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Based on facility observation and staff interview and verification the facility failed to ensure that if a building had a common wall with a nonconforming building, the common wall was a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings include:

On 06/23/10 at 1:40 P.M. tour of the first floor of the Hammon Building was continued with Staff T and U. Review of facility floor plans revealed a two hour fire rated wall separated the Hammon Building and the South Building. Review of facility documentation revealed the Hammon Building was construction type I(332) and the South Building was I(443).

Observation of the two hour fire rated wall with Staff T and U, revealed penetrations in the fire wall. Penetrations were observed near room S1 105D, reception. The penetration was estimated by the facility staff to be approximately 2 inches in length.

Further observation of the separating fire wall revealed another penetration near the elevator lobby, outside S1-22. The penetration was estimated by the facility staff to be approximately 2 inches and encircled a pipe which extended through the wall.

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

Based on staff interview it was determined this facility failed to ensure all interior finish, specifically carpeting, met the standards of National Fire Protection Agency (NFPA) 10.2. This facility has an average of 3 patient's a day.

Findings include:

Tour of this facility took place on 06/24/10 from 4:10 PM to 5:10 PM with Staff Y. During tour the question was proposed to staff Y if any new interior finish has been installed and staff Y replied "the carpeting was replaced about a year ago." This surveyor requested the flame spread rating of the carpeting but no documentation was available up to and including to the time of the exit conference on 06/25/10.

Based on facility observation and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In sprinklered buildings, partitions were only required to resist the passage of smoke.
The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings include:

On 06/23/10 between the hours of 2:18 P.M. and 4:30 P.M., tour of the Gannon Building was completed with Staff S, T and U. Observation of the fourth floor of the Gannon Building revealed the area was fully sprinklered.

Observation of the fourth floor in the area of rooms S407 to S449, revealed 14 ceiling tiles with penetrations in the tiles. There was no smoke detection noted in the corridor. Staff S and T verified that since the area had sprinkler system protection the ceiling tiles were expected to resist the passage of any smoke.

Staff S and T verified the ceiling tiles were in poor repair and indicated the tiles were to be replaced.

Based on facility observation and staff interview and verification the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas were substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors were to be provided with a means suitable for keeping the door closed. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

During tour of the facility on 06/22/10 through 06/24/10 between the hours of 8:30 A.M. and 5:00 P.M. with Staff P,Q, R, S, T, U and V, the following fire rated doors were tested and were observed to fail to securely latch when in the closed position. Doors designed to resist the passage of smoke were observed to fail to adequately close to resist passage of smoke;

a. The fire door on the eight floor of the Core Building which lead into the rehabilitation unit.

b. The fire doors on the seventh floor of the Core building which lead to the Towers

c. The smoke doors located on the ground floor of the Core Building leading from the pharmacy area to the radiology area.

Staff present on tour observed and verified the fire rated doors and the doors designed to resist the passage of smoke failed to positively latch or close adequately to resist smoke.

Based on observation during tour and staff verification it was determined this facility failed to ensure all smoke barrier doors were held open only by devices that would allow automatic closure upon activation of the fire alarm, sprinkler or smoke detector systems. This had the potential to affect all those utilizing this area of the facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.

Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour of the emergency department observation was made of two smoke barrier doors that were held open with devices that would not allow closure of the door upon activation of the fire alarm, sprinkler or smoke detector systems.
*Door identified as CPG748 was observed to have some type of metal device lodged in the automatic closure mechanism in order to keep the door open. When this device was removed the door failed to close completely.
*Door identified as CPG702 was observed to have a wood wedge lodged under the door in order to keep the door propped open. When the wood wedge was removed the door closed properly.

These findings were observed and acknowledged by all staff present during tour.

Based on observation and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least a half hour fire resistance rating in accordance with the National Fire Protection Association (NFPA) 101, Chapter 19. This had the potential to affect all those utilizing this facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.

Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour, observation was made of multiple penetrations in the smoke barriers located above the ceiling tile in the following locations:

Ground Floor:
Critical care pavilion
*Two unsealed conduits and an approximate two by four inch penetration near room CPG611
*Two unsealed conduits near room CPG610
*Within the trauma room five open end conduits and an unsealed black water line was observed
*Above the smoke barrier doors between bays 8 and 10, one open end conduit and four unsealed green flex conduits were observed
*Above the smoke barrier doors located between bay number 2 and 7, two sets (four in each set) of unsealed conduits penetrating the smoke barrier just below the upper deck and an approximate two inch by two inch penetration in the bottom corner.
*West of bay number 1 observation was made of an approximate two foot by one inch gap at the bottom of the duct. Also, an unsealed flex conduit was penetrating the smoke barrier in the bottom left corner.
*Above the smoke barrier doors near bay 148 observation was made of one unsealed wire penetrating the barrier.
*Three unsealed conduits above the smoke barrier doors by bay 45
*One unsealed flex conduit above door CPG415
*One unsealed silver conduit above door CPG424
*Across from room CPG401, four unsealed conduits were observed
*From within CPG132 the west wall was observed to have five unsealed conduits
*Within the waiting area near and above the wall mounted thermostat, an approximate two by four inch penetration was observed.

First Floor:
Critical care pavilion east/west wall:
*one foot by one and a half foot opening where fire "bricks" had fallen out across from operating room 20
*Unsealed three inch conduit across from operating room 19
*Unsealed yellow wires and two open end conduits across from sub-sterile room
*Three unsealed conduits across from operating room 16
*Three penetrations ranging in approximate sizes of four by eight inches, 2-two by three inches midway between operating rooms 16 and 8.
*One unsealed conduit across from sub-sterile room by operating room 8
*One unsealed conduit above the anesthesia work room door
North/south wall:
*Unsealed cable tray above the smoke barrier doors near CP1101

Patient Towers
Third Floor:
*Above the smoke barrier doors entering unit B CICU, observation of a three inch open end conduit

Sixth Floor:
*Above the smoke barrier doors entering unit B behavioral health suite, observation of unsealed red wires passing through a conduit

Eighth Floor:
*Above the smoke barrier doors entering unit C women's specialty unit, observation was made of one unsealed silver conduit, one open end conduit and an approximate two by four inch opening around four silver conduits

These findings were verified by staff R during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the swinging double doors located in the smoke barriers had less than a one eighth inch gap between the door panels when in the closed position.
This facility failed to ensure all doors located in smoke barriers were equipped with a self-closing or automatic closing device.
Additionally, this facility failed to ensure the doors mounted in smoke barriers or one hour fire rated wall also serving as a smoke barrier were of proper fire ratings and vision panels were in accordance with NFPA 101, Chapter 8.3.4 and 8.2.3.2.2.
This had the potential to affect all those utilizing this area of the facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.


Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour, observation was made of doors with gaps between the leafs when in the closed position, doors lacking self-closer and doors with no or improper fire resistance ratings in the following locations:

Ground Floor:
*Observation made in the dietary department; the northeast smoke barrier doors and door NS03 had gaps greater than one eighth inch between the door panels when in the closed position.
*Within the critical care pavilion waiting area, observation was made of a metal door located in the smoke barrier which had no fire resistance rating and was equipped with a two foot square vision panel which was not fire resistant rated.

Patient Towers
Third Floor:
*Smoke barrier door number 363 was not equipped with a self or automatic closing device
*Smoke barrier door which leads into the small corridor between the elevators and B unit failed to shut
*Smoke door in the environmental service room lacked a self or automatic closing device

Sixth Floor:
*One door within the one hour fire rated construction bordering the east portion of unit B, which also served as a smoke barrier, lacked the proper fire resistance rating. The south metal door was not fire rated and was equipped with a 22 inch by 22 inch plexiglass vision panel which was also not fire rated.

