door in a corridor near room 816.

Fifth Floor
* A smoke barrier door in a corridor near the nursing station.

Fourth Floor
* A smoke door located in the connector corridor to the west building.

Staff present on tour observed and verified the smoke doors had gaps greater than one eighth inch when in the closed position.

2. Tour of the South portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U.
During tour of the smoke/fire rated barriers observation was made of:

Level One
* Smoke barrier door which was not equipped with an automatic or self closing device. This door was located in the physician's sleep room near the north stairs.

Level Two:
* South end double smoke barrier doors entering into the CCU was observed with a gap greater than one eighth inch between the door leafs when in the closed position.
* North end double smoke barrier doors entering into the ICU was observed with a gap greater than one eighth inch between the door leafs when in the closed position.


Level Four
* South end double smoke barrier doors by the bio-hazard room was observed with a gap greater than one eighth inch between the door leafs when in the closed position.
* Double smoke barrier doors across from cath lab number 3 was observed with a gap greater than one eighth inch between the door leafs when in the closed position.


These findings were acknowledged by staff T and U during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke/fire barrier doors were constructed to provide at least a twenty minute fire resistance rating, specifically in the one hour fire separation located between building one and three. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of building three took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the one hour fire rated wall located in the intensive care unit on level two separating building one and three, observation was made of a gap greater than one eighth inch between the north smoke barrier door leafs when in the closed position.

These findings were verified by staff T and U during tour on 02/03/11.

Based on facility observation and staff verification the facility failed to ensure that when the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings included:

1. On 02/03/11 between 9:45 A.M. and 5:00 P.M., tour of the West building was conducted with Staff W and V. Observation of the second floor medical library at 2:20 P.M., revealed the area was provided with automatic sprinkler protection. The medical library was noted to have a significant amount of books and papers and other combustibles.

Observation of the library revealed that eight ceiling tiles were missing from various locations of the ceiling and one ceiling tile was broken. The missing and broken ceiling tiles would fail to provide the desired smoke resisitance protection desired when the automatic sprinkler option was used. Staff W indicated that tiles were probably missing due to maintenance work in the room. No workers were observed and no signage was visible to indicate that repair work was in progress.

2. Tour of the first floor of the West building with Staff W and V revealed the presence of a mechanical room. The mechanical room was located near the oncology services area. Observation of the mechanical room revealed two doors in the one hour fire rated separation. One door was noted to be the primary means of entrance and exit. The second door was noted to exit into the corridor and had no self closing device in place. Staff present on tour verified there was no self closing device on one of the mechanical room doors.

3. Tour of level 0 of the West building with Staff W and Staff V on 02/03/11 at 3:55 P.M. revealed the presence of a soiled linen chute discharge room. The chute discharge room was located across the corridor from the cleaning storage room. Observation of the chute discharge room revealed the door to the room was held open and was unable to self close. Staff present on tour verified the chute room door was held open which negated the self closing activation of the door.

Based on facility tour and staff interviewed and versification, the facility failed to ensure that when the approved automatic fire extinguishing system option was used, the area was separated from other spaces by smoke resisting partitions. Potentially all persons who utilized the outpatient therapy services could be affected. The hospital had capacity of 346 patients and had a census of 147 patients at the time of survey.

Findings included:

On 02/08/11 between the hours of 9:30 A.M. and 12:30 P.M. tour of the facility was completed with Staff W. Observation of the electrical room located near the physical therapy room gym revealed the room was equipped with sprinkler and smoke detector protection. Observation of the ceiling in the electrical room revealed a significant number of tiles missing from the ceiling of the room.

Staff W present on tour observed and verified a large number of ceiling tiles were missing from the room. Staff W further verified smoke could easily travel to other areas in the facility when the ceiling tiles were missing.

Based on observation during tour and staff verification it was determined this facility failed to ensure all doors in hazardous areas were equipped with automatic or self closing devices. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings include:

Tour of the south portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U.

Level Zero:
* During tour of the x-ray film storage hazardous area, observation was made of two doors at either end of the room which was not equipped with an automatic or self-closing device.
* Additionally, observation was made of the gift shop storage room door which was not equipped with an automatic or self-closing device.

This finding was verified by staff T and U during tour.

Based on facility observation and staff interview and verification the facility failed to ensure that exit access was arranged so that exits were readily accessible at all times with regards to snow, ice and access to the public way. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey. All patients, visitors and staff could potentially be affected.

Findings included:

On 02/01/11 at 8:45 A.M. observation of the sidewalk at the front of the facility revealed it to be covered with a layer of snow and ice. Tour of the East portion of the building on 02/01/11 between 10:40 A.M. and 5:00 P.M. with Staff T and Staff V revealed that stairwell B was means of exit from the top floors of the East building to the level of discharge at the ground floor.

Observation of stairwell B at 2:45 P.M. revealed that at the exit discharge there were 15 steps to climb to reach ground level. The steps were covered with snow. The steps lead to a landscaped area where there were small shrubs, trees and a grassy area. All was covered with snow and ice. Observation from the landscaped area revealed the same sidewalk at the front of the facility noted earlier in the day. The sidewalk had not been cleared. Snow removed from the street had been thrown onto the sidewalk as well.

Interview with Staff T regarding the exit discharge verified there was no paved way to the sidewalk from the landscaped area at the front of the facility. Staff had not cleared the sidewalk of the snow as the city snow removal continually threw the snow back onto the sidewalk when the street was cleaned.

On 02/02/11 the sidewalk was observed to have been cleared at least one time. On 02/04/11 the sidewalk was observed to be covered with packed snow and ice which left an uneven surface for travel.

Based on facility tour, review of the facility schematic and staff interview and verification the facility failed to ensure that horizontal exits were in accordance with 7.2.4 with regards to fire barriers without penetrations and corridor fire doors designed to minimize air leakage. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 02/01/11 between 10:40 A.M. and 5:00 P.M. and on 02/02/11 between the hours of 9:30 A.M. and 2:30 P.M., tour of the East building was conducted with Staff T, U, V, and X. The following observations were noted in 1 and/or 2 hour fire rated separation walls and with the function of fire rated doors within the fire barrier walls.

1. The fire rated corridor doors on the eighth floor, near the east elevator lobby, did not close and latch when tested

2. Review of the facility schematic revealed a 1 hour fire rated smoke/ fire barrier separation located in a corridor near the pathology office located on the first floor. Observation of the area with Staff T and X revealed the office locations and fire barrier walls and the facility schematic did not match. Staff T and X indicated the pathology office area had been renovated. The facility schematic no longer accurately refected the location of the fire/smoke barrier wall.

On 02/02/11 at 9:30 A.M. the area was observed with Staff T and Staff Z. Staff Z verified the location of the fire barrier wall in the area. Observation of the fire barrier near the conference room and above the fire door in the corridor, revealed a penetration at the roof decking. Staff X observed and verified the opening in the fire barrier wall above the fire door.

3. On 02/02/11 observation of the nuclear medicine area located on the first floor of the east building revealed penetrations in the 2 hour fire rated separation wall. Observation above the ceiling tiles revealed three penetrations in the fire barrier around duct work. Staff U and Staff Z observed and verified the penetrations in the fire barrier.

Further observation above the ceiling tiles of the 2 hour fire rated barrier separation, in the corridor of the nuclear medication area, were penetrations located on both sides of fire door, S01FD17.

Continued observation above the ceiling tiles of the same 2 hour fire barrier in the nuclear medicine area revealed two penetrations located in treatment room. One penetration was a square area surrounding a pipe and the second area was a square area surrounding red fire alarm wires.

4. On 02/02/11 tour of the dietary area located on level 0 of the east building with Staff T and U revealed one hour fire rated doors in the corridor near the storage area had a gap greater than 1/8 inch at the edges of the door when the door was in the closed position. A second corridor fire door located in a 2 hour fire rated separation wall, near the mail room was tested and noted to fail to latch when closed.

