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Building A-3 - Pediatric Emergency

Through observation, during the survey, March 13, through March 20, 2018, it was determined that the facility failed to maintain the fire ratings of the occupancy separation.

During the walk through of the facility, with the Maintenance Staff, there was one (1) unsealed pipe conduit above the second (2nd) exit door.
Note: This deficiency was corrected during the survey

Building A-1 - Main Hospital

Through observation, during the survey, March 13, through March 20, 2018, it was determined that the facility failed to maintain the fire ratings on the structural beams as required.

During the walk through of the facility, with the Maintenance Staff, the facility failed to mintain the monocoat system on the structural beams to maintain a 2 hour fire rating on the beams. The monocoat was missing in the following areas:
1) One beam at center of room on the 7th floor
2) Four spots by smaller elevator control room on the 7th floor
3) Two areas in the Garden level mechanical room

This deficiency effected 2 smoke compartments throughout the facility.

Building A-3 - Pediatric Emergency

Through observation, during the survey, March 13, through March 20, 2018, it was determined that the facility failed to maintain the fire ratings on the structural beams as required.

During the walk through of the facility, with the Maintenance Staff, the facility failed to maintain the monocoat system on the structural beams to maintain a 1 hour fire rating on the beams. The beam was missing monocoat in the middle of the long corridor.

This deficiency potential effected one smoke compartment.

Building A-1-Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with theMaintenance Staff, items were being stored in the corridor that prevented the corridor from being clear and unobstructed and did not meet the exceptions in the Life Safety Code. The following areas were observed:
1) Four trash cans located in ED exit vestibule
2) Storage of clothing outside of gift shop including our clotches racks and a table of gifts.
3) Table in main corridor outside 1st floor elevators protrudes into the corridor more than 6".
4) Education office had 2 rolling carts in the path of egress-please maintain a 48" walkway to exits from the suite
NOTE: All deficiencies were corrected by moving the items or storing items in different areas during the survey.

These deficiencies effected four smoke compartments and four different egress paths throughout the facility.

Building A-1-Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility had not maintained the exit access door from being locked.

During the walk through of the facility, with the Maintenance Staff,, doors contained locks on the doors or did not release on fire alarm activation as required. The following doors were efeeceted:
1) Exit door from the Decontamination room has a lock from the inside which prevented the door from opening from the inside.
2) Door to Labor and delivery is keyed access only from 2A to 2E. This locked door creates a dead end corridor greater than 50'.
3) Doors to end stairs on 6200 and 6300 did not unlock during the fire alarm test-they stayed in delayed egress mode and did not release on fire alarm activation.
Note: The delayed egeress doors on 6200 were corrected during the survey.
4) Two doors located in the emeregncy department contained locked doors for security of patients. When a nurse was asked by the surveyor if she could open the door, her response was "Only the security officer has a key."
Note: The locks were removed from these doors during the survey

These deficiencies effected one stairwell egress, one corridor, and one room within the hospital.

Building A-1 - Main Hospital

Through observation and record review during the survey, March 13 through March 20, 2018, it was determined the facility failed to test the fire doors per NFPA 80 as required.

During the record review, with the Maintenance Staff, the records for four fire doors could not be located indicating that they had been tested within the past year, the last inspection report on record was dated February 28, 2017.
1) Main lobby horizontal sliding fire door
2) Two Vertical drop down doors at the Cafateria
3) Vertical sliding door at blood bank area

These deficiencies potentially effected 3 smoke compartments.

Building A-1 - Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the kitchen extinguishing system as required.

During the walk through of the facility, with the Maintenance Staff, the extinguishment nozzles over the deep fryers in the main serving area were not covering the deep fryers adequately. The fryers were placed to the right of the extinguishment nozzles.

This deficiency effected 1 smoke compartment.

Building A-1 - Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walkthrough of the facility, with the Maintenance Staff, the alcohol based hand rub dispensers (ABHR) were installed above or adjacent to an electrical source in two locations. Those areas are listed below:
1) Located above an in wall nite light in room #LDR 10
2) Located above wave open sensor in hybrid Operting Room
Note: All deficiencies listed above were corrected during the survey

These deficiencies effected 2 patient care rooms throughout the hospital.

Building A-3 - Pediatric Emergency

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walkthrough of the facility, with the Maintenance Staff, the alcohol based hand rub dispensers (ABHR) was installed above an electric "push to open" button at the second (2nd) exit.
Note: This deficiency was corrected during the survey.

This deficiency effected 1 smoke compartment

Building A-1 - Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72.