These findings was acknowledged by all staff present during tour.

Based on facility observation and staff interview and verification the facility failed to ensure that when an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected a hazardous area, the areas were separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/23/10 between the hours of 9:55 A.M. and 12:00 P.M. tour of the third floor of the Gannon/ South building was completed with Staff S, T and U. Observation of the floor revealed the presence of a mechanical room which housed some of the facility air handlers. The mechanical room was noted to have a sprinkler system. The door to the room did not have a fire resistant rating. Penetrations were observed around two pipes which went through the mechanical room wall. Another penetration was observed to be approximately 8 inches in diameter and extended through the room ceiling.

Staff present on the tour verified the mechanical room door was not a fire rated door and that the penetrations observed in the wall and ceiling would allow for the passage of smoke

Based on facility observation and staff interview and verification, the facility failed to ensure that patient room doors were arranged so that the patient could open the door from inside without using a key. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

1. On 06/22/10 at 11:45 A.M. tour with Staff S, T, and V was completed on the eighth floor of the Core Building. Observation of semi-private patient rooms 804, 805 and 806, revealed the presence of dead bolt locks on the patient rooms. The dead bolts could be locked from outside the room using a key and could not be opened from inside the room.

Interview of Staff W revealed the rooms were part of a rehabilitation unit designed to treat patients with brain injuries. The patient rooms were in a corridor that was also secured with two doors that when closed could only be opened with a coded key pad. Staff T verified the doors would open automatically upon activation of the fire alarm system.

Staff W did not have a key to open the patient rooms with dead bolts and stated that the dead bolts were not used when patients were in the rooms. Staff T and W verified the dead bolts could be removed as the locks were not used. The patient census at that time was four patients on the unit.

2. Tour on 06/24/10 at 3:25 P.M. with Staff S and T of the maternity unit located on the second floor of the South/Gannon Building, revealed the presence of dead bolt locks on two birthing rooms. The birthing rooms numbered #8 and #9, were seldom used in that the rooms were somewhat secluded from the main area of the unit.

Staff S and T verified there was no need for locks on the patient rooms and they would be removed.

Based on facility observation and staff interview and verification the facility failed to ensure that a horizontal door used as a fire door closed properly. One door steel paneled door was affected.. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/22/10 at 3:35 P.M. tour of the first floor Core Building completed with Staff T and V. Observation of the area near a cafe and at the entrance to the Towers building revealed the presence of steel paneled doors which were to close upon activation of the fire alarm system.

Staff T demonstrated the function of the steel paneled doors with use of a key. Upon activation of the doors it was observed that the doors failed to securely close, leaving a gap at the door edges. Staff T tested the doors three times and after manipulation of the doors, the doors closed more securely. Staff T verified the doors still were not completely functional. Staff T verified the doors were tested annually with the last test completed in September 2009. Staff T further verified that the doors were considered fire rated doors which separated the Core building and the Towers building.

Based on facility observation and staff interview and verification, the facility failed to ensure that illumination of means of egress, including exit discharge, was arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. (This does not refer to emergency lighting in accordance with section 7.8.) The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/24/10 between the hours of 8:45 A.M. and 9:45 A.M. tour of a portion of the exterior building was completed with Staff S and T. Observation of the exit discharge at the South Building, east stairwell, revealed the exit to the public way was near the hospital morgue area. The exit door was noted to be located between two walls which were high enough to seclude the exit door. A walkway was estimated to be 12 to 15 feet in length from the door to the more open public way. There was no exit lighting observed at the exit discharge or along the 12 to 15 foot walkway.

Staff T verified that exit lighting was not provided at the exit discharge.

Based on observation during tour and staff verification it was determined this facility failed to ensure the means of egress would remain illuminated in the event of a power failure. This had the potential to affect all those utilizing this portion of the facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.

Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour of the business services and cafeteria portion of the main building, observation was made of three emergency egress lights which failed to illuminate when tested. Their locations were identified as BS-7, BS-10 in K-206B and BS-11 by K-200 stairs.

These findings were acknowledged by Staff P and Staff Q during tour.

Based on staff interview it was determined this facility failed to ensure all emergency lights were tested in accordance with National Fire Protection Agency (NFPA) 7.9. This facility has an average of 3 patient's a day.

Findings include:

Tour of this facility took place on 06/24/10 from 4:10 PM to 5:10 PM with Staff Y. During tour observation was made of an emergency light located just outside the entrance door of each sleep lab. The question was proposed to Staff Y if the emergency lights were tested monthly for 30 seconds and annually for 90 minutes and if so, would there be any form of documentation to verify this. Staff Y replied "no, they are not tested by that schedule and there is no documentation."

Based on record review and staff verification it was determined this facility failed to ensure the sprinkler system was inspected quarterly as required by National Fire Protection Agency (NFPA) 25. This facility averages 230 patients a day.

Findings include:

Tour of this facility took place on 06/24/10 from 1:30 PM to 3:30 PM with Staff members S, T and Z. Review of the sprinkler maintenance logs took place on 06/24/10 with staff Z.
Observation by this surveyor and verification by staff Z confirmed the sprinkler inspections took place annually. This surveyor proposed the question to staff Z during documentation review as to if this task (sprinkler system testing) is performed quarterly and staff Z replied "no". The last documented sprinkler test was performed on 06/10/09.

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 ensuring the sprinkler heads were cleaned properly of the dust and debris. This had the potential to affect all those utilizing this facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.

Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour, observation was made of several sprinkler heads which were coated with a thick layer of dust or debris.
These locations are as follows:

Ground Floor:
*Within the dietary department several sprinkler heads were noted to be coated with greasy looking dust which includes the supervisors office number D49.
*Within the critical care pavilion near room CPG475

First Floor:
*Within the nurse's station of the pre-op area

Eleventh Floor:
*Within B unit at the nurse's station and in the soiled utility room number 1152
*Within C unit at the nurse's station and in room number 1184

These findings were acknowledged by all staff during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were mounted properly in accordance with National Fire Protection Agency (NFPA) 10 Chapter 1-6.7 and visually checked monthly according to NFPA 4-3.1. This facility has an average of 3 patient's a day.

Findings include:

Tour of this facility took place on 06/24/10 from 4:10 PM to 5:10 PM with Staff Y. Observation was made in both sleep labs of a portable fire extinguisher sitting on the counter top. The question was proposed to staff Y if this is where the fire extinguisher's are kept and staff Y stated "yes."
These fire extinguisher's were observed to have inspection tags attached to them with the last inspection dated for 10/29/09. The back of the tags lacked documentation for the monthly visual checks and the question was proposed to staff Y if they perform the required monthly visual checks on the fire extinguisher's and staff Y stated "no."

Based on facility tour and staff interview and verification, the facility failed to ensure that soiled linen or trash collection receptacles did not exceed 32 gal (121 L) in capacity. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/23/10 between the hours of 3:25 P.M. and 4:30 P.M. and on 06/25/10 between the hours of 1:00 P.M. and 3:00 P.M. tour with Staff P, Q, S, and T was completed in two areas of the hospital. The following locations were observed, with the staff present, to have large wheeled trash or soiled linen receptacle stored in corridors.

a. On 06/23/10 between 3:25 P.M. and 4:30 P.M., Staff S and T were present when tour of the second floor of the South/Gannon Building was completed. Observation of the second floor corridor, near the female locker room, revealed the presence of a large wheeled trash cart. The cart was significantly larger than 32 gallons in size and contained multiple bags of trash. The wheeled container was piled to near capacity with bags of trash. A second large container was also stored in the corridor with at least 13 cardboard boxes piled in and around it. Staff present verified the boxes were from supplies that had been delivered. The boxes had been emptied and were ready to be discarded.

b. On 06/25/10 tour of the first floor, South Building, between the hours of 1:00 P.M. and 3:00 P.M. with Staff P and Q, revealed a large wheeled container with multiple bags of soiled linen inside stored in the corridor. The large wheeled soiled linen cart was stored near elevators, outside the Gannon Building near S177 and S1DD .