Staff present on tour observed and verified the observation related to the fire doors.

Based on facility tour, review of the facility schematic and staff interview and verification the facility failed to ensure that horizontal exits were in accordance with 7.2.4 with regards to fire doors designed to minimize air leakage. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 02/03/11 between 9:45 A.M. and 5:00 P.M. tour of the West building was conducted with Staff W and Staff V. The following observations were noted in 1 and/or 2 hour fire rated separation walls and with the function of fire rated doors within the fire barrier walls.

1. The fire rated corridor doors on the fifth floor, in the 2 hour fire rated building separation were observed to have a gap greater than one eighth inches when in the closed position.

2. The fire rated corridor doors on the third floor, in the 2 hour fire rated building separation were observed to have a gap greater than one eighth inch when in the closed position.


3. The fire rated corridor doors ( NO2FD01) on the second floor, in the 2 hour fire rated building separation were observed to fail to close and positively latch when tested.

Staff present on tour observed and verified the observation related to the fire doors.

Based on review of facility documentation and staff interview and verification the facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift. Potentially all patients utilizing the sleep center could be affected.

Findings included:

On 02/04/11 between the hours of 8:45 A.M. and 9:15 A.M. review of facility documentation and observation of the facility and was completed with Staff W and Staff CC. Interview of Staff W revealed the hours of operation at the Sleep Center was 8:00 P.M. until 6:30 A.M. with some 8:00 A.M. unit 4:00 P.M. shifts. The Sleep Center was located in a corridor within another hospital. The Sleep Center was observed to be separated by a smoke barrier wall from the host hospital.

Review of documented fire drills completed for 2010 and to date in 2011 revealed one documented fire drill completed in February 2011 for the 8:00 P.M. until 6:30 A.M. shift. Staff CC present from the host facility verified there was no other documented fire drills specific to the Sleep Center.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in reliable operating condition specifically in regards to dirt and debris on sprinkler heads and escutcheon rings missing which are required by the National Fire Protection Association (NFPA) 13 3-2.7.2. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings included:

1. On 02/01/11 at 11:00 A.M., tour of the ninth floor of the facility was conducted with Staff T and Staff V. Observation of the soiled linen chute located in a small room near the nursing station, revealed the presence of a sprinkler head for the automatic sprinkler system in the chute.

Observation of the sprinkler head revealed it was covered with dust, dirt and debris. Staff present indicated that it was not known if the sprinkler system maintenance company for the facility routinely observed and cleaned the chute sprinkler head. Staff present on tour verified the sprinkle head was very dirty.

During tour of the East building on 02/02/11 observation was made of two sprinkler heads missing escutcheon rings on level one in the pathology lab.

2. Tour of the South portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the south building observation was made of several sprinkler heads missing escutcheon rings in the following locations:

Level Zero:
* One escutcheon ring missing located in the closet of the meeting rooms.

Level One:
* Between the two sets of double doors leading to the emergency department and located near radiology exam room number 7, two escutcheon rings were observed to be missing.
* Just beyond the north double doors of the CT room near the stairs, one escutcheon ring was observed to be missing.
* Going in exam room number 8 and through the back door into a smaller room, one escutcheon ring was observed to be missing.
* One escutcheon ring was observed to be missing within the oxygen storage room located at the north west corner of the south building.

Sprinkler heads observed to be coated with dirt and/or debris was observed in the following locations:
* Within the MRI waiting area.
* Within the special procedure room near the south west stairs.
* In the corridor just north of radiology room number 7.

Level Three:
* A sprinkler head located in the kitchen was observed to have a very thick coating of dirt and/or debris.

These findings were verified and acknowledged by staff T and U during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in reliable operating condition specifically in regards to escutcheon rings required by the National Fire Protection Association (NFPA) 13 3-2.7.2. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of building three took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the emergency department located on level one, observation was made of three areas where escutcheon rings were missing, listed as:
* Near the double doors located near exam room number 20.
* Within the rest room of the staff dressing room located adjacent to the south stairs.
* Within the corner room bordering the restroom nearest the south exit of the waiting area.

These findings were verified by staff T and U during tour.

Based on facility tour and observation, review of facility documentation and staff interview and verification, the facility failed to ensure interior walls and partitions in buildings were noncombustible or limited-combustible materials. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 01/31/11 construction information was provided by the Staff T of the facility. Review of the information revealed the West building was first constructed in early 1900s and was added onto several times. Construction type included load bearing masonry, to steel post and beam, bar joists and some wood floor joist and wood roof joists. Attic spaces with exposed wood joists housed both mechanical and storage areas on two southerly wings. The West building was noted be approximately sixty percent sprinklered.

On 02/03/11 between 9:45 A.M. and 5:00 P.M., tour of the West building was conducted with Staff W and V. Located on the fourth floor were two wings. One wing was identified to be storage and the other was a mechanical area. Observation of both areas revealed an attic type appearance with exposed wood construction at the roof and at the walls. The areas were provided automatic sprinkler protection and smoke detection. The floors were noted to be concrete. The exposed wood ceiling and walls were noted to be not treated with fire retardant.

Staff V and W verified the exposed wood in the mechanical room was not treated with fire retardant.

Based on facility observation and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 02/03/11 between 9:45 A.M. and 5:00 P.M. tour of the West building was conducted with Staff W and Staff V. During tour of the facility observation were made of several smoke detectors located significantly closer than 36 inches from air flow devices in the following areas:

Level Two:
* Located in the pharmacy, four smoke detectors were noted to be less than 24 inches from air flow devices.

Level One
* Located in the work med area, one smoke detector was noted to be in very close proximity to an air flow device.

*Located in the administration area two smoke detectors were noted to be less than 24 inches from an air flow devices.

Staff present on tour observed and verified the location of the smoke detectors.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 147 at the beginning of the survey.

Findings include:

1. On 02/01/11 between 10:40 A.M. and 5:00 P.M. and on 02/02/11 between the hours of 9:30 A.M. and 2:30 P.M., tour of the East building was conducted with Staff T, U, V, and X. During tour observation was made of several smoke detectors located near air flow devices in the following areas:

Level One:
* Located in the pathology lab storage, two smoke detectors were noted to be approximately 12 inches from air flow devices.

* Located in the gift shop, three smoke detectors were noted to be place in very close proximity to ceiling fans and air flow devices.

2. Tour of the South portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour observation was made of several smoke detectors located near air flow devices in the following areas:

Level Zero:
* In the northwest section of the south building within a storage room and forms managing room next to the mail room.

Level One:
* Within the operation's managers room adjacent to the exit ramp.
* On the north side of the double doors leading to the exit ramp.

Level Two:
* Within the female locker room in the critical care department.
* In front of the service elevators.
* Within the office of the chief surgeon across from the main elevators.

Level Three:
* Within the lounge area of the psychology unit, four smoke detectors were observed.
* In front of the service elevator.
* Within the nurse's station behind the counter near the smoke barrier door.

Level Four:
* At the center core within the bio-hazard room.
* In the corridor north of lab number 3 by the north stairs.
* In the corridor south of lab number 3 outside the bio-hazard room.
* In the corridor outside of room number 476.

These findings were verified and acknowledged by staff T and U during tour.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of building three took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the emergency department, critical care and intensive care units, observation was made of several smoke detectors located near air flow devices as follows:

Level One ED:
* Within exam room numbers 5, 6, 8, 9, 10,11, 17, 18, 19 and 20.
* Within the soiled utility room next to exam room number 5.

Level Two CCU:
* Within the clean utility room located in the center core.
* West end of the corridor outside of the clean utility room.
* Within the chart room, south end of the center core.

