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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 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 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 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 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 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 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.