Staff present at both observations verified the large wheeled containers were greater than 32 gallons in size and were not stored in areas considered acceptable for hazardous materials storage.

REVISED

Based on facility observation and staff interview and verification, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities. NFPA 99 requirements for storage requirements (location, construction, arrangement) are addressed at 4-3.1.1.2.

Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3) area as follows:

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Doors to such locations shall be provided with louvered openings having a minimum of 72 in 2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.

Requirements of 4-3.1.1.2(b)3 states that the walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.

Requirement 4-3.1.1.2(b)4 states that locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.

The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/23/10 between the hours of 9:55 A.M. and 12:00 P.M. tour of the third and fourth floor of the Gannon/ South building was completed with Staff S, T and U.

1. Observation of the fourth floor revealed the entrance to the roof top helipad. A small storage room was noted at the edge of the helipad. Staff T opened the small storage room to reveal the storage of medical gases, medical supplies and packaged dressings. One H size cylinder of oxygen (250 cubic feet), six D size helium cylinders (90 cubic feet) and 12 E size cylinders of oxygen (288 cubic feet) were stored in the room. Shelving in the storage room contained packaged wound dressing supplies and other patient care supplies. The floor of the storage room was noted to be wood. A motorized vent was not in operation. Staff present could not address if the ventilation system had to be manually operated or provided ventilation automatically. The door to the room was not louvered. The room was noted to have smoke detection and a sprinkler system.

2. Observation of the third floor revealed three rooms designated for pulmonary function testing. The hours of operation for pulmonary function testing was between 8:00 A.M. and 5:00 P.M. Two of the three pulmonary function rooms were observed with the third being used for patient testing.

The two rooms observed were noted to have a sprinkler system present. One room contained four H cylinders which could total 1000 cubic feet. The four cylinders were one each of oxygen, medical air, nitrogen and helium. Also present were two E size cylinders of oxygen (48 cubic feet) and four D size cylinders (60 cubic feet) which contained nitrogen, carbon dioxide, helium and oxygen.

The second pulmonary function testing room contained two H size helium cylinders, two H size cylinders of nitrogen/ carbon dioxide, totaling 1000 cubic feet and seven E size cylinders of oxygen (168 cubic feet).

Staff present verified the rooms were used for patient testing during the day shift and the medical gases remained stored in the rooms when testing was not in progress.

The room walls and doors were noted to have no known fire resistance rating, no venting system for the rooms and light switches were not observed to be at least 5 feet from the floor of the rooms.

These findings were verified by all staff present during tour.

Chapter 39
Section 39.2 Means of Egress
39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

Based on facility observation, review of facility documentation, staff interview and verification, the facility failed to ensure the means of egress for the outpatient plaza were in accordance with Chapter 7 with regards to 7.1.3.2, Exits. The facility failed to ensure the exit was separated from other parts of the building, where the separating construction was to meet the requirements 8.2 in that the separation did not have a fire resistance rating of not less than one hour where the exit connected three stories or less. The rehabilitation, women and children's pavilion, the medical specialty and the cancer care pavilions were affected.

Finding included:

1. On 06/24/10 between the hours of 9:20 A.M. and 3:30 P.M. tour of the Outpatient Plaza was completed with Staff P, Q, S, and T. Review of building floor plans reviewed the presence of a one hour fire rated wall located on the first and second floor exit assess of the women and children's pavilion and the medical specialty building. The exit access from each building lead to a large atrium and exit from the buildings.

Observation of the one hour fire rated walls revealed the following;

1. In the exit access from the women and children's pavilion, in the fetal diagnostic waiting area, penetrations were observed above the ceiling tiles and at the floor decking above. Multiple penetrations were observed in the one hour fire rated wall around a pipe, at the floor decking and an open area approximately 2 inches in diameter.

Multiple penetrations were observed in the one hour fire rated wall located in the exit corridor near the entrance to the atrium. Penetrations were noted around duct work inserted through the fire rated wall.

2. In the exit access from the medical specialty pavilion, near the entrance of the atrium, penetrations were observed around telecommunications wiring, at the floor decking above and around sprinkler system piping

3. Located in the cancer care pavilion, on the first floor, penetrations were observe in the exit access in the one hour fire rated wall at the floor decking above and around pipes through the fire rated wall.

Staff present on the tour observed and verified the exit access walls were one hour fire rated walls with penetrations which would affect the fire resistance.

2. Observation of corridor door and fire door testing revealed the following;

During tour on 06/24/10 with Staff P, Q, S, and T observations were completed with regards to the operation of doors located in building separations and in exit corridors. The following doors noted to be on self- closing devices were observed to fail to close completely or lacked identification as to adequate fire rating.

a. In the rehabilitation pavilion, corridor doors near rooms RP225C and RP 224A were noted to have gaps greater than 1/8 inch at the edge of the doors when the doors were in the closed position.

b. In the walkway to the women/children's pavilion, fire doors designated by the facility floor plan to be in a 2 hour fire rated wall and were noted to be 2 hour fire rated doors lacked identification on the doors to verify the fire rating. Staff present on tour verified there was no labeling on the doors which indicated any fire rating.
In the walkway between the orthopedics and cancer pavilion, two fire doors designated by the facility floor plan to be in a 2 hour fire rated wall and were noted to be 2 hour fire rated doors lacked identification on the doors to verify the fire rating. Staff present on tour verified there was no labeling on the doors which indicated any fire rating.

Doors observed to be on closers located at the entrance to "OB" and at 2112H were noted to have gaps greater than 1/8 th inch when in the closed position which would allow for the passage of smoke in the event of a fire.

c. Observation of 2 hour fire rated doors located in the corridor on the second floor of the medical specialty building revealed the doors would not latch when activated. The fire rated doors were noted to provide separation from the outpatient plaza and the bridge to the main hospital.

d. Observation of the 2 hour fire rated doors located on the hospital side of the bridge(East doors) leading to the outpatient plaza revealed the doors failed to securely latch when tested. A hole was observed through the top of the fire door. Staff present on tour verified the fire rated doors did not latch as intended and that the hole on the top of the fire door appeared to have been drilled.


EMERGENCY LIGHTING
39.2.9.1
Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.

7.9 EMERGENCY LIGHTING
7.9.1 General.
7.9.1.1*
Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

Based on facility tour and staff interview and verification the facility failed to enure that emergency lighting was provided at exit discharge from the facility. One of four pavilion buildings ( rehabilitation ) located in the Outpatient Plaza was affected.

Findings included;

During tour on 06/24/10 between the hours of 9:20 A.M. and 10:05 A.M. with Staff T, observation of the rehabilitation pavilion revealed there was no emergency lighting at the exit discharge on South Point Drive. The exit discharge was identified by Staff T to lead persons evacuating the building to the public way. Staff T verified there was no emergency lighting at the point of exit discharge from the rehabilitation building.


SMOKE DETECTOR PLACEMENT
Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were located where airflow patterns would not 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.