Level Two ICU:
* Within the soiled utility room of the center core.
* Within the chart room adjacent to the soiled utility room.
* Within the clean utility room located on the west side.
* Within room number 16.
* North end of the corridors on each side of the dictation room.

These findings were acknowledged by staff T and U during tour.

1. Any door with a required fire protection rating, such as stairways, exit passageways, horizontal exits, smoke barriers, or hazardous area enclosures, if held open, is arranged to close automatically by the actuation of the manual fire alarm system and either smoke detectors arranged to detect smoke on either side of the opening or a complete automatic sprinkler system. NFPA 21.2.2.3

This requirement was not met as evidenced by:

Based on facility tour and staff verification it was determined this facility failed to ensure all doors located within smoke/fire barriers were held open with devices that would self close or automatically close all such doors upon activation of the fire alarm, sprinkler or smoke detection system. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the smoke barrier which included the door of the decontamination room which was equipped with a self closing device, observation was made of a small table with wheels being used to prop the door open, essentially deactivating the self closing device.

This finding was verified by all staff present during tour.




2. Hazardous areas separated from other parts of the building by fire barriers having at least a one hour fire resistance rating or such areas are enclosed with partitions and doors and the area is provided with an automatic sprinkler system. High hazard areas are provided with both fire barriers and sprinkler systems as required by NFPA 39.3.2

This requirement was not met as evidenced by:

Based on facility tour and staff verification it was determined this facility failed to ensure all high hazardous areas were separated from other parts of the building with at least a one hour fire barrier and is equipped with a suppression system. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this facility.


Findings include:

Tour of the basement portion of the facility took place on 02/04/11 at 9:30 AM with staff members T and U. During tour of the basement area observation was made of a huge quantity of flammable materials in the form of medical records, medical beds, chairs, cushions, wood pallets, carts and miscellaneous medical devices.
Observation was made of boxes of medical records estimated to be between one and two thousand, of which most but not all were secured in five open fenced areas. Approximately two hundred were stacked on wood pallets and wood carts outside of the fenced area.
Beds, chairs, cushions and other medical devices were randomly placed through the basement area outside of the fenced in medical records.
Although the basement was sprinklered, it lacked at least a one hour fire resistance rating identified by the unprotected steel deck and girders.

This finding was verified and acknowledged by staff T and U during tour.



3. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. NFPA 21.7.1.2

This requirement was not met as evidenced by:

Based on review of fire drill documentation and staff verification it was determined this facility failed to ensure all fire drills were conducted at least once per shift per quarter. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include;

Review of fire drill documentation took place on 02/07/11. Observation was made of two fire drills documented as being conducted in the year 2010 for the second and fourth quarters. The question was proposed to staff J on 02/07/11 if there was any other fire drill documentation available for the first and third quarter of 2010 and staff J stated, what was brought to us is probably all there is but he/she will check again.
No additional information was provided before the time of the life safety code exit on 02/08/11.

This finding confirms only two fire drills were conducted in the year 2010.



4. A manual fire alarm system, not a pre-signal type, is provided to automatically warn the building occupants. Fire alarm system has initiation notification and control function. The fire alarm system is arranged to automatically transmit an alarm to summon the fire department. NFPA 21.3.4.1

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire alarm system was equipped with initiation devices, specifically fire pull stations, near or in the direct path of all designated exits in order to automatically transmit an alarm to summon the local fire department. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

During tour of the northwest section of the facility with staff T and U on 02/04/11, observation was made of a designated exit at the dock area utilized by the ambulance and receiving personnel. This exit access lacked a fire pull station near or in the direct path of the exit egress.

This was verified by staff T and U during tour when staff J stated never realizing this exit did not have a fire pull station.



5. Portable fire extinguishers are provided in ambulatory health care facilities in accordance with NFPA 21.3.5.2 and 9.7.4.1.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the portable fire extinguishers were visible and accessible at all times. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the ambulance and receiving area observation was made of a portable fire extinguisher mounted by the exit access. There was portable metal stairs directly in front of the fire extinguisher blocking access to it.
Additionally, during tour of the staff lounge observation was made of a portable fire extinguisher mounted on the wall. There was a large plastic trash can placed in front of it blocking access to it.

This was verified by all staff present during tour.




6. Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities, and NFPA 101.

(a) Oxygen storage locations of greater than 3,000 cu. ft. are enclosed by a one hour separation.

(b) Locations for supply systems of greater than 3,000 cu. ft. are vented to the outside.

NFPA 4.3.1.1.2 and 21.3.2.4

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure medical gasses were securely stored and protected as required. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the medical gas storage room observation was made of four E-tanks containing nitrogen and oxygen which were not secured in holding devices or chained to the wall as required.

This finding was verified by staff T and U during tour of the medical gas room.



7. Ambulatory health care occupancies are separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Doors in such barriers are solid bonded core wood of 1 inches or equivalent and are equipped with a positive latch and closing device. Vision panels, if provided in fire barriers or doors, are fixed fire window assemblies in accordance with 8.2.3.2.2.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the health care occupancy was separated from other tenants with at least a one hour fire resistance barrier, specifically regarding the door. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the occupancy separation which is an enclosed walkway containing a two hour fire rated door. After deactivating the door leafs from the holding device, observation was made of one of the door leafs failing to close and latch properly. With closer observation it was noticed the door leaf had been damaged near the bottom inner edge which caused and prevented the door from closing properly.
Additionally, above the doors and ceiling tile observation was made of a penetration located between the top of the drywall and the upper deck. This gap was approximately eight foot in length by two inches deep.

This finding was confirmed by staff T and U during tour.



8. Ambulatory health care facilities are divided into at least two smoke compartments with smoke barriers having at least 1 hour fire resistance rating. Doors in smoke barriers are equipped with positive latching device. Doors are constructed of not less than 1 inch thick solid bonded core wood or equivalent. Vision panels are provided and are of fixed wire glass limited to 1,296 sq. inch per panel. NFPA 21.3.7.1, 21.3.7.2, 21.3.7.3

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the health care occupancy was separated into at least two smoke compartments having at least a one hour fire resistance rating. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the smoke/fire barriers observation was made of five areas of penetrations noted as:

First Floor:
* Within the lift at the loading dock an approximate 15 foot long by two inch deep section of open area was observed between the top of the cement block and the corrugated upper deck.
* From the corridor side of the decontamination room and above the door to the left, an approximate 16 foot long by two inch deep section of open area was observed between the top of the drywall and the corrugated upper deck.
* Following this same wall around to the left, one unsealed conduit was observed.
* At the far left corner of this same wall to the right of the double doors leading into the post operating area, a one inch unsealed conduit was observed.
* Above the double doors leading into the post operating area, a two inch open end conduit was observed.

These findings were verified by staff T and U during tour.



9. The facility must ensure that smoke detectors in spaces served by air-handling systems are not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke detectors were not mounted near air flow devices where the normal operation of the smoke detectors may be compromised. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 19 at the time of the survey.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour observation was made of multiple smoke detectors mounted within several inches of air flow devices in the following areas:

First Floor:
* Two smoke detectors in the corridor north of the staff lounge.
* Within the corridor bordering the east side of the staff lounge and in the storage room.
* In the utility room across from the storage room.
* Within the men's locker room.
* Within the sub-sterile room, dirty utility room and trash room of the west side of the surgical corridor.
* Within the sub-sterile room, dirty utility room and trash room of the east side of the surgical corridor.
* In the processing room across from the anesthesia office.
* In the pre and post-op corridors, seven smoke detectors were observed near air flow devices.
* In the pre and post-op corridors med room, dirty utility room and supply room.
* In the interior waiting area near the draw station and within the storage room in the same location.
* In the interior waiting area of the laser rooms.
* In the admitting area.
* In the vending area.

These findings were verified by staff BB during tour.



