HospitalInspections.org

Based on observations made on October 12-14, 2010, the facility failed to maintain the 2-hour fire resistance of fire barrier walls and doors in fire walls.

Findings included:

1. Room 1202-C (a locked closet) on the exit corridor in the Maintenance department was observed at 2:00 p.m. on 10/12/10. There was a six inch by twelve inch penetration above the corridor door into the space above the corridor which was not sealed.

2. The electrical subpanel on the north wall of room 1518 was observed at 3:00 p.m. on 10/12/10. The subpanel was not sealed for twelve penetrations through the 2-hour wall between the phone room and the mechanical room.

3. The exit stairwell by the Sterile Processing Department was observed at 10:30 a.m. on 10/13/10. New wiring had been installed in the stairwell for expanded cell phone coverage. The 2-hour wall between the exit corridor and the stairwell had a penetration where the wiring had not been sealed.

4. The room under the Cameron Auditorium was observed at 9:50 a.m. on 10/13/10. There were penetrations through the two hour ceiling in this room exposing wood construction in the interior spaces.

5. The door leading to the tunnels near the south tower was observed at 1:07 p.m. on 10/13/10. The fire wall above the door had two penetrations through it. One was for the sprinkler pipe and the remaining was for a half inch conduit which was not sealed.


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6. A 3-hour fire wall had an unsealed penetration around an open ended conduit above the rated double doors, where ER connecting tunnel met the South tower as observed at 1:30 p.m. on 10/13/10.

Based on observations on October 12-14, 2010, the facility failed to maintain the fire and smoke resistance rating of wall and ceiling assemblies.

Findings included:

1. Room 1202-B (a locked closet) on the exit corridor in the Maintenance department was observed at 1:40 p.m. on 10/12/10.
a) There were three open penetrations in the east wall of this room, and
b) three open penetrations in the west wall of this room.
All were penetrations from where conduits had been removed and the gypsum board had not been properly sealed.

2. Room 1202-A (a locked closet) on the exit corridor in the Maintenance department was observed at 1:55 p.m. on 10/12/10.
a) There were three penetrations in the east wall of this room,
b) There was one penetration in the west wall of this room, and
c) There were two penetrations in the south wall of this room which had not been properly sealed.

3. Room 1805 (a network server room) was observed at 4:00 p.m. on 10/12/10. There were two ceiling tiles missing in this server room.

4. The DuFresne classroom was observed at 4:30 p.m. on 10/12/10. The DaLite screen in this room was installed through a hole in the ceiling tile. There was no sprinkler or smoke detection above the ceiling tile in this room.

5. The Hub room in Medical Records was observed at 7:40 a.m. on 10/13/10. The following deficiencies were found:
a) a ceiling tile was missing, and
b) the wall in this room had a two inch hole.

6. The Audio/Video (AV) storeroom in the Cameron Auditorium was observed at 9:40 a.m. on 10/13/10. The walls and ceiling in this room were not finished and had no rating.

7. The corridor near the Nutrition office was observed at 2:35 p.m. on 10/13/10. One ceiling tile had a two inch penetration at this location.


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8. Room 570C had a missing ceiling tile at 4:10 p.m. on 10/12/10 on the 5th floor.

9. Rooms 515A and 515B had several missing ceiling tiles at 4:15 p.m. on 10/12/10 on the 5th floor.

10. Room 393 had two missing ceiling tiles at 3:01 p.m. on 10/12/10 on the 3rd floor.

11. Patient room 10 had a missing ceiling tile at 3:04 p.m. on 10/12/10.

12. The old open heart room had four missing ceiling tiles at 3:06 p.m. on 10/12/10 on the 3rd floor.

13. Elevator #17's lobby ceiling tile had a two inch by four inch hole on the 4th floor (PCU)of the surgical tower.

Based on observations on October 12-14, 2010, the facility failed to maintain the fire and smoke resistance rating of wall and ceiling assemblies.

Findings include:

1. The first floor east x-ray room was observed on 10/12/10 at 1:30 p.m. Two, two foot square tiles were missing in the suspended ceiling assembly.

2. The first floor lab blood draw area was reviewed at 3:20 p.m. on 10/12/10. A condensate drain was run through the tile ceiling and the ceiling tile was not notched to accommodate the drain. The tile was approximately 1/2 inch above the ceiling assembly where the drain passed through.

3. Mechanical room 1300 was observed on 10/12/10 at 3:30 p.m. Two ceiling tiles were out of place in the room.

4. The old MRI Computer Room was observed at 3:38 p.m. on 10/12/10. Several ceiling tile were out of place in the room.

5. Room 1344 was observed on 10/12/10 at 4:05 p.m. Some of the ceiling tile in the room was either missing or out of place.