Findings include:

During tour of the facility on 06/24/10 between the hours of 11:15 A.M. and 12:30 P.M. with Staff P and Q observation was made of several smoke detectors located in areas where air flow devices may affect their normal operation. These locations are as follows:

First Floor Orthopedics:
*Exam room K
*Room 1234
*Soiled utility room 1227

Cancer Care Pavilion
*Within the waiting area
*Within the nurse's station
*Within the treatment planning room

Second Floor Orthopedics
*Rooms I, J and K

Cancer Care Pavilion
*Within the inner core corridor

These findings were acknowledged by both staff during tour.

SMOKE DETECTOR PLACEMENT
Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were located where airflow patterns would not 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 those utilizing this facility. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings include:

During tour of the facility on 06/22/10 through 06/24/10 between the hours of 8:30 A.M. and 5:00 P.M. with Staff P,Q, R, S, T, U and V, the following smoke detectors were observed to be significantly less than 36 inches from air diffusers or air flow devises.

a. Two smoke detectors on the seventh floor of the Core Building located near the Towers Building entrance were less than 12 inches from an air return.

b. On the fourth floor of the Core Building two smoke detectors located in the "tree house room" were significantly less than 36 inches from an air diffuser.

c On the second floor of the Core Building in the store room of the neonatal intensive care unit a smoke detector was less than 30 inches from an air device.

d. On the first floor of the Core Building, near the entrance to the Towers building a smoke detector was significantly less than 36 inches from an air diffuser.

e. On the third floor of the Gannon Building in the cardiac rehabilitation area a smoke detector was significantly less than 36 inches from an air diffuser






21957

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour, observation was made of several smoke detectors which were located in areas where air flow devices might inhibit their normal operation.
These locations are as follows:

Ground Floor:
*Within the fire command center room BG01A

Critical Care Pavilion (CCP)
*Just outside of room CPG748
*Near smoke barrier doors around the corner of room CPG748

First Floor CCP:
*Within the pre-op area located in room CP1304

Patient Towers
Second Floor:
*In C unit nursery room 280
*In B unit corridor next to room 262
*In front of the elevators located in the family waiting area

Second Floor of the business services building
*Near K-200 stairs

Patient Towers
Third Floor:
*In C unit cardiac step down room numbers 367, 369, 370, 371, 372, 373, 374, 376, 377, 378, 379 and 380
*Two smoke detectors in B unit CICU nurse's station
*B unit where the circular and straight corridors meet
*Between B and C units by room 363
*In front of the elevators located in the family waiting area

Third floor of the business services building
*By the entrance door of the business services building

Fourth Floor:
*Within B unit pediatrics by room 442
*In corridor adjacent to the environmental service room near the elevators
*In front of the elevators located in the family waiting area

Fifth Floor:
*One smoke detector in B unit MICU nurse's station
*In corridor near room 5537

Sixth Floor:
*By the entrance to 6B behavioral health suites

Seventh Floor:
*In the corridor near room S737
*In corridor near room S776
*In C unit stroke rehabilitation room number 781

Eighth floor:
*Within the corridor by room S837
*By service elevator number 8
*Within C unit corridor by room 879

Ninth Floor:
*Within B stroke unit by room 936 and within room 976
*Within C medicine unit nurse's station and corridor by room 968

Tenth Floor:
*In front of elevator number 6
*Within C medicine unit nurse's station

Eleventh Floor:
*Within the nurse's station and room number 1136

These findings were verified and acknowledged by all staff during the tour.

USE OF ALCOHOL BASED HAND RUB

o Where Alcohol Based Hand Rub (ABHR) dispensers are installed in a corridor, the corridor is at least 6 feet wide
o The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
o The dispensers have a minimum spacing of 4 ft from each other
o Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
o Dispensers are not installed over or adjacent to an ignition source.
o If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

Based on facility observation and staff interview and verification, the facility failed to ensure that Alcohol Based Hand Rub (ABHR) dispensers were not installed over or adjacent to an ignition source. Three of four operating rooms were affected. The facility provided surgical services for 3140 patients from June 2009 until June 2010.

Findings included:

On 06/24/10 between 3:00 P.M. and 5:00 P.M. tour of the ambulatory surgical center was completed with Staff P, Q and X. Observation of the four operating rooms in the facility revealed the presence of ABHR dispensers installed inside the doors in three of four operating rooms. Closer inspection of the ABHR dispensers revealed they were installed directly over the electric light switch for the room. The spray of the ABHR was inches away from the light switch.

Staff Q and X verified the ABHR dispensers were installed too close to the electrical switch.


OCCUPANCY SEPARATION

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 1¾ 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.

Based observation of the facility and staff interview and verification the facility failed to ensure the ambulatory health care occupancy was separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Doors in such barriers were to be solid bonded core wood of 1¾ inches or equivalent and were to be equipped with a positive latch and closing device. The facility provided surgical services for 3140 patients from June 2009 until June 2010.

Findings included:

On 06/24/10 between 3:00 P.M. and 5:00 P.M. tour of the ambulatory surgical center (ASC) was completed with Staff P, Q and X. Observation of the entrance into the ASC revealed sliding glass doors at the exit discharge. Once inside the sliding doors there was a small foyer. A large glass paneled door fitted into a partial glass wall established the entrance into the ASC. There was no visible fire rating on the partial glass wall or glass door and no positive latching device on the door.

The ASC was noted to share the building with another health care provider. The waiting area was separated into two sections by a half glass brick wall. There was one receptionist desk which was shared by two staff. One staff member assisted the ASC patients and the other receptionist assisted the other provider's patients.

Interview with Staff P verified the ASC was 9660 square feet and was complete with an automatic sprinkler system. Observation of the separating wall between the ASC and the other tenant in the building revealed multiple penetrations in the one hour fire rated wall. Staff P and Q verified the penetrations in the occupancy separating wall.

Based on documentation review and staff interview it was determined this facility failed to ensure all smoke detectors were sensitivity tested in accordance with National Fire Protection Agency (NFPA) 72, Chapter 7-3.2.1.

Findings include:

Tour of this facility took place on 06/24/10 from 4:10 PM to 5:10 PM with Staff Y. During tour observation was made of smoke detectors located in both sleep labs. The question was proposed to staff Y if they have them tested as required. Staff Y replied "yes."
A request was made for the documentation of smoke detector testing and Staff Y presented to this surveyor the latest test documentation dated for 12/16/09. This documentation lacked any sensitivity testing and a thorough search was performed by Staff Y for the sensitivity testing but none was available even up to the time of the exit conference on 06/25/10.

Based on record review and staff verification it was determined this facility failed to ensure the generators were visually inspected each week and run with a monthly load test as required by National Fire Protection Agency (NFPA) 99 Chapter 3.4.4.1. This facility averages 230 patients a day.

Findings include:

Tour of this facility took place on 06/24/10 from 1:30 PM to 3:30 PM with Staff members S, T and Z. Review of the generator maintenance logs took place on 06/24/10 with staff Z.
Observation by this surveyor and verification by staff Z confirmed the generator maintenance logs failed to have proper documentation of monthly generator load testing and weekly visual inspections. This surveyor proposed the question to staff Z during documentation review as to if these tasks are performed and staff Z replied "no".

Based on observations and staff interviews, the facility failed to ensure alcohol based hand rubs (ABHRs) were not installed over carpeted areas where the building is not fully sprinklered, in accordance with the National Fire Protection Agency code at 19.3.2.7. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.
This potentially could affect all staff, patients, and visitors in the facility.

Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour, observation was made of several alcohol based hand rubs which were located over carpeted areas in a building which lacked complete sprinkler coverage.
These locations are as follows:

First Floor:
*On the dining room wall which separates the large dining room from the small one
* In the operating room waiting area
Patient Towers
*In the admitting department's left side of the circular corridor

Second Floor:
*By the entry door next to room 262
*Within the corridors of B and C units, approximately 16 were located outside of rooms

Third Floor:
*Within the nurse's station of units B and C
*By exit door K300 of the business services building

Fourth Floor:
*Within the nurse's station of B unit

Seventh Floor:
*Within the nurse's station of C unit

Tenth Floor:
*Within the nurse's station of C unit
*Next to room S1037 by the entrance of B unit

These findings were verified and acknowledged by all staff during the tour.