10. The facility must ensure the sprinkler system is maintained in reliable operating condition required by the National Fire Protection Association (NFPA) 13 3-2.7.2.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in reliable operating condition specifically in regards to missing escutcheon rings which are required. The facility patient census at the beginning of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour observation was made of five areas on the first floor where escutcheon rings were missing from the sprinkler heads.
* Within the pathology room.
* Within the corridor near the tank storage room and in the contaminated trash room across from the tank storage room.
* In the cart storage room.
* Within a small storage room located at the far south end of the surgical corridor.

These findings were verified by staff BB during tour.



11. Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure that safe exit access was available from an exit egress which leads to a paved common way. The facility patient census at the beginning of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour observation was made of one exit egress from an enclosed stairwell located at the northeast corner of the building which lacked a continuous safe path to a paved common way. From within the stairwell this surveyor opened the exit access door and found the area covered with about one or two inches of snow. The exit access door was not able to be opened completely due to the snow on the cement stoop. Staff U obtained a snow shovel and cleaned the snow off from the cement stoop which measured approximately four foot square. Snow covered grass surrounded the cement stoop and it was estimated to be 50 to 60 feet from the nearest paved access.

This finding was verified by staff T and U during tour.

Based on review of the facility fire watch plan and staff interview and verification, the facility failed to ensure that if the required automatic sprinkler system was out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction was notified, and the building was evacuated or an approved fire watch was provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.


Findings included:

On 02/08/11 the facility's fire watch policy and plan was requested and reviewed. Review of the four page policy and procedure revealed it did not specifically address actions to be implemented if the required automatic sprinkler system was out of service for 4 or more hours in a 24 hour period. The policy addressed programs of inspection, testing and maintenance of the automatic sprinkler systems. Fire safety training of employees was noted which involved fire drills and safety education. The interim life safety policy addressed procedures when construction was planned, which included periodic inspection of the construction sites to ensure the health and safety of all persons in the facility.

The policy and procedure did not address consideration to the nature of the automatic sprinkler system shutdown, the location of the problem, increase hazards that may be involved and action to mitigate the hazards. The policy did not address notification of the authority having jurisdiction when the automatic sprinkler system may be out of service for 4 or more hours in a 24 hour period. There was no indication that special action beyond normal staffing could be implemented with such actions as increased observation of the areas affected. The fire watch policy also did not address any procedure for documentation of actions taken during implementation of a fire watch.

On 02/08/11 Staff I and Staff T verified the four page policy and procedure was the facility's complete fire watch plan.

Based on review of the facility fire watch plan and staff interview and verification, the facility failed to ensure that if the required fire alarm system was out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction was notified, and the building was evacuated or an approved fire watch was provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.


Findings included:

On 02/08/11 the facility's fire watch policy and plan was requested and reviewed. Review of the four page policy and procedure revealed it did not specifically address actions to be implemented if the fire alarm system was out of service for 4 or more hours in a 24 hour period. The policy addressed programs of inspection, testing and maintenance of the fire alarm systems. Fire safety training of employees was noted which involved fire drills and safety education. The interim life safety policy addressed procedures when construction was planned, which included periodic inspection of the construction sites to ensure the health and safety of all persons in the facility.

The policy and procedure did not address consideration to the nature of the fire alarm shutdown, the location of the problem, increase hazards that may be involved and action to mitigate the hazards. The policy did not address notification of the authority having jurisdiction when the fire alarm system may be out of service for 4 or more hours in a 24 hour period. There was no indication that special action beyond normal staffing could be implemented with such actions as increased observation of the areas affected. The fire watch policy also did not address any procedure for documentation of actions taken during implementation of a fire watch.

On 02/08/11 Staff I and Staff T verified the four page policy and procedure was the facility's complete fire watch plan.

Based on facility tour and observation, review of facility documentation and staff interview and verification, the facility failed to ensure the building construction type and height met an approved construction type for the height, composition and use of the building. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 01/31/11 construction information was provided by the Staff T of the facility. Review of the information revealed the West building was first constructed in early 1900s and was added onto several times. Construction type included load bearing masonry, to steel post and beam, bar joists and some wood floor joist and wood roof joists. Attic spaces with exposed wood joists housed both mechanical and storage areas on two southerly wings. The West building was noted be approximately sixty percent sprinklered.

On 02/03/11 between 9:45 A.M. and 5:00 P.M., tour of the West building was conducted with Staff W and V. Located on the fourth floor were two wings. One wing was identified to be storage and the other was a mechanical area. Observation of both areas revealed an attic type appearance with exposed wood construction at the roof and at the walls. The areas were provided automatic sprinkler protection and smoke detection. The floors were noted to be concrete.

Review of the facility schematic indicated there was a 2 hour fire rated building separation between the mechanical room and the storage room and the reminder of the fourth floor. Observation above the ceiling tiles at the entrance to the mechanical room revealed a small space for visibility, approximately 4 inches in height by 5 feet in width. Exposed wood was visible above the door frame. Observation inside the mechanical room of the same 2 hour barrier wall revealed that due to pipes and other mechanical items access and visibility of the the two hour fire barrier was very limited. Staff V present verified that visibility of the fire wall from inside the mechanical room was very limited. Staff V and W verified that exposed wood was visible above the door frame outside the mechanical room. Staff V and W also verified that due to the limited space available for observation, it was not possible to determine if the 2 hour fire wall was intact.

Further observation of the fourth floor revealed the presence of a locked geriatric psychiatric unit located between the two wings that were used as the mechanical room and and storage. Staff present on tour observed and verified the observations.

Continued observation of the West building did not reveal further observation of exposed wood in the construction of the building.

Based on facility tour and staff verification it was determined this facility failed to ensure all doors located within smoke/fire barriers were held open with devices that would automatically close all such doors upon activation of the fire alarm, sprinkler or smoke detection system. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings include:

Tour of the south portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the third level locked psychiatric unit observation was made of the smoke barrier door equipped with an automatic closing device, bordering the west end of the break room. This door was held open using a rubber wedge placed between the bottom of the door and the floor which essentially disarmed the self closing device.

During tour of the forth level cardiac cath lab, observation was made of the smoke barrier door of the south end bio-hazard room which was equipped with an automatic closing device. This door was held open using a wood wedge placed between the bottom of the door and the floor which essentially disarmed the self closing device.

These findings were verified by Staff T and U during tour.

Based on facility observation and staff interview and verification the facility failed the ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Potentially all persons who utilized the Sleep Center could be affected.

Findings included:

On 02/04/11 between the hours of 8:45 A.M. and 9:15 A.M. observation of the facility was completed with Staff W, Staff CC and Staff DD. Staff CC indicated the Sleep Center had two smoke barrier walls at each end of the corridor where the Sleep Center was coated. Observation of the smoke barrier walls above the ceiling tiles in patient rooms 1208 and 1209 revealed penetrations.

In room 1208 a penetration estimated to be approximately six inches by eight inches was observed. In room 1209 another penetration was located. The penetration in room 1209 was noted to be approximately six inches by eight inches. Staff present on tour observed and verified the penetrations in the smoke barrier walls.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke/fire barriers were constructed to provide at least a one half hour fire resistance rating. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings included:

1. On 02/01/11 at 11:50 A.M., tour of the seventh floor of the East building was conducted with Staff T and Staff V. Observation of the seventh floor revealed the floor was unoccupied and closed. Staff T stated the floor was to closed and not used for patient care as renovation was planned in the near future.

Observation of the smoke barrier wall that divided the seventh floor revealed multiple penetrations. The smoke barrier was identified to have extended from outside wall to outside wall which included between patient rooms 703 and 704. Observation above the ceiling tiles in rooms 703 and 704 revealed multiple penetrations in the smoke barrier wall. Observation above ceiling tiles in room 704 revealed the smoke barrier wall was not continuous and was open above the bathroom. Staff T and V observed and verified the penetrations in the smoke barrier wall in both patient rooms.

