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Based on observation and interview, the facility did not provide a common separation wall with taped joints on rated walls. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 4, 2014 at 1:00 pm, observation revealed on the 1st floor separating the nursing home and hospital, that the enclosing wall was not constructed to a 2-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.1.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide corridor finishes with rated wall finish materials. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 4:20 pm, observation revealed on the 1st floor in the corridor half wall of the nurse station, that the facility could not confirm the wall finish material had an appropriate rating. The corridor wall was finished with 3 feet in height made of a carpet type material. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.3.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with rooms open to the corridor with the required safe-guards. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 11:20 am, observation revealed on the 1st floor in the Main entrance greeting area, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied staff location. The Main entrance greeting contained a shutter, yet this shutter was prevented from fully closing which circumvented the corridor wall smoke tight requirement due to facility placed objects on the shelf. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.6.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide corridor separation doors with positive-latching Dutch doors. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 1:00 pm, observation revealed on the 1st floor in the Laboratory, that the door to the corridor was split in the middle to form a "Dutch door". The upper door would not positively self-latch into the bottom door or the frame. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.6.3.6.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 3:20 pm, observation revealed on the 1st floor in the corridor outside the laundry room, that the smoke barrier wall was not constructed to a minimum 30 minute fire resistance rating because there is a 2 inch gap between the dry wall and ventilation air duct. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility did not enclose hazardous rooms with rated doors, sealed wall penetrations, rated walls in a hazardous room, closer's on all doors, rated doors, and sealed wall penetrations. This deficiency occurred in 3 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 12:55 pm, observation revealed on the 1st floor in the ambulance garage, that penetrations were not sealed according to an approved method. The deficiency included 3 electrical conduits: two 1/2" and one 3/4" in diameter. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.2.1.

2. On March 3, 2014 at 2:08 pm, observation revealed on the 1st floor in the Sterilizer recess, that a penetration was not sealed according to an approved method. The deficiency included a 2 inch copper pipe that was not properly fire caulked. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.2.1.

3. On March 3, 2014 at 2:15 pm, observation revealed on the 1st floor in Material management, that the fire barrier door could not be verified to have the required rating. The door has bolt holes in the rated door where the 'old' closer use to be and was subsequently removed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.2.1.

4. On March 3, 2014 at 3:00 pm, observation revealed on the 1st floor in the laundry room, that penetrations were not sealed according to an approved method. The deficiency included a 6" pipe and a 1/2" conduit not properly fire sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.2.1.

5. On March 4, 2014 at 11:00 am, observation revealed on the 1st floor in the storage room, that penetrations were not sealed according to an approved method. The deficiency included 4 conduits below the ceiling and holes were present above the ceiling. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide egress paths at all times with a compliant egress path. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 11:45 am, observation revealed on the 1st floor at the exterior doors, that the egress door was locked with an access control magnetic lock that was not compliant with the code. All of the exterior doors, when the magnet is activated, does not have a lever or push bar on the door to open (break the power to the magnetic) or a door occupancy sensor (break the power to the magnetic) to open the door. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 18.2.7, and 7.2.1.6.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation, record review, and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare and Medicaid Services (CMS) have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility provided relocation instructions yet did not provide this information through the facility automatic fire alarm system. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On 3/03/2014 at 2:00 pm, during a record review and interview, it was determined that an overhead speaker system, that is not part of the fire alarm system, was used to inform staff, visitors and patients of fire emergency related conditions. After the speaker system announcement, then a separation action by staff would activate the fire alarm system. Relocation or partial evacuation voice communication used to inform occupants of a fire emergency condition shall be through the fire alarm system per NFPA 72 (1999 edition), Sections 3-8.4.3, 3-8.4.1.3.5 and 3-8.4.1. In addition, the system circuits shall be protected per 3-8.4.1.1.4 from the point at which the circuits exit the control unit until the point that they enter the notification zone.

This condition was confirmed at the time of discovery by a concurrent observation, record review, and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).
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Based on observation, interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 72 testing requirements. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 1:45 pm, observation revealed on the 1st floor at the corridor shutter by the reception (administration) area, that during a review of facility testing documents, the fire alarm testing reports were not available to verify that code-required tests of the fire alarm system were conducted. There was also no record that the shutters had been exercised and worked properly. Facility staff interviewed confirmed that the shutter did not come down during fire alarm testing. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-5.2.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution, ceilings sealed above the sprinklers to collect heat, and sprinklers located the appropriate distance apart. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 12:45 pm, observation revealed on the 1st floor in the ambulance garage, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included 9 electrical conduits above the south garage door. This observed situation was not compliant with NFPA 13 (1999 ed.), section 5-6.5.

2. On March 3, 2014 at 1:15 pm, observation revealed on the 1st floor in the Mammogram and x-ray room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a curtain that did not have a mesh to allow water to pass through. This observed situation was not compliant with NFPA 13 (1999 ed.), section 5-6.5.

3. On March 4, 2014 at 9:40 am, observation revealed on the 1st floor in the Data room by the nurse station, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate within its designed response time, due to missing lay-in ceiling tile(s). This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1.