Based on facility observation and staff interview and verification the facility failed to ensure that if a building had a common wall with a nonconforming building, the common wall was a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings include:

On 06/23/10 at 1:40 P.M. tour of the first floor of the Hammon Building was continued with Staff T and U. Review of facility floor plans revealed a two hour fire rated wall separated the Hammon Building and the South Building. Review of facility documentation revealed the Hammon Building was construction type I(332) and the South Building was I(443).

Observation of the two hour fire rated wall with Staff T and U, revealed penetrations in the fire wall. Penetrations were observed near room S1 105D, reception. The penetration was estimated by the facility staff to be approximately 2 inches in length.

Further observation of the separating fire wall revealed another penetration near the elevator lobby, outside S1-22. The penetration was estimated by the facility staff to be approximately 2 inches and encircled a pipe which extended through the wall.

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

Based on staff interview it was determined this facility failed to ensure all interior finish, specifically carpeting, met the standards of National Fire Protection Agency (NFPA) 10.2. This facility has an average of 3 patient's a day.

Findings include:

Tour of this facility took place on 06/24/10 from 4:10 PM to 5:10 PM with Staff Y. During tour the question was proposed to staff Y if any new interior finish has been installed and staff Y replied "the carpeting was replaced about a year ago." This surveyor requested the flame spread rating of the carpeting but no documentation was available up to and including to the time of the exit conference on 06/25/10.

Based on facility observation and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In sprinklered buildings, partitions were only required to resist the passage of smoke.
The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings include:

On 06/23/10 between the hours of 2:18 P.M. and 4:30 P.M., tour of the Gannon Building was completed with Staff S, T and U. Observation of the fourth floor of the Gannon Building revealed the area was fully sprinklered.

Observation of the fourth floor in the area of rooms S407 to S449, revealed 14 ceiling tiles with penetrations in the tiles. There was no smoke detection noted in the corridor. Staff S and T verified that since the area had sprinkler system protection the ceiling tiles were expected to resist the passage of any smoke.

Staff S and T verified the ceiling tiles were in poor repair and indicated the tiles were to be replaced.

Based on facility observation and staff interview and verification the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas were substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors were to be provided with a means suitable for keeping the door closed. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

During tour of the facility on 06/22/10 through 06/24/10 between the hours of 8:30 A.M. and 5:00 P.M. with Staff P,Q, R, S, T, U and V, the following fire rated doors were tested and were observed to fail to securely latch when in the closed position. Doors designed to resist the passage of smoke were observed to fail to adequately close to resist passage of smoke;

a. The fire door on the eight floor of the Core Building which lead into the rehabilitation unit.

b. The fire doors on the seventh floor of the Core building which lead to the Towers

c. The smoke doors located on the ground floor of the Core Building leading from the pharmacy area to the radiology area.

Staff present on tour observed and verified the fire rated doors and the doors designed to resist the passage of smoke failed to positively latch or close adequately to resist smoke.

Based on observation during tour and staff verification it was determined this facility failed to ensure all smoke barrier doors were held open only by devices that would allow automatic closure upon activation of the fire alarm, sprinkler or smoke detector systems. This had the potential to affect all those utilizing this area of the facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.

Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour of the emergency department observation was made of two smoke barrier doors that were held open with devices that would not allow closure of the door upon activation of the fire alarm, sprinkler or smoke detector systems.
*Door identified as CPG748 was observed to have some type of metal device lodged in the automatic closure mechanism in order to keep the door open. When this device was removed the door failed to close completely.
*Door identified as CPG702 was observed to have a wood wedge lodged under the door in order to keep the door propped open. When the wood wedge was removed the door closed properly.

These findings were observed and acknowledged by all staff present during tour.

Based on observation and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least a half hour fire resistance rating in accordance with the National Fire Protection Association (NFPA) 101, Chapter 19. This had the potential to affect all those utilizing this facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.

Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour, observation was made of multiple penetrations in the smoke barriers located above the ceiling tile in the following locations:

Ground Floor:
Critical care pavilion
*Two unsealed conduits and an approximate two by four inch penetration near room CPG611
*Two unsealed conduits near room CPG610
*Within the trauma room five open end conduits and an unsealed black water line was observed
*Above the smoke barrier doors between bays 8 and 10, one open end conduit and four unsealed green flex conduits were observed
*Above the smoke barrier doors located between bay number 2 and 7, two sets (four in each set) of unsealed conduits penetrating the smoke barrier just below the upper deck and an approximate two inch by two inch penetration in the bottom corner.
*West of bay number 1 observation was made of an approximate two foot by one inch gap at the bottom of the duct. Also, an unsealed flex conduit was penetrating the smoke barrier in the bottom left corner.
*Above the smoke barrier doors near bay 148 observation was made of one unsealed wire penetrating the barrier.
*Three unsealed conduits above the smoke barrier doors by bay 45
*One unsealed flex conduit above door CPG415
*One unsealed silver conduit above door CPG424
*Across from room CPG401, four unsealed conduits were observed
*From within CPG132 the west wall was observed to have five unsealed conduits
*Within the waiting area near and above the wall mounted thermostat, an approximate two by four inch penetration was observed.

First Floor:
Critical care pavilion east/west wall:
*one foot by one and a half foot opening where fire "bricks" had fallen out across from operating room 20
*Unsealed three inch conduit across from operating room 19
*Unsealed yellow wires and two open end conduits across from sub-sterile room
*Three unsealed conduits across from operating room 16
*Three penetrations ranging in approximate sizes of four by eight inches, 2-two by three inches midway between operating rooms 16 and 8.
*One unsealed conduit across from sub-sterile room by operating room 8
*One unsealed conduit above the anesthesia work room door
North/south wall:
*Unsealed cable tray above the smoke barrier doors near CP1101

Patient Towers
Third Floor:
*Above the smoke barrier doors entering unit B CICU, observation of a three inch open end conduit

Sixth Floor:
*Above the smoke barrier doors entering unit B behavioral health suite, observation of unsealed red wires passing through a conduit

Eighth Floor:
*Above the smoke barrier doors entering unit C women's specialty unit, observation was made of one unsealed silver conduit, one open end conduit and an approximate two by four inch opening around four silver conduits

These findings were verified by staff R during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the swinging double doors located in the smoke barriers had less than a one eighth inch gap between the door panels when in the closed position.
This facility failed to ensure all doors located in smoke barriers were equipped with a self-closing or automatic closing device.
Additionally, this facility failed to ensure the doors mounted in smoke barriers or one hour fire rated wall also serving as a smoke barrier were of proper fire ratings and vision panels were in accordance with NFPA 101, Chapter 8.3.4 and 8.2.3.2.2.
This had the potential to affect all those utilizing this area of the facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.


Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour, observation was made of doors with gaps between the leafs when in the closed position, doors lacking self-closer and doors with no or improper fire resistance ratings in the following locations:

Ground Floor:
*Observation made in the dietary department; the northeast smoke barrier doors and door NS03 had gaps greater than one eighth inch between the door panels when in the closed position.
*Within the critical care pavilion waiting area, observation was made of a metal door located in the smoke barrier which had no fire resistance rating and was equipped with a two foot square vision panel which was not fire resistant rated.