2. Tour of the South portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the smoke/fire rated walls observation was made of penetrations above the ceiling tile in the following locations:

Level Zero:
* At the west end of the half hour rated smoke barrier bordering the storage room and above the door and ceiling tile, observation was made of one 2 inch open end conduit and one 1 inch unsealed copper line.

Level One:
* At the west end of the 2 hour fire rated barrier bordering the physician's convenience center above the door to the left, observation was made of two 1 inch unsealed conduits.
* In the 2 hour fire rated barrier above the double doors of the radiology department waiting area, observation was made of one 1 inch open end conduit and one unsealed conduit.

Level Two:
* Above the double doors located in the 2 hour fire rated barrier between the main elevators, a one 1 inch unsealed conduit was observed.
* Around the corner of the main elevators near the snack area and above the TV, observation was made of two unsealed flex conduits penetrating the 2 hour fire rated barrier.

Level Three:
* Within the one half hour smoke barrier located at the back wall of the kitchen, observation was made of an approximate 2 foot by 4 inch unsealed area where the drywall meets the upper deck.
* Above the north end one half hour smoke barrier double doors, observation was made of penetrations around one conduit and a set of wires. Additionally, observation was made of one unsealed conduit.

Level Four:
* Near the center of the core just south of the stairs and behind the bio-hazard soiled room, observation was made of penetrations in the one half hour smoke barrier. Facing the back of the bio-hazard room and to the right, observation was made of a large portion of drywall missing within the smoke barrier. At each end an approximate 2-3 foot by 3 foot section was missing and an approximate 6 foot by 4 inch middle section was missing.
* Following the smoke barrier around the corner from the above description and across from cath lab number three. At the corner of the smoke barrier just prior to the double smoke barrier doors, observation was made of an approximate 6 foot section of unsealed groves where the drywall meets the corrugated steel upper deck.
* At the back smoke barrier wall of the kitchen in the center of the core observation was made of an approximate 7 foot long by 1 inch section of unsealed area where the drywall meets the corrugated upper steel deck.
* Observation was made of one flex and one straight unsealed conduit located above the smoke barrier door of the south end bio-hazard room.
* Within the storage room at the south end of the smoke barrier, observation was made of several inches of an unsealed area around a duct penetrating the smoke barrier. Six other penetrations were observed around six conduits. Additionally, observation was made of an approximate 16 foot by one inch section of unsealed area where the drywall meets the upper corrugated steel deck.

These findings were verified by staff T and U during tour on 02/03/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke/fire barriers were constructed to provide at least a one hour fire resistance rating, specifically in the one hour fire separation located between building one and three. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of building three took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the one hour fire rated wall located on level one separating building one and three, observation was made of three areas of penetrations above the ceiling tiles listed as:
* Six open end conduits and one open junction box observed at the back end of exam room number eleven.
* Above the south double leafed smoke barrier doors located between exam room eight and nine, observation was made of two one inch holes, one unsealed copper line and one unsealed 2.5 inch square conduit.
* One open end conduit located above the smoke barrier door within the nurse manager's room.

These findings were verified by staff T and U during tour on 02/03/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure all doors located in smoke barriers were equipped with an automatic or self-closing device and no gaps greater than one eighth inch existed between door leafs when in the closed position. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings include:

1. On 02/01/11 between 10:40 A.M. and 5:00 P.M. and on 02/02/11 between the hours of 9:30 A.M. and 2:30 P.M., tour of the East building was conducted with Staff T, U, V, and X.

The following smoke doors were observed to have gaps greater than one eighth inch at the edges of the doors when in the closed position;

Eighth Floor
* A smoke barrier door in a corridor near room 816.

Fifth Floor
* A smoke barrier door in a corridor near the nursing station.

Fourth Floor
* A smoke door located in the connector corridor to the west building.

Staff present on tour observed and verified the smoke doors had gaps greater than one eighth inch when in the closed position.

2. Tour of the South portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U.
During tour of the smoke/fire rated barriers observation was made of:

Level One
* Smoke barrier door which was not equipped with an automatic or self closing device. This door was located in the physician's sleep room near the north stairs.

Level Two:
* South end double smoke barrier doors entering into the CCU was observed with a gap greater than one eighth inch between the door leafs when in the closed position.
* North end double smoke barrier doors entering into the ICU was observed with a gap greater than one eighth inch between the door leafs when in the closed position.


Level Four
* South end double smoke barrier doors by the bio-hazard room was observed with a gap greater than one eighth inch between the door leafs when in the closed position.
* Double smoke barrier doors across from cath lab number 3 was observed with a gap greater than one eighth inch between the door leafs when in the closed position.


These findings were acknowledged by staff T and U during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke/fire barrier doors were constructed to provide at least a twenty minute fire resistance rating, specifically in the one hour fire separation located between building one and three. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of building three took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the one hour fire rated wall located in the intensive care unit on level two separating building one and three, observation was made of a gap greater than one eighth inch between the north smoke barrier door leafs when in the closed position.

These findings were verified by staff T and U during tour on 02/03/11.

Based on facility observation and staff verification the facility failed to ensure that when the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings included:

1. On 02/03/11 between 9:45 A.M. and 5:00 P.M., tour of the West building was conducted with Staff W and V. Observation of the second floor medical library at 2:20 P.M., revealed the area was provided with automatic sprinkler protection. The medical library was noted to have a significant amount of books and papers and other combustibles.

Observation of the library revealed that eight ceiling tiles were missing from various locations of the ceiling and one ceiling tile was broken. The missing and broken ceiling tiles would fail to provide the desired smoke resisitance protection desired when the automatic sprinkler option was used. Staff W indicated that tiles were probably missing due to maintenance work in the room. No workers were observed and no signage was visible to indicate that repair work was in progress.

2. Tour of the first floor of the West building with Staff W and V revealed the presence of a mechanical room. The mechanical room was located near the oncology services area. Observation of the mechanical room revealed two doors in the one hour fire rated separation. One door was noted to be the primary means of entrance and exit. The second door was noted to exit into the corridor and had no self closing device in place. Staff present on tour verified there was no self closing device on one of the mechanical room doors.

3. Tour of level 0 of the West building with Staff W and Staff V on 02/03/11 at 3:55 P.M. revealed the presence of a soiled linen chute discharge room. The chute discharge room was located across the corridor from the cleaning storage room. Observation of the chute discharge room revealed the door to the room was held open and was unable to self close. Staff present on tour verified the chute room door was held open which negated the self closing activation of the door.

Based on facility tour and staff interviewed and versification, the facility failed to ensure that when the approved automatic fire extinguishing system option was used, the area was separated from other spaces by smoke resisting partitions. Potentially all persons who utilized the outpatient therapy services could be affected. The hospital had capacity of 346 patients and had a census of 147 patients at the time of survey.

Findings included:

On 02/08/11 between the hours of 9:30 A.M. and 12:30 P.M. tour of the facility was completed with Staff W. Observation of the electrical room located near the physical therapy room gym revealed the room was equipped with sprinkler and smoke detector protection. Observation of the ceiling in the electrical room revealed a significant number of tiles missing from the ceiling of the room.

Staff W present on tour observed and verified a large number of ceiling tiles were missing from the room. Staff W further verified smoke could easily travel to other areas in the facility when the ceiling tiles were missing.

Based on observation during tour and staff verification it was determined this facility failed to ensure all doors in hazardous areas were equipped with automatic or self closing devices. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying these areas of the facility.

Findings include:

Tour of the south portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U.

Level Zero:
* During tour of the x-ray film storage hazardous area, observation was made of two doors at either end of the room which was not equipped with an automatic or self-closing device.
* Additionally, observation was made of the gift shop storage room door which was not equipped with an automatic or self-closing device.

This finding was verified by staff T and U during tour.