6. Room 1369 was reviewed at 4:00 p.m. on 10/12/10. A ceiling tile in the room was incomplete where electrical service had been run through it.

7. The Lewis & Clark exit vestibule to the north was observed on 10/13/10 at 8:41 a.m. A ceiling tile was out of place at the time of survey and replaced by staff during the survey process.

8. Clinical Engineering was inspected at 9:01 a.m. on 10/13/10. The ceiling grid had one section of ceiling support hanging down from one end and two of the tiles not fitted tightly.

Based on observations which were made on October 12-14, 2010, the facility failed to maintain the fire resistive construction of all corridor walls in order that they would be resistant to the passage of smoke. In sprinklered buildings, wall partitions are only required to resist the passage of smoke, 19.3.6.1.

Findings included:

In accordance with Sections 19.3.6.1, 19.3.6.2.1, 19.3.6.5 of NFPA 101, 2000 edition; corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.)

The sprinkler chase room 472 on the 4th floor had an unsealed penetration that extended above the room door into exit corridor at 7:41 a.m. on 10/12/10.

Based on observations which were made on October 12-14, 2010, the facility failed to maintain the fire resistive construction of all corridor walls to prevent the passage of smoke. In fully sprinklered buildings, wall partitions are only required to resist the passage of smoke, 19.3.6.1.

Findings included:

In accordance with Sections 19.3.6.1, 19.3.6.2.1, 19.3.6.5 of NFPA 101, 2000 edition; corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.)

The maintenance shop G105 was reviewed at 10:30 a.m. on 10/13/10. An unsealed penetration to the corridor existed in the room.

Based on observation made on October 12-14, 2010, the facility failed to ensure that there were no impediments to closing or using a corridor door opening onto the exit corridor system.

Findings included:

Hold-open devices that release when the corridor door is pushed or pulled shall be permitted per Section 19.3.6.3.3 of NFPA 101 LSC, (2000 Edition). However, a hold-open device can not be used on doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, fire barrier or hazardous area enclosure unless they conform with Section 7.2.1.8.2 of NFPA 101 LSC, (2000 Edition). Doors cannot be blocked open by furniture, door stops, chocks, wedges, or devices that necessitate manual releasing action to close the door.

The self closure of the Equipment Depot corridor door on the 7th floor had a magnetic hold device that was interfaced with the fire alarm system (opened onto the exit corridor). When exercised, the door closure was inhibited by 4 sets of metal hooks over the door at 1:48 p.m. on 10/12/10. The facility staff removed all but one of the metal hooks and the door would positively latch and close.

Based on observation made on October 12-14, 2010, the facility failed to ensure that there were no impediments to closing or using a corridor door opening onto the exit corridor system.

Findings include:

The corridor door to room 311 was closed on 10/12/10. The door would not latch as required.

Based on observations made on October 12-14, 2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings included:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with Section 8.2.5 of NFPA 101. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101; pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The northwest corner of the Maintenance Shop was observed at 1:35 p.m. on 10/12/10. An electrical box cover was missing on a piece of conduit which extended to the level above.

2. Room 1200 (a mechanical room) in Maintenance was observed at 2:05 p.m. on 10/12/10. A copper pipe above an air-conditioning unit was not sealed as it passed through the ceiling to the level above.


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3. An unsealed floor penetration (open end of a two inch conduit) was observed in the north east corner of the Communications room on 8th floor at 12:44 p.m. on 10/12/10.

Based on observations made on October 14, 2010, the facility failed to seal penetrations through floors or in vertical shafts.

Findings included:

In accordance with Section 3.1.1 of Chapter 38 (New Business Occupancies) Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

In accordance with Section 8.2.5.2 of the Life Safety Code (LSC), Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance of the barrier.

Room 310 of the Sletten Cancer Center was observed at 8:15 a.m. on 10/14/10. The following unsealed penetrations were noted:
a) Three open penetrations from this room to the penthouse above which were all two inch conduits, and
b) One open two inch conduit between room 310 and the basement level which was not properly sealed.

Based on observations made on October 12-14, 2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

1. The Simulator Control Room was observed at 4:12 p.m. on 10/12/10. An electrical control box still in the room contains conduits from the floor below (Ground Floor). The penetrations were unsealed.

2. Mechanical Room MG001 was observed at 8:50 a.m. on 10/13/10. The room contained three unsealed vertical penetrations to the floor above. They consisted of one, two inch and two, two and one half inch unsealed holes.