Patient Towers
Third Floor:
*Smoke barrier door number 363 was not equipped with a self or automatic closing device
*Smoke barrier door which leads into the small corridor between the elevators and B unit failed to shut
*Smoke door in the environmental service room lacked a self or automatic closing device

Sixth Floor:
*One door within the one hour fire rated construction bordering the east portion of unit B, which also served as a smoke barrier, lacked the proper fire resistance rating. The south metal door was not fire rated and was equipped with a 22 inch by 22 inch plexiglass vision panel which was also not fire rated.

These findings was acknowledged by all staff present during tour.

Based on facility observation and staff interview and verification the facility failed to ensure that when an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected a hazardous area, the areas were separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/23/10 between the hours of 9:55 A.M. and 12:00 P.M. tour of the third floor of the Gannon/ South building was completed with Staff S, T and U. Observation of the floor revealed the presence of a mechanical room which housed some of the facility air handlers. The mechanical room was noted to have a sprinkler system. The door to the room did not have a fire resistant rating. Penetrations were observed around two pipes which went through the mechanical room wall. Another penetration was observed to be approximately 8 inches in diameter and extended through the room ceiling.

Staff present on the tour verified the mechanical room door was not a fire rated door and that the penetrations observed in the wall and ceiling would allow for the passage of smoke

Based on facility observation and staff interview and verification, the facility failed to ensure that patient room doors were arranged so that the patient could open the door from inside without using a key. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

1. On 06/22/10 at 11:45 A.M. tour with Staff S, T, and V was completed on the eighth floor of the Core Building. Observation of semi-private patient rooms 804, 805 and 806, revealed the presence of dead bolt locks on the patient rooms. The dead bolts could be locked from outside the room using a key and could not be opened from inside the room.

Interview of Staff W revealed the rooms were part of a rehabilitation unit designed to treat patients with brain injuries. The patient rooms were in a corridor that was also secured with two doors that when closed could only be opened with a coded key pad. Staff T verified the doors would open automatically upon activation of the fire alarm system.

Staff W did not have a key to open the patient rooms with dead bolts and stated that the dead bolts were not used when patients were in the rooms. Staff T and W verified the dead bolts could be removed as the locks were not used. The patient census at that time was four patients on the unit.

2. Tour on 06/24/10 at 3:25 P.M. with Staff S and T of the maternity unit located on the second floor of the South/Gannon Building, revealed the presence of dead bolt locks on two birthing rooms. The birthing rooms numbered #8 and #9, were seldom used in that the rooms were somewhat secluded from the main area of the unit.

Staff S and T verified there was no need for locks on the patient rooms and they would be removed.

Based on facility observation and staff interview and verification the facility failed to ensure that a horizontal door used as a fire door closed properly. One door steel paneled door was affected.. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/22/10 at 3:35 P.M. tour of the first floor Core Building completed with Staff T and V. Observation of the area near a cafe and at the entrance to the Towers building revealed the presence of steel paneled doors which were to close upon activation of the fire alarm system.

Staff T demonstrated the function of the steel paneled doors with use of a key. Upon activation of the doors it was observed that the doors failed to securely close, leaving a gap at the door edges. Staff T tested the doors three times and after manipulation of the doors, the doors closed more securely. Staff T verified the doors still were not completely functional. Staff T verified the doors were tested annually with the last test completed in September 2009. Staff T further verified that the doors were considered fire rated doors which separated the Core building and the Towers building.

Based on facility observation and staff interview and verification, the facility failed to ensure that illumination of means of egress, including exit discharge, was arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. (This does not refer to emergency lighting in accordance with section 7.8.) The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/24/10 between the hours of 8:45 A.M. and 9:45 A.M. tour of a portion of the exterior building was completed with Staff S and T. Observation of the exit discharge at the South Building, east stairwell, revealed the exit to the public way was near the hospital morgue area. The exit door was noted to be located between two walls which were high enough to seclude the exit door. A walkway was estimated to be 12 to 15 feet in length from the door to the more open public way. There was no exit lighting observed at the exit discharge or along the 12 to 15 foot walkway.

Staff T verified that exit lighting was not provided at the exit discharge.

Based on observation during tour and staff verification it was determined this facility failed to ensure the means of egress would remain illuminated in the event of a power failure. This had the potential to affect all those utilizing this portion of the facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.

Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour of the business services and cafeteria portion of the main building, observation was made of three emergency egress lights which failed to illuminate when tested. Their locations were identified as BS-7, BS-10 in K-206B and BS-11 by K-200 stairs.

These findings were acknowledged by Staff P and Staff Q during tour.

Based on staff interview it was determined this facility failed to ensure all emergency lights were tested in accordance with National Fire Protection Agency (NFPA) 7.9. This facility has an average of 3 patient's a day.

Findings include:

Tour of this facility took place on 06/24/10 from 4:10 PM to 5:10 PM with Staff Y. During tour observation was made of an emergency light located just outside the entrance door of each sleep lab. The question was proposed to Staff Y if the emergency lights were tested monthly for 30 seconds and annually for 90 minutes and if so, would there be any form of documentation to verify this. Staff Y replied "no, they are not tested by that schedule and there is no documentation."

Based on record review and staff verification it was determined this facility failed to ensure the sprinkler system was inspected quarterly as required by National Fire Protection Agency (NFPA) 25. This facility averages 230 patients a day.

Findings include:

Tour of this facility took place on 06/24/10 from 1:30 PM to 3:30 PM with Staff members S, T and Z. Review of the sprinkler maintenance logs took place on 06/24/10 with staff Z.
Observation by this surveyor and verification by staff Z confirmed the sprinkler inspections took place annually. This surveyor proposed the question to staff Z during documentation review as to if this task (sprinkler system testing) is performed quarterly and staff Z replied "no". The last documented sprinkler test was performed on 06/10/09.

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 ensuring the sprinkler heads were cleaned properly of the dust and debris. This had the potential to affect all those utilizing this facility. The hospital has a total bed capacity of 702 with a census of 347 at the time of the survey.

Findings include:

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour, observation was made of several sprinkler heads which were coated with a thick layer of dust or debris.
These locations are as follows:

Ground Floor:
*Within the dietary department several sprinkler heads were noted to be coated with greasy looking dust which includes the supervisors office number D49.
*Within the critical care pavilion near room CPG475

First Floor:
*Within the nurse's station of the pre-op area

Eleventh Floor:
*Within B unit at the nurse's station and in the soiled utility room number 1152
*Within C unit at the nurse's station and in room number 1184

These findings were acknowledged by all staff during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were mounted properly in accordance with National Fire Protection Agency (NFPA) 10 Chapter 1-6.7 and visually checked monthly according to NFPA 4-3.1. This facility has an average of 3 patient's a day.

Findings include:

Tour of this facility took place on 06/24/10 from 4:10 PM to 5:10 PM with Staff Y. Observation was made in both sleep labs of a portable fire extinguisher sitting on the counter top. The question was proposed to staff Y if this is where the fire extinguisher's are kept and staff Y stated "yes."
These fire extinguisher's were observed to have inspection tags attached to them with the last inspection dated for 10/29/09. The back of the tags lacked documentation for the monthly visual checks and the question was proposed to staff Y if they perform the required monthly visual checks on the fire extinguisher's and staff Y stated "no."