Based on facility observation and staff interview and verification the facility failed to ensure that exit access was arranged so that exits were readily accessible at all times with regards to snow, ice and access to the public way. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey. All patients, visitors and staff could potentially be affected.

Findings included:

On 02/01/11 at 8:45 A.M. observation of the sidewalk at the front of the facility revealed it to be covered with a layer of snow and ice. Tour of the East portion of the building on 02/01/11 between 10:40 A.M. and 5:00 P.M. with Staff T and Staff V revealed that stairwell B was means of exit from the top floors of the East building to the level of discharge at the ground floor.

Observation of stairwell B at 2:45 P.M. revealed that at the exit discharge there were 15 steps to climb to reach ground level. The steps were covered with snow. The steps lead to a landscaped area where there were small shrubs, trees and a grassy area. All was covered with snow and ice. Observation from the landscaped area revealed the same sidewalk at the front of the facility noted earlier in the day. The sidewalk had not been cleared. Snow removed from the street had been thrown onto the sidewalk as well.

Interview with Staff T regarding the exit discharge verified there was no paved way to the sidewalk from the landscaped area at the front of the facility. Staff had not cleared the sidewalk of the snow as the city snow removal continually threw the snow back onto the sidewalk when the street was cleaned.

On 02/02/11 the sidewalk was observed to have been cleared at least one time. On 02/04/11 the sidewalk was observed to be covered with packed snow and ice which left an uneven surface for travel.

Based on facility tour, review of the facility schematic and staff interview and verification the facility failed to ensure that horizontal exits were in accordance with 7.2.4 with regards to fire barriers without penetrations and corridor fire doors designed to minimize air leakage. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 02/01/11 between 10:40 A.M. and 5:00 P.M. and on 02/02/11 between the hours of 9:30 A.M. and 2:30 P.M., tour of the East building was conducted with Staff T, U, V, and X. The following observations were noted in 1 and/or 2 hour fire rated separation walls and with the function of fire rated doors within the fire barrier walls.

1. The fire rated corridor doors on the eighth floor, near the east elevator lobby, did not close and latch when tested

2. Review of the facility schematic revealed a 1 hour fire rated smoke/ fire barrier separation located in a corridor near the pathology office located on the first floor. Observation of the area with Staff T and X revealed the office locations and fire barrier walls and the facility schematic did not match. Staff T and X indicated the pathology office area had been renovated. The facility schematic no longer accurately refected the location of the fire/smoke barrier wall.

On 02/02/11 at 9:30 A.M. the area was observed with Staff T and Staff Z. Staff Z verified the location of the fire barrier wall in the area. Observation of the fire barrier near the conference room and above the fire door in the corridor, revealed a penetration at the roof decking. Staff X observed and verified the opening in the fire barrier wall above the fire door.

3. On 02/02/11 observation of the nuclear medicine area located on the first floor of the east building revealed penetrations in the 2 hour fire rated separation wall. Observation above the ceiling tiles revealed three penetrations in the fire barrier around duct work. Staff U and Staff Z observed and verified the penetrations in the fire barrier.

Further observation above the ceiling tiles of the 2 hour fire rated barrier separation, in the corridor of the nuclear medication area, were penetrations located on both sides of fire door, S01FD17.

Continued observation above the ceiling tiles of the same 2 hour fire barrier in the nuclear medicine area revealed two penetrations located in treatment room. One penetration was a square area surrounding a pipe and the second area was a square area surrounding red fire alarm wires.

4. On 02/02/11 tour of the dietary area located on level 0 of the east building with Staff T and U revealed one hour fire rated doors in the corridor near the storage area had a gap greater than 1/8 inch at the edges of the door when the door was in the closed position. A second corridor fire door located in a 2 hour fire rated separation wall, near the mail room was tested and noted to fail to latch when closed.

Staff present on tour observed and verified the observation related to the fire doors.

Based on facility tour, review of the facility schematic and staff interview and verification the facility failed to ensure that horizontal exits were in accordance with 7.2.4 with regards to fire doors designed to minimize air leakage. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 02/03/11 between 9:45 A.M. and 5:00 P.M. tour of the West building was conducted with Staff W and Staff V. The following observations were noted in 1 and/or 2 hour fire rated separation walls and with the function of fire rated doors within the fire barrier walls.

1. The fire rated corridor doors on the fifth floor, in the 2 hour fire rated building separation were observed to have a gap greater than one eighth inches when in the closed position.

2. The fire rated corridor doors on the third floor, in the 2 hour fire rated building separation were observed to have a gap greater than one eighth inch when in the closed position.


3. The fire rated corridor doors ( NO2FD01) on the second floor, in the 2 hour fire rated building separation were observed to fail to close and positively latch when tested.

Staff present on tour observed and verified the observation related to the fire doors.

Based on review of facility documentation and staff interview and verification the facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift. Potentially all patients utilizing the sleep center could be affected.

Findings included:

On 02/04/11 between the hours of 8:45 A.M. and 9:15 A.M. review of facility documentation and observation of the facility and was completed with Staff W and Staff CC. Interview of Staff W revealed the hours of operation at the Sleep Center was 8:00 P.M. until 6:30 A.M. with some 8:00 A.M. unit 4:00 P.M. shifts. The Sleep Center was located in a corridor within another hospital. The Sleep Center was observed to be separated by a smoke barrier wall from the host hospital.

Review of documented fire drills completed for 2010 and to date in 2011 revealed one documented fire drill completed in February 2011 for the 8:00 P.M. until 6:30 A.M. shift. Staff CC present from the host facility verified there was no other documented fire drills specific to the Sleep Center.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in reliable operating condition specifically in regards to dirt and debris on sprinkler heads and escutcheon rings missing which are required by the National Fire Protection Association (NFPA) 13 3-2.7.2. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings included:

1. On 02/01/11 at 11:00 A.M., tour of the ninth floor of the facility was conducted with Staff T and Staff V. Observation of the soiled linen chute located in a small room near the nursing station, revealed the presence of a sprinkler head for the automatic sprinkler system in the chute.

Observation of the sprinkler head revealed it was covered with dust, dirt and debris. Staff present indicated that it was not known if the sprinkler system maintenance company for the facility routinely observed and cleaned the chute sprinkler head. Staff present on tour verified the sprinkle head was very dirty.

During tour of the East building on 02/02/11 observation was made of two sprinkler heads missing escutcheon rings on level one in the pathology lab.

2. Tour of the South portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the south building observation was made of several sprinkler heads missing escutcheon rings in the following locations:

Level Zero:
* One escutcheon ring missing located in the closet of the meeting rooms.

Level One:
* Between the two sets of double doors leading to the emergency department and located near radiology exam room number 7, two escutcheon rings were observed to be missing.
* Just beyond the north double doors of the CT room near the stairs, one escutcheon ring was observed to be missing.
* Going in exam room number 8 and through the back door into a smaller room, one escutcheon ring was observed to be missing.
* One escutcheon ring was observed to be missing within the oxygen storage room located at the north west corner of the south building.

Sprinkler heads observed to be coated with dirt and/or debris was observed in the following locations:
* Within the MRI waiting area.
* Within the special procedure room near the south west stairs.
* In the corridor just north of radiology room number 7.

Level Three:
* A sprinkler head located in the kitchen was observed to have a very thick coating of dirt and/or debris.

These findings were verified and acknowledged by staff T and U during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in reliable operating condition specifically in regards to escutcheon rings required by the National Fire Protection Association (NFPA) 13 3-2.7.2. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of building three took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the emergency department located on level one, observation was made of three areas where escutcheon rings were missing, listed as:
* Near the double doors located near exam room number 20.
* Within the rest room of the staff dressing room located adjacent to the south stairs.
* Within the corner room bordering the restroom nearest the south exit of the waiting area.

