HospitalInspections.org

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Based on document review, the facility failed to establish a proper Fire Watch Training of staff for procedures that must conducted when the "Fire Alarm System" is out of service for more than 4 hours in a 24-hour period. This deficient practice could affect an indeterminable number of patients, staff and visitors in all Smoke Zones, if staff did not conduct the proper procedures when the fire alarm system was inoperable.

Findings include:

A. On 02/06/24 at 11:28 AM, Document Review revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of LSC; Section 9.6.1.6.

B. On 02/06/24 at 11:28 AM, Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all the parties left unprotected by the shutdown until the fire alarm system has been returned to service in accordance with NFPA 101, 2012 Edition, Section 9.6.1.8.

Examples of missing Key Directives:

1. Facility provide policy and procedures when the fire alarm system is out of service for more than 4 hours in a 24-hour time frame the facility shall evacuated effected portions of the building or provide an approved Fire Watch. NFPA 101, 2012 Edition Section 9.6.1.6.

2. The Authorities Having Jurisdiction (AHJ) shall be notified including:

(1) The local fire department
(2) IDPH Regional Office.

3. Fire Watch policy and procedures include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, Which Reads: "The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers. NFPA 101, 2012 Edition Section 3.3.104

(1) The fire watch is continuous
(2) The personnel conducting the fire watch has no other duties.
(3) Method of recording and documenting the fire watch
(4) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention.
(5) Identification of Staff performing the Fire Watch
(6) Access to all spaces provided to Fire Watch Staff

This finding was reviewed at the Exit Conference with E-1, E-2, E-3 and E-4.
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Based on an observation, the facility failed to provide proper maintenance, required clearance at devices, or required maintenance of the automatic sprinkler system. This deficient practice could affect an indeterminable number of patients, staff and visitors in the Lobby Smoke Zone, if the sprinkler system failed to operate properly due to improper maintenance.

Findings include:

On 02/06/24 at 2:15 PM, while accompanied by E-1, E-2, E-3 and E-4., an observation revealed that the Lobby Smoke Zone - Entrance Canopy had one (1) dirty sprinkler head. The sprinkler head cover was missing, the sprinkler head was covered with dirt and lint and was not in accordance with NFPA 25; 2011 Edition, Section 5-2.1.1.1 and NFPA 101; 2012 Edition, Section 9.7.

This finding was reviewed at the Exit Conference with E-1, E-2, E-3 and E-4.
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Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the "Sprinkler System" is out of service for more than 10 hours in a 24-hour period. This deficient practice could affect an indeterminable number of staff and visitors in all Smoke Zones, if staff did not conduct the proper procedures when the sprinkler system was inoperable.

Findings include:

A. On 02/06/24 at 11:28 AM, Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6.

B. On 02/06/24 at 11:28 AM, Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all the parties left unprotected by the shutdown until the sprinkler system has been returned to service in accordance with NFPA 25; Section, 2011 Edition Section 15.5.2(6).

Examples of missing Key Directives:

1. Impairment Coordinator is established. NFPA 25, 2011 Edition Section 15.2.1

2. Impairment tags are posted at each fire department connection and control valves. NFPA 25, 2011 Edition Section 15.3.2

3. Where a required automatic sprinkler system is out of service for more than 10 hours in a 24-hour period the impairment coordinator shall arrange for one of the following: NFPA 25, 2011 Edition Section 15.5.2(4):

(1) Evacuation of the building or portion of the building affected by the service outage
(2) An approved Fire Watch

4. Fire Watch policy and procedures shall include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, Which Reads: "The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers. NFPA 101, 2012 Edition Section 3.3.104.:

(1) The fire watch is continuous
(2) The personnel conducting the fire watch has no other duties
(3) Method of recording and documenting the fire watch
(4) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention.
(5) Identification of Staff performing the Fire Watch
(6) Access to all spaces provided to Fire Watch Staff

5. When the sprinkler is out of service the facility shall notify the local fire department has been notified. NFPA 25, 2011 Edition Section 15.5.2(5)

6. When the sprinkler is out of service the facility shall notify the following: NFPA 25, 2011 Edition Section 15.5.2(6):

(1) The insurance carrier
(2) The alarm company
(3) IDPH Regional Office
(4) All other authorities having jurisdiction are notified

7. Restoring System to Service the following provided:

(1) Necessary inspections and tests have been conducted to verify that the effected systems are operational
(2) Supervisors are notified
(3) Fire Department is notified
(4) Property Owner or designated representative, Insurance Carrier, Alarm Company, IDPH and other AHJs are notified
(5) Impairment tags removed.


These findings were reviewed at the Exit Conference with E-1, E-2, E-3 and E-4.
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Based on observations the facility failed to install electrical wiring to ensure the safety of the staff and residents. This deficient practice could affect an indeterminable number of patients, staff and visitors in the Support Core 1, 2 and 5 Smoke Zones, if the electrical wiring started a fire from overloading electrical circuits or electrical shock occurred due to the failure.

Findings include:

A. On 02/06/24 at 1:28 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 1 Smoke Zone - Hospitalist's office, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strip was lying on the floor where it could pose a tripping hazard and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM'S S & C Memo 14-46-SC.

B. On 02/06/24 at 1:29 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 1 Smoke Zone - Infusion Manager's office, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strip was lying on the floor where it could pose a tripping hazard and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM'S S & C Memo 14-46-SC.

C. On 02/06/24 at 1:47 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 5 Smoke Zone - Lab Director's office, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strip was lying on the floor where it could pose a tripping hazard and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM'S S & C Memo 14-46-SC.

D. On 02/06/24 at 1:56 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 5 Smoke Zone - Same Day Surgery Educator's office, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strip was lying on the floor where it could pose a tripping hazard and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM'S S & C Memo 14-46-SC.

E. On 02/06/24 at 2:43 PM, while accompanied by E-1, E-2, E-3 and E-4, an observation revealed that the Support Core 2 Smoke Zone - Lab Director's office, was using six (6) surge-protected power strips, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strips were lying on the floor where they could pose a tripping hazard and were not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CM'S S & C Memo 14-46-SC.


These findings were reviewed at the Exit Conference with E-1, E-2, E-3 and E-4.
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