Based on facility tour and staff interview and verification, the facility failed to ensure that soiled linen or trash collection receptacles did not exceed 32 gal (121 L) in capacity. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/23/10 between the hours of 3:25 P.M. and 4:30 P.M. and on 06/25/10 between the hours of 1:00 P.M. and 3:00 P.M. tour with Staff P, Q, S, and T was completed in two areas of the hospital. The following locations were observed, with the staff present, to have large wheeled trash or soiled linen receptacle stored in corridors.

a. On 06/23/10 between 3:25 P.M. and 4:30 P.M., Staff S and T were present when tour of the second floor of the South/Gannon Building was completed. Observation of the second floor corridor, near the female locker room, revealed the presence of a large wheeled trash cart. The cart was significantly larger than 32 gallons in size and contained multiple bags of trash. The wheeled container was piled to near capacity with bags of trash. A second large container was also stored in the corridor with at least 13 cardboard boxes piled in and around it. Staff present verified the boxes were from supplies that had been delivered. The boxes had been emptied and were ready to be discarded.

b. On 06/25/10 tour of the first floor, South Building, between the hours of 1:00 P.M. and 3:00 P.M. with Staff P and Q, revealed a large wheeled container with multiple bags of soiled linen inside stored in the corridor. The large wheeled soiled linen cart was stored near elevators, outside the Gannon Building near S177 and S1DD .

Staff present at both observations verified the large wheeled containers were greater than 32 gallons in size and were not stored in areas considered acceptable for hazardous materials storage.

REVISED

Based on facility observation and staff interview and verification, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities. NFPA 99 requirements for storage requirements (location, construction, arrangement) are addressed at 4-3.1.1.2.

Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3) area as follows:

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Doors to such locations shall be provided with louvered openings having a minimum of 72 in 2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.

Requirements of 4-3.1.1.2(b)3 states that the walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.

Requirement 4-3.1.1.2(b)4 states that locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.

The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings included;

On 06/23/10 between the hours of 9:55 A.M. and 12:00 P.M. tour of the third and fourth floor of the Gannon/ South building was completed with Staff S, T and U.

1. Observation of the fourth floor revealed the entrance to the roof top helipad. A small storage room was noted at the edge of the helipad. Staff T opened the small storage room to reveal the storage of medical gases, medical supplies and packaged dressings. One H size cylinder of oxygen (250 cubic feet), six D size helium cylinders (90 cubic feet) and 12 E size cylinders of oxygen (288 cubic feet) were stored in the room. Shelving in the storage room contained packaged wound dressing supplies and other patient care supplies. The floor of the storage room was noted to be wood. A motorized vent was not in operation. Staff present could not address if the ventilation system had to be manually operated or provided ventilation automatically. The door to the room was not louvered. The room was noted to have smoke detection and a sprinkler system.

2. Observation of the third floor revealed three rooms designated for pulmonary function testing. The hours of operation for pulmonary function testing was between 8:00 A.M. and 5:00 P.M. Two of the three pulmonary function rooms were observed with the third being used for patient testing.

The two rooms observed were noted to have a sprinkler system present. One room contained four H cylinders which could total 1000 cubic feet. The four cylinders were one each of oxygen, medical air, nitrogen and helium. Also present were two E size cylinders of oxygen (48 cubic feet) and four D size cylinders (60 cubic feet) which contained nitrogen, carbon dioxide, helium and oxygen.

The second pulmonary function testing room contained two H size helium cylinders, two H size cylinders of nitrogen/ carbon dioxide, totaling 1000 cubic feet and seven E size cylinders of oxygen (168 cubic feet).

Staff present verified the rooms were used for patient testing during the day shift and the medical gases remained stored in the rooms when testing was not in progress.

The room walls and doors were noted to have no known fire resistance rating, no venting system for the rooms and light switches were not observed to be at least 5 feet from the floor of the rooms.

These findings were verified by all staff present during tour.

Chapter 39
Section 39.2 Means of Egress
39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

Based on facility observation, review of facility documentation, staff interview and verification, the facility failed to ensure the means of egress for the outpatient plaza were in accordance with Chapter 7 with regards to 7.1.3.2, Exits. The facility failed to ensure the exit was separated from other parts of the building, where the separating construction was to meet the requirements 8.2 in that the separation did not have a fire resistance rating of not less than one hour where the exit connected three stories or less. The rehabilitation, women and children's pavilion, the medical specialty and the cancer care pavilions were affected.

Finding included:

1. On 06/24/10 between the hours of 9:20 A.M. and 3:30 P.M. tour of the Outpatient Plaza was completed with Staff P, Q, S, and T. Review of building floor plans reviewed the presence of a one hour fire rated wall located on the first and second floor exit assess of the women and children's pavilion and the medical specialty building. The exit access from each building lead to a large atrium and exit from the buildings.

Observation of the one hour fire rated walls revealed the following;

1. In the exit access from the women and children's pavilion, in the fetal diagnostic waiting area, penetrations were observed above the ceiling tiles and at the floor decking above. Multiple penetrations were observed in the one hour fire rated wall around a pipe, at the floor decking and an open area approximately 2 inches in diameter.

Multiple penetrations were observed in the one hour fire rated wall located in the exit corridor near the entrance to the atrium. Penetrations were noted around duct work inserted through the fire rated wall.

2. In the exit access from the medical specialty pavilion, near the entrance of the atrium, penetrations were observed around telecommunications wiring, at the floor decking above and around sprinkler system piping

3. Located in the cancer care pavilion, on the first floor, penetrations were observe in the exit access in the one hour fire rated wall at the floor decking above and around pipes through the fire rated wall.

Staff present on the tour observed and verified the exit access walls were one hour fire rated walls with penetrations which would affect the fire resistance.

2. Observation of corridor door and fire door testing revealed the following;

During tour on 06/24/10 with Staff P, Q, S, and T observations were completed with regards to the operation of doors located in building separations and in exit corridors. The following doors noted to be on self- closing devices were observed to fail to close completely or lacked identification as to adequate fire rating.

a. In the rehabilitation pavilion, corridor doors near rooms RP225C and RP 224A were noted to have gaps greater than 1/8 inch at the edge of the doors when the doors were in the closed position.

b. In the walkway to the women/children's pavilion, fire doors designated by the facility floor plan to be in a 2 hour fire rated wall and were noted to be 2 hour fire rated doors lacked identification on the doors to verify the fire rating. Staff present on tour verified there was no labeling on the doors which indicated any fire rating.
In the walkway between the orthopedics and cancer pavilion, two fire doors designated by the facility floor plan to be in a 2 hour fire rated wall and were noted to be 2 hour fire rated doors lacked identification on the doors to verify the fire rating. Staff present on tour verified there was no labeling on the doors which indicated any fire rating.

Doors observed to be on closers located at the entrance to "OB" and at 2112H were noted to have gaps greater than 1/8 th inch when in the closed position which would allow for the passage of smoke in the event of a fire.

c. Observation of 2 hour fire rated doors located in the corridor on the second floor of the medical specialty building revealed the doors would not latch when activated. The fire rated doors were noted to provide separation from the outpatient plaza and the bridge to the main hospital.

d. Observation of the 2 hour fire rated doors located on the hospital side of the bridge(East doors) leading to the outpatient plaza revealed the doors failed to securely latch when tested. A hole was observed through the top of the fire door. Staff present on tour verified the fire rated doors did not latch as intended and that the hole on the top of the fire door appeared to have been drilled.


EMERGENCY LIGHTING
39.2.9.1
Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.

7.9 EMERGENCY LIGHTING
7.9.1 General.
7.9.1.1*
Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

Based on facility tour and staff interview and verification the facility failed to enure that emergency lighting was provided at exit discharge from the facility. One of four pavilion buildings ( rehabilitation ) located in the Outpatient Plaza was affected.

Findings included;

During tour on 06/24/10 between the hours of 9:20 A.M. and 10:05 A.M. with Staff T, observation of the rehabilitation pavilion revealed there was no emergency lighting at the exit discharge on South Point Drive. The exit discharge was identified by Staff T to lead persons evacuating the building to the public way. Staff T verified there was no emergency lighting at the point of exit discharge from the rehabilitation building.