These findings were verified by staff T and U during tour.

Based on facility tour and observation, review of facility documentation and staff interview and verification, the facility failed to ensure interior walls and partitions in buildings were noncombustible or limited-combustible materials. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 01/31/11 construction information was provided by the Staff T of the facility. Review of the information revealed the West building was first constructed in early 1900s and was added onto several times. Construction type included load bearing masonry, to steel post and beam, bar joists and some wood floor joist and wood roof joists. Attic spaces with exposed wood joists housed both mechanical and storage areas on two southerly wings. The West building was noted be approximately sixty percent sprinklered.

On 02/03/11 between 9:45 A.M. and 5:00 P.M., tour of the West building was conducted with Staff W and V. Located on the fourth floor were two wings. One wing was identified to be storage and the other was a mechanical area. Observation of both areas revealed an attic type appearance with exposed wood construction at the roof and at the walls. The areas were provided automatic sprinkler protection and smoke detection. The floors were noted to be concrete. The exposed wood ceiling and walls were noted to be not treated with fire retardant.

Staff V and W verified the exposed wood in the mechanical room was not treated with fire retardant.

Based on facility observation and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.

Findings included:

On 02/03/11 between 9:45 A.M. and 5:00 P.M. tour of the West building was conducted with Staff W and Staff V. During tour of the facility observation were made of several smoke detectors located significantly closer than 36 inches from air flow devices in the following areas:

Level Two:
* Located in the pharmacy, four smoke detectors were noted to be less than 24 inches from air flow devices.

Level One
* Located in the work med area, one smoke detector was noted to be in very close proximity to an air flow device.

*Located in the administration area two smoke detectors were noted to be less than 24 inches from an air flow devices.

Staff present on tour observed and verified the location of the smoke detectors.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 147 at the beginning of the survey.

Findings include:

1. On 02/01/11 between 10:40 A.M. and 5:00 P.M. and on 02/02/11 between the hours of 9:30 A.M. and 2:30 P.M., tour of the East building was conducted with Staff T, U, V, and X. During tour observation was made of several smoke detectors located near air flow devices in the following areas:

Level One:
* Located in the pathology lab storage, two smoke detectors were noted to be approximately 12 inches from air flow devices.

* Located in the gift shop, three smoke detectors were noted to be place in very close proximity to ceiling fans and air flow devices.

2. Tour of the South portion of building one took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour observation was made of several smoke detectors located near air flow devices in the following areas:

Level Zero:
* In the northwest section of the south building within a storage room and forms managing room next to the mail room.

Level One:
* Within the operation's managers room adjacent to the exit ramp.
* On the north side of the double doors leading to the exit ramp.

Level Two:
* Within the female locker room in the critical care department.
* In front of the service elevators.
* Within the office of the chief surgeon across from the main elevators.

Level Three:
* Within the lounge area of the psychology unit, four smoke detectors were observed.
* In front of the service elevator.
* Within the nurse's station behind the counter near the smoke barrier door.

Level Four:
* At the center core within the bio-hazard room.
* In the corridor north of lab number 3 by the north stairs.
* In the corridor south of lab number 3 outside the bio-hazard room.
* In the corridor outside of room number 476.

These findings were verified and acknowledged by staff T and U during tour.

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility patient census at the beginning of the survey was 147. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of building three took place on 02/03/11 beginning at 9:50 AM with staff members T and U. During tour of the emergency department, critical care and intensive care units, observation was made of several smoke detectors located near air flow devices as follows:

Level One ED:
* Within exam room numbers 5, 6, 8, 9, 10,11, 17, 18, 19 and 20.
* Within the soiled utility room next to exam room number 5.

Level Two CCU:
* Within the clean utility room located in the center core.
* West end of the corridor outside of the clean utility room.
* Within the chart room, south end of the center core.

Level Two ICU:
* Within the soiled utility room of the center core.
* Within the chart room adjacent to the soiled utility room.
* Within the clean utility room located on the west side.
* Within room number 16.
* North end of the corridors on each side of the dictation room.

These findings were acknowledged by staff T and U during tour.

1. Any door with a required fire protection rating, such as stairways, exit passageways, horizontal exits, smoke barriers, or hazardous area enclosures, if held open, is arranged to close automatically by the actuation of the manual fire alarm system and either smoke detectors arranged to detect smoke on either side of the opening or a complete automatic sprinkler system. NFPA 21.2.2.3

This requirement was not met as evidenced by:

Based on facility tour and staff verification it was determined this facility failed to ensure all doors located within smoke/fire barriers were held open with devices that would self close or automatically close all such doors upon activation of the fire alarm, sprinkler or smoke detection system. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the smoke barrier which included the door of the decontamination room which was equipped with a self closing device, observation was made of a small table with wheels being used to prop the door open, essentially deactivating the self closing device.

This finding was verified by all staff present during tour.




2. Hazardous areas separated from other parts of the building by fire barriers having at least a one hour fire resistance rating or such areas are enclosed with partitions and doors and the area is provided with an automatic sprinkler system. High hazard areas are provided with both fire barriers and sprinkler systems as required by NFPA 39.3.2

This requirement was not met as evidenced by:

Based on facility tour and staff verification it was determined this facility failed to ensure all high hazardous areas were separated from other parts of the building with at least a one hour fire barrier and is equipped with a suppression system. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this facility.


Findings include:

Tour of the basement portion of the facility took place on 02/04/11 at 9:30 AM with staff members T and U. During tour of the basement area observation was made of a huge quantity of flammable materials in the form of medical records, medical beds, chairs, cushions, wood pallets, carts and miscellaneous medical devices.
Observation was made of boxes of medical records estimated to be between one and two thousand, of which most but not all were secured in five open fenced areas. Approximately two hundred were stacked on wood pallets and wood carts outside of the fenced area.
Beds, chairs, cushions and other medical devices were randomly placed through the basement area outside of the fenced in medical records.
Although the basement was sprinklered, it lacked at least a one hour fire resistance rating identified by the unprotected steel deck and girders.

This finding was verified and acknowledged by staff T and U during tour.



3. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. NFPA 21.7.1.2

This requirement was not met as evidenced by:

Based on review of fire drill documentation and staff verification it was determined this facility failed to ensure all fire drills were conducted at least once per shift per quarter. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include;

Review of fire drill documentation took place on 02/07/11. Observation was made of two fire drills documented as being conducted in the year 2010 for the second and fourth quarters. The question was proposed to staff J on 02/07/11 if there was any other fire drill documentation available for the first and third quarter of 2010 and staff J stated, what was brought to us is probably all there is but he/she will check again.
No additional information was provided before the time of the life safety code exit on 02/08/11.

This finding confirms only two fire drills were conducted in the year 2010.



4. A manual fire alarm system, not a pre-signal type, is provided to automatically warn the building occupants. Fire alarm system has initiation notification and control function. The fire alarm system is arranged to automatically transmit an alarm to summon the fire department. NFPA 21.3.4.1

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire alarm system was equipped with initiation devices, specifically fire pull stations, near or in the direct path of all designated exits in order to automatically transmit an alarm to summon the local fire department. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

During tour of the northwest section of the facility with staff T and U on 02/04/11, observation was made of a designated exit at the dock area utilized by the ambulance and receiving personnel. This exit access lacked a fire pull station near or in the direct path of the exit egress.

This was verified by staff T and U during tour when staff J stated never realizing this exit did not have a fire pull station.



5. Portable fire extinguishers are provided in ambulatory health care facilities in accordance with NFPA 21.3.5.2 and 9.7.4.1.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the portable fire extinguishers were visible and accessible at all times. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the ambulance and receiving area observation was made of a portable fire extinguisher mounted by the exit access. There was portable metal stairs directly in front of the fire extinguisher blocking access to it.
Additionally, during tour of the staff lounge observation was made of a portable fire extinguisher mounted on the wall. There was a large plastic trash can placed in front of it blocking access to it.