During the walk through of the facility with the Maintenance Staff, the following smoke detectors were placed within three feet (3') of the air inlet or exhaust diffuser:
1) At nurse station across from room 6214 (#11154)
2) At nurse station at 4100 wing
3) At 2C smoke barrier door
4) At smoke barrier doors to 1J
5) At smoke barrier 1B
6) One located within the laboratory
7) At Physical Therapy vestibule
8) One located in Infusion hallway outside soiled hold room
9) In sterile core of Main Operating Rooms
Note: All of the above were corrected during survey with the exception of #9

These deficiencies potentially effected 9 seperate smoke compartments

Building A-1 - Main Hospital

Through a review of the records and discussions with staff during the survey, March 13 through March 20, 2018, it was determined that the facility failed to have the sensitivity test recorded every two years as required.

During the review of the facility records, with the Maintenance Staff, the sensitivity records were not available for inspection.
Note: The sensitivity test was sent to the inspector the day after the exit interview.

This deficiency potentially effected the entire hospital.

Building A-1 - Main Building

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to provide smoke detectors in all areas open to the corridor.

During the walk through of the facility, with the Maintenance Staff, the facility failed to provide smoke detector coverage in all areas which were open to the corridor in the following areas:
1) Nutrition area across from room #5212
2) Nutrition area across from room #4212
3) Nutrition area across from room #3214

These deficiencies potentially effected three smoke compartments within the facility.

Building A-1 - Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility, with the Maintenance Staff, it was determined that a soffit area, located on the second floor in compartment 2D (between rooms 2202 and 2218), failed to have sprinkler coverage as required. The soffit measured approximately twenty four inches (24") deep and did not have coverage from the adjacent sprinklers.

This deficiency effected one smoke compartment.

Building A-3 - Pediatric Emergency

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility had not maintained the doors to the corridor as being smoke resistive.

During the walk through of the facility, with the Maintenance Staff, the door to exam room #1 contained a gap, when closed, which was greater than 1/2" thick which prevented the door from being smoke resistive.

This deficiency effected 1 smoke compartment.

Through observation during the survey, March 13 through March 20, 2018, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director, corridor doors did not positively latch, were held open by a door wedge, or failed to maintain any type of latching mechanism. The following doors were effected:
1) Closet door adjacent to room 5107-has a left leaf with a manual lock
2) Left leaf of closet door adjacent to 4310 will not latch-corrected during survey
3) Closet door would not latch at 3rd floor nurses station--corrected during survey
4) Closet door adjacent to ED room 5 has a roller latch
5) Door to floor 4 dictation room propped with door wedge, no smoke detector in space. Door wedge removed during
survey
6) STJ waiting room measures approx 1400 sq. Ft with another waiting area at 432 square feet in size. The corridor runs in between the two waiting rooms. There were three (3) sliding doors, located at the reception check in desks, that did not contain any type of latching mechanism on the doors.

These deficiencies potentially effected six smoke compartments.

Building A-1 - Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the smoke barrier walls to a one hour rating.

During the walk through of the facility, with the Maintenance Staff, the smoke barrier walls in three locations contained "blow out" patches to seal large holes. The locations are as follows:
1) Electrical room on 3rd floor
2) Above rated doors to 5C
3) Soiled utility room conduit side on 1st floor

These deficiencies effected 6 smoke compartments throughout the facility.

Building A-1 - Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility, with the Maintenance Staff, smoke barrier doors failed to close properly in the following areas:
1) Zone 5A
2) Zone 4A
3) Zone 2B
4) Zone G-E
5) Zone G-C
Note: All doors were corrected during the survey

These deficiencies potentially effected ten smoke compartments throughout the hospital.

Building A-1 - Main Hospital

Through record review during the survey, March 13 through March 20, 2018, it was determined the facility failed to test smoke dampers the first year after they were installed.

During the review of the records, with the Maintenance Staff, documentation was not available to indicate that three (3) smoke dampers, that had been replaced in February 2017, had been tested the one year after installation. The three smoke dampers were:
1) ID# 27150987493 Endoscopy corridor
2) ID#27150987495 Inside OR equipment storage
3) ID #27150987498 Inside Hybrid OR

These deficiencies potentially effected 3 smoke compartments.

Building A-1 - Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the walk through and observation, with the Maintenance Staff, the electrical box contained two (2) items named "Fire Alarm TBS" located on the criticial branch of the electrical panels in the 2nd floor LDS room. Unknown what the Fire Alarm RBS circuits are for and if they are part of the fire alarm system or another system. The electrical supervisor was on vacation and these items could not be determined what they were for during the survey.

The deficiency potentially effected one floor of the building.

Building A-1 - Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the generator batteries as required per NFPA 110, section 8.3.7.1.

During the record review, with the Maintenance Staff, the generator battery conductive testing had not been completed monthly as required.

This deficiency potentially effected all staff and patients.

Building A-1 - Main Hospital

Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility, with the Maintenance Staff, an extension cord was plugged into a powerstrip in the Education Office area.
Note: The 50' extension cord was removed during the survey.

This deficiency potentially effected one smoke compartment.