SMOKE DETECTOR PLACEMENT
Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were located where airflow patterns would not 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.

Findings include:

During tour of the facility on 06/24/10 between the hours of 11:15 A.M. and 12:30 P.M. with Staff P and Q observation was made of several smoke detectors located in areas where air flow devices may affect their normal operation. These locations are as follows:

First Floor Orthopedics:
*Exam room K
*Room 1234
*Soiled utility room 1227

Cancer Care Pavilion
*Within the waiting area
*Within the nurse's station
*Within the treatment planning room

Second Floor Orthopedics
*Rooms I, J and K

Cancer Care Pavilion
*Within the inner core corridor

These findings were acknowledged by both staff during tour.

SMOKE DETECTOR PLACEMENT
Based on observation during tour and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were located where airflow patterns would not 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 those utilizing this facility. The hospital had a capacity of 702 patient beds with a census of 347 patients at the time of the survey.

Findings include:

During tour of the facility on 06/22/10 through 06/24/10 between the hours of 8:30 A.M. and 5:00 P.M. with Staff P,Q, R, S, T, U and V, the following smoke detectors were observed to be significantly less than 36 inches from air diffusers or air flow devises.

a. Two smoke detectors on the seventh floor of the Core Building located near the Towers Building entrance were less than 12 inches from an air return.

b. On the fourth floor of the Core Building two smoke detectors located in the "tree house room" were significantly less than 36 inches from an air diffuser.

c On the second floor of the Core Building in the store room of the neonatal intensive care unit a smoke detector was less than 30 inches from an air device.

d. On the first floor of the Core Building, near the entrance to the Towers building a smoke detector was significantly less than 36 inches from an air diffuser.

e. On the third floor of the Gannon Building in the cardiac rehabilitation area a smoke detector was significantly less than 36 inches from an air diffuser






21957

Tour of the main building took place on 06/22/10 to 06/24/10 with Staff P, Staff Q and Staff R. During tour, observation was made of several smoke detectors which were located in areas where air flow devices might inhibit their normal operation.
These locations are as follows:

Ground Floor:
*Within the fire command center room BG01A

Critical Care Pavilion (CCP)
*Just outside of room CPG748
*Near smoke barrier doors around the corner of room CPG748

First Floor CCP:
*Within the pre-op area located in room CP1304

Patient Towers
Second Floor:
*In C unit nursery room 280
*In B unit corridor next to room 262
*In front of the elevators located in the family waiting area

Second Floor of the business services building
*Near K-200 stairs

Patient Towers
Third Floor:
*In C unit cardiac step down room numbers 367, 369, 370, 371, 372, 373, 374, 376, 377, 378, 379 and 380
*Two smoke detectors in B unit CICU nurse's station
*B unit where the circular and straight corridors meet
*Between B and C units by room 363
*In front of the elevators located in the family waiting area

Third floor of the business services building
*By the entrance door of the business services building

Fourth Floor:
*Within B unit pediatrics by room 442
*In corridor adjacent to the environmental service room near the elevators
*In front of the elevators located in the family waiting area

Fifth Floor:
*One smoke detector in B unit MICU nurse's station
*In corridor near room 5537

Sixth Floor:
*By the entrance to 6B behavioral health suites

Seventh Floor:
*In the corridor near room S737
*In corridor near room S776
*In C unit stroke rehabilitation room number 781

Eighth floor:
*Within the corridor by room S837
*By service elevator number 8
*Within C unit corridor by room 879

Ninth Floor:
*Within B stroke unit by room 936 and within room 976
*Within C medicine unit nurse's station and corridor by room 968

Tenth Floor:
*In front of elevator number 6
*Within C medicine unit nurse's station

Eleventh Floor:
*Within the nurse's station and room number 1136

These findings were verified and acknowledged by all staff during the tour.

USE OF ALCOHOL BASED HAND RUB

o Where Alcohol Based Hand Rub (ABHR) dispensers are installed in a corridor, the corridor is at least 6 feet wide
o The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
o The dispensers have a minimum spacing of 4 ft from each other
o Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
o Dispensers are not installed over or adjacent to an ignition source.
o If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

Based on facility observation and staff interview and verification, the facility failed to ensure that Alcohol Based Hand Rub (ABHR) dispensers were not installed over or adjacent to an ignition source. Three of four operating rooms were affected. The facility provided surgical services for 3140 patients from June 2009 until June 2010.

Findings included:

On 06/24/10 between 3:00 P.M. and 5:00 P.M. tour of the ambulatory surgical center was completed with Staff P, Q and X. Observation of the four operating rooms in the facility revealed the presence of ABHR dispensers installed inside the doors in three of four operating rooms. Closer inspection of the ABHR dispensers revealed they were installed directly over the electric light switch for the room. The spray of the ABHR was inches away from the light switch.

Staff Q and X verified the ABHR dispensers were installed too close to the electrical switch.


OCCUPANCY SEPARATION

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 1¾ 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.

Based observation of the facility and staff interview and verification the facility failed to ensure the ambulatory health care occupancy was separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Doors in such barriers were to be solid bonded core wood of 1¾ inches or equivalent and were to be equipped with a positive latch and closing device. The facility provided surgical services for 3140 patients from June 2009 until June 2010.

Findings included:

On 06/24/10 between 3:00 P.M. and 5:00 P.M. tour of the ambulatory surgical center (ASC) was completed with Staff P, Q and X. Observation of the entrance into the ASC revealed sliding glass doors at the exit discharge. Once inside the sliding doors there was a small foyer. A large glass paneled door fitted into a partial glass wall established the entrance into the ASC. There was no visible fire rating on the partial glass wall or glass door and no positive latching device on the door.

The ASC was noted to share the building with another health care provider. The waiting area was separated into two sections by a half glass brick wall. There was one receptionist desk which was shared by two staff. One staff member assisted the ASC patients and the other receptionist assisted the other provider's patients.

Interview with Staff P verified the ASC was 9660 square feet and was complete with an automatic sprinkler system. Observation of the separating wall between the ASC and the other tenant in the building revealed multiple penetrations in the one hour fire rated wall. Staff P and Q verified the penetrations in the occupancy separating wall.

Based on documentation review and staff interview it was determined this facility failed to ensure all smoke detectors were sensitivity tested in accordance with National Fire Protection Agency (NFPA) 72, Chapter 7-3.2.1.

Findings include:

Tour of this facility took place on 06/24/10 from 4:10 PM to 5:10 PM with Staff Y. During tour observation was made of smoke detectors located in both sleep labs. The question was proposed to staff Y if they have them tested as required. Staff Y replied "yes."
A request was made for the documentation of smoke detector testing and Staff Y presented to this surveyor the latest test documentation dated for 12/16/09. This documentation lacked any sensitivity testing and a thorough search was performed by Staff Y for the sensitivity testing but none was available even up to the time of the exit conference on 06/25/10.

Based on record review and staff verification it was determined this facility failed to ensure the generators were visually inspected each week and run with a monthly load test as required by National Fire Protection Agency (NFPA) 99 Chapter 3.4.4.1. This facility averages 230 patients a day.

Findings include:

Tour of this facility took place on 06/24/10 from 1:30 PM to 3:30 PM with Staff members S, T and Z. Review of the generator maintenance logs took place on 06/24/10 with staff Z.
Observation by this surveyor and verification by staff Z confirmed the generator maintenance logs failed to have proper documentation of monthly generator load testing and weekly visual inspections. This surveyor proposed the question to staff Z during documentation review as to if these tasks are performed and staff Z replied "no".