This was verified by all staff present during tour.




6. Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities, and NFPA 101.

(a) Oxygen storage locations of greater than 3,000 cu. ft. are enclosed by a one hour separation.

(b) Locations for supply systems of greater than 3,000 cu. ft. are vented to the outside.

NFPA 4.3.1.1.2 and 21.3.2.4

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure medical gasses were securely stored and protected as required. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the medical gas storage room observation was made of four E-tanks containing nitrogen and oxygen which were not secured in holding devices or chained to the wall as required.

This finding was verified by staff T and U during tour of the medical gas room.



7. Ambulatory health care occupancies are separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Doors in such barriers are solid bonded core wood of 1 inches or equivalent and are equipped with a positive latch and closing device. Vision panels, if provided in fire barriers or doors, are fixed fire window assemblies in accordance with 8.2.3.2.2.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the health care occupancy was separated from other tenants with at least a one hour fire resistance barrier, specifically regarding the door. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the occupancy separation which is an enclosed walkway containing a two hour fire rated door. After deactivating the door leafs from the holding device, observation was made of one of the door leafs failing to close and latch properly. With closer observation it was noticed the door leaf had been damaged near the bottom inner edge which caused and prevented the door from closing properly.
Additionally, above the doors and ceiling tile observation was made of a penetration located between the top of the drywall and the upper deck. This gap was approximately eight foot in length by two inches deep.

This finding was confirmed by staff T and U during tour.



8. Ambulatory health care facilities are divided into at least two smoke compartments with smoke barriers having at least 1 hour fire resistance rating. Doors in smoke barriers are equipped with positive latching device. Doors are constructed of not less than 1 inch thick solid bonded core wood or equivalent. Vision panels are provided and are of fixed wire glass limited to 1,296 sq. inch per panel. NFPA 21.3.7.1, 21.3.7.2, 21.3.7.3

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the health care occupancy was separated into at least two smoke compartments having at least a one hour fire resistance rating. The facility patient census at the time of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this area of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour of the smoke/fire barriers observation was made of five areas of penetrations noted as:

First Floor:
* Within the lift at the loading dock an approximate 15 foot long by two inch deep section of open area was observed between the top of the cement block and the corrugated upper deck.
* From the corridor side of the decontamination room and above the door to the left, an approximate 16 foot long by two inch deep section of open area was observed between the top of the drywall and the corrugated upper deck.
* Following this same wall around to the left, one unsealed conduit was observed.
* At the far left corner of this same wall to the right of the double doors leading into the post operating area, a one inch unsealed conduit was observed.
* Above the double doors leading into the post operating area, a two inch open end conduit was observed.

These findings were verified by staff T and U during tour.



9. The facility must ensure that smoke detectors in spaces served by air-handling systems are not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke detectors were not mounted near air flow devices where the normal operation of the smoke detectors may be compromised. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 19 at the time of the survey.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour observation was made of multiple smoke detectors mounted within several inches of air flow devices in the following areas:

First Floor:
* Two smoke detectors in the corridor north of the staff lounge.
* Within the corridor bordering the east side of the staff lounge and in the storage room.
* In the utility room across from the storage room.
* Within the men's locker room.
* Within the sub-sterile room, dirty utility room and trash room of the west side of the surgical corridor.
* Within the sub-sterile room, dirty utility room and trash room of the east side of the surgical corridor.
* In the processing room across from the anesthesia office.
* In the pre and post-op corridors, seven smoke detectors were observed near air flow devices.
* In the pre and post-op corridors med room, dirty utility room and supply room.
* In the interior waiting area near the draw station and within the storage room in the same location.
* In the interior waiting area of the laser rooms.
* In the admitting area.
* In the vending area.

These findings were verified by staff BB during tour.



10. The facility must ensure the sprinkler system is maintained in reliable operating condition required by the National Fire Protection Association (NFPA) 13 3-2.7.2.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in reliable operating condition specifically in regards to missing escutcheon rings which are required. The facility patient census at the beginning of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour observation was made of five areas on the first floor where escutcheon rings were missing from the sprinkler heads.
* Within the pathology room.
* Within the corridor near the tank storage room and in the contaminated trash room across from the tank storage room.
* In the cart storage room.
* Within a small storage room located at the far south end of the surgical corridor.

These findings were verified by staff BB during tour.



11. Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1.

This requirement was not met as evidenced by:

Based on observation during tour and staff verification it was determined this facility failed to ensure that safe exit access was available from an exit egress which leads to a paved common way. The facility patient census at the beginning of the survey was 19. This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings include:

Tour of the facility took place on 02/04/11 at 9:30 AM with staff members T, U and BB. During tour observation was made of one exit egress from an enclosed stairwell located at the northeast corner of the building which lacked a continuous safe path to a paved common way. From within the stairwell this surveyor opened the exit access door and found the area covered with about one or two inches of snow. The exit access door was not able to be opened completely due to the snow on the cement stoop. Staff U obtained a snow shovel and cleaned the snow off from the cement stoop which measured approximately four foot square. Snow covered grass surrounded the cement stoop and it was estimated to be 50 to 60 feet from the nearest paved access.

This finding was verified by staff T and U during tour.

Based on review of the facility fire watch plan and staff interview and verification, the facility failed to ensure that if the required automatic sprinkler system was out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction was notified, and the building was evacuated or an approved fire watch was provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.


Findings included:

On 02/08/11 the facility's fire watch policy and plan was requested and reviewed. Review of the four page policy and procedure revealed it did not specifically address actions to be implemented if the required automatic sprinkler system was out of service for 4 or more hours in a 24 hour period. The policy addressed programs of inspection, testing and maintenance of the automatic sprinkler systems. Fire safety training of employees was noted which involved fire drills and safety education. The interim life safety policy addressed procedures when construction was planned, which included periodic inspection of the construction sites to ensure the health and safety of all persons in the facility.

The policy and procedure did not address consideration to the nature of the automatic sprinkler system shutdown, the location of the problem, increase hazards that may be involved and action to mitigate the hazards. The policy did not address notification of the authority having jurisdiction when the automatic sprinkler system may be out of service for 4 or more hours in a 24 hour period. There was no indication that special action beyond normal staffing could be implemented with such actions as increased observation of the areas affected. The fire watch policy also did not address any procedure for documentation of actions taken during implementation of a fire watch.

On 02/08/11 Staff I and Staff T verified the four page policy and procedure was the facility's complete fire watch plan.

Based on review of the facility fire watch plan and staff interview and verification, the facility failed to ensure that if the required fire alarm system was out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction was notified, and the building was evacuated or an approved fire watch was provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. The hospital had a capacity of 346 certified beds with a census of 147 patients at the time of the survey.


Findings included:

On 02/08/11 the facility's fire watch policy and plan was requested and reviewed. Review of the four page policy and procedure revealed it did not specifically address actions to be implemented if the fire alarm system was out of service for 4 or more hours in a 24 hour period. The policy addressed programs of inspection, testing and maintenance of the fire alarm systems. Fire safety training of employees was noted which involved fire drills and safety education. The interim life safety policy addressed procedures when construction was planned, which included periodic inspection of the construction sites to ensure the health and safety of all persons in the facility.

The policy and procedure did not address consideration to the nature of the fire alarm shutdown, the location of the problem, increase hazards that may be involved and action to mitigate the hazards. The policy did not address notification of the authority having jurisdiction when the fire alarm system may be out of service for 4 or more hours in a 24 hour period. There was no indication that special action beyond normal staffing could be implemented with such actions as increased observation of the areas affected. The fire watch policy also did not address any procedure for documentation of actions taken during implementation of a fire watch.

On 02/08/11 Staff I and Staff T verified the four page policy and procedure was the facility's complete fire watch plan.