4. On March 4, 2014 at 9:09 am, observation revealed on the 1st floor in the autoclave/OR, that two sprinklers were located 2 feet apart. This observed situation was not compliant with NFPA 13 (1999 ed.), section 5-6.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 4, 2014 at 8:30 am, observation revealed on the 1st floor in the OR, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Two 40 gallon trash containers were observed. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.7.5.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility used life support systems and did not provide a compliant Type I Essential electrical system. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 4, 2014 at 8:31 am, observation revealed on the 1st floor in the OR, that the facility admitted patients that depend on life support equipment and did not have a Type 1 Essential electrical system. The electrical system present failed to have two independent electrical systems in the critical patient care areas. There is no normal power or second source (back to the transfer switch) of emergency power via receptacles in the critical care patient area of the operating room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.9.1 and NFPA 99 (1999 ed.), 3-4.2.2.

2. On March 3, 2014 at 1:35 pm, observation revealed on the 1st floor in Emergency rooms 1 and 2, that the facility admitted patients that depend on life support equipment and did not have a Type 1 Essential electrical system. There is no normal power or second source (back to the transfer switch) of emergency power via receptacles in the critical care area of the emergency department exam rooms. Emergency room 2, an exam room, did not have a normal power source. Emergency room 1, an exam room, did not have a normal power source. It is assumed critical life support is being used in these patient rooms. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.9.1 and NFPA 99 (1999 ed.), 3-4.2.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Hospital K130

Item #1
NFPA 50 Bulk Oxygen System at Consumers Sites (2001 edition) section 2.1.4: "Where oxygen is stored as a liquid, surfacing on noncombustible material shall be provided at ground level under liquid delivery connections for the storage container and mobile supply equipment. This area of noncombustible surfacing shall be at least 3 ft in diameter from points at ground level where leakage of liquid oxygen might fall during unloading and normal operation of the system. The area under the mobile supply equipment shall be at least the full width of the vehicle and at least 8 ft in the direction of the vehicle axis. For purposes of this standard, asphaltic or bitumastic paving is considered to be combustible. The slope, if any, of such area shall take into consideration the possible flow of spilled liquid oxygen to adjacent combustible material. If expansion joints are used, filler shall also be of noncombustible materials."

Based on observation and interview, the facility failed to locate the tanker truck for refilling the bulk oxygen tank and the emergency oxygen service port over a noncombustible surface. This deficient practice could affect all patients.
FINDING INCLUDE:
1. On 03/04/2014 at 2:51 pm, observation revealed that the bulk oxygen storage tanks did not have a non-flammable surface for the oxygen tanker to park while unloading liquid oxygen.
2. On 03/04/2014 at 2:55 pm, observation revealed that the emergency oxygen connection port did not have a non-flammable surface for the oxygen tanker to park while unloading liquid oxygen.
These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).


Item #2
NFPA 50 Bulk Oxygen System at Consumers Sites (2001 edition) section 2.2.7: "The minimum distance from any bulk oxygen system to solid materials that burn rapidly, such as excelsior or paper, shall be 50 feet. Section 2.2.8: The minimum distance from any bulk oxygen system to solid materials that burn slowly, such as coal and heavy timber, shall be 25 feet."

Based on observation and interview, the facility failed to locate combustible material that burn rapidly at least 50 feet from the oxygen bulk tanks. This deficient practice could affect all patients.

FINDINGS INCLUDE:
On 03/04/2014 at 2:50 pm, observation revealed that the bulk oxygen storage tanks were adjacent to wood located within the fencing of the oxygen bulk storage tank area. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).

Based on observation and interview, the facility did have the emergency electrical generator installed in accordance with NFPA 110 because the generator did not have a remote stop. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 3:40 pm, observation revealed on the 1st floor outside the generator room, that the emergency generator was not provided with a remote stop switch. This observed situation was not compliant with NFPA 110 (1999 ed.), section 3-5.5.6.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, hospital grade outlets where medical device are used, proper use of extension cords, and fixed wiring rather than extension cords. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 3, 2014 at 2:20 pm, observation revealed on the 1st floor in the kitchen, that access to electrical panel was less than 3'-0" clearance. The panel was obstructed by shelving. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

2. On March 3, 2014 at 1:30 pm, observation revealed on the 1st floor in the Emergency room, that a standard grade receptacle was used in lieu of a hospital grade receptacle. This observed situation was not compliant with NFPA 70 (1999 ed.), 517-18(b).

3. On March 3, 2014 at 2:40 pm, observation revealed on the 1st floor in the Laundry room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a radio and a fan. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

4. On March 3, 2014 at 4:10 pm, observation revealed on the 1st floor in the Emergency room, that a standard strip plug extension cord (temporary power tap) was used in a patient care area as a substitute for fixed wiring. The strip plug was used to provide power to monitors. Underwriters laboratory (UL) User Guide UL 1363 for relocatable power (T) taps dictate that they not intended for use with medical or healthcare facilities equipment. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8 and 517-18.

5. On March 4, 2014 at 10:20 am, observation revealed on the 1st floor in the Finance and PT areas, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to the '6 outlet tap' and was plugged into a 2 plug receptacle. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance) and staff P (Maintenance Supervisor).
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