3. The first floor smoke barrier was observed near the old radiology door at 2:31 p.m. on 10/13/10. At least two unsealed penetrations were seen to the second floor above.

4. Three vertical plumbing penetrations were seen to the floor above near the Rehabilitation Equipment Depot as observed on 10/13/10 at 3:29 p.m. Two were black sewer lines while the other was a copper water line.

Based on observation made on October 12-14, 2010, the facility failed to ensure that all access to exits were properly marked by readily visible signs.

Findings included:

In accordance with Section 7.10.1.2 of the LSC, exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

1. The DuFresne classroom was observed to be twenty four feet by forty six feet with only one exit to the east, at 4:32 p.m. on 10/12/10. There was another way out of this space to the west but the door did not have an exit sign.

2. The classroom identified as 5-A and 5-B was observed at 4:45 p.m. on 10/12/10. The classroom had an exit sign at the east end of the exit corridor but did not have an exit sign at the west door.

3. The north exit corridor directly behind Registration was observed at 8:20 a.m. on 10/13/10. The exit sign directed one to enter the stairway instead of exiting the outside double doors around the column.


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4. The court yard door at the surgery waiting area lacked a NO EXIT sign at 11:32 a.m. on 10/13/10. This enclosed court yard and the secondary door into it leads to a staff meeting lounge on the other side of the court yard.

5. The two exit doors on the west side of the OR core lacked an illuminating exit sign at 10:21 a.m. on 10/13/10.

6. The corridor exit location near the operating room 7 in OR was reviewed. At this juncture, this south stairway was identified as an exit stairway after the smoke barrier doors (interfaced with the fire alarm system). In an emergency event, these double doors would close and the occupants could not see the exit sign on the other side of the doors. There was no exit sign above these smoke barrier doors. Additionally, the exit sign after the smoke barrier doors pointing at the south stairway was not visible to the occupants traveling from the opposite side (north to south).

Based on observation made on October 12-14, 2010, the facility failed to ensure that all access to exits were properly marked by readily visible signs.

Findings include:

The first floor lab was reviewed at 2:30 p.m. on 10/12/10. Two signs were placed on the door marked with an exit sign as follows: "Please DO NOT OPEN when cold and/or windy" and "Do Not Open from 0500 to 1200". The door had an illuminated exit sign above it indicating it was a required exit.

Based on observations made on October 12-14, 2010, the facility failed to maintain the fire resistive rating of fire/smoke barrier walls.

Findings included:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The smoke barrier wall above the doctor's dictation on the 8th floor had an unsealed penetration around a conduit housing three data cables at 1:15 p.m. on 10/12/10.

2. The smoke barrier wall above the double doors on the West corridor of the 8th floor had an unsealed penetration around fiber communication cables at 1:20 p.m. on 10/12/10.

3. The smoke barrier wall above the double doors on the west corridor of the 7th floor had an unsealed penetration around a conduit housing communication cables at 1:45 p.m. on 10/12/10.

4. The smoke barrier wall above the fire rated double doors near room 369 on the 3rd floor had an unsealed penetration at 2:33 p.m. on 10/12/10. The penetration was unsealed on both sides.

5. The smoke barrier wall above fire rated (90 minute) door at Med-South nurse station on the 3rd floor had an unsealed conduit penetration at 2:36 p.m. on 10/12/10.

6. The smoke barrier wall above the ceiling tiles in cubicle #7 in the old observation area on the 3rd floor had an unsealed penetration around a conduit at 2:38 p.m. on 10/12/10.

7. The smoke barrier wall above the double doors near room 375 outside the old CCU had a penetration around a two inch open ended conduit at 2:53 p.m. on 10/12/10.

8. The smoke barrier wall near room marked 4109 on the 4th floor of the surgical tower had a two inch thick previously sealed penetration that required additional fire rated sealant at 8:50 a.m. on 10/13/10.

Note: All of these penetrations were sealed during the survey after the maintenance department was notified.

Based on observations made on October 12-14, 2010, the facility failed to maintain the fire resistive rating of fire/smoke barrier walls.

Findings included:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The second floor smoke barrier that runs along the east end portion of the north wall of room 217 Clean Utility was observed on 10/13/10 at 1:45 p.m. The smoke barrier was not complete around both a structural beam and duct work.

2. The first floor corridor smoke barrier across from room 1501 was observed on 10/30/10 at 1:55 p.m. An approximately one inch copper pipe passed through the smoke barrier and was unsealed as it passed through the gypsum wallboard.

3. The first floor corridor smoke barrier near the mens' and women's locker rooms was observed on 10/13/10 at 2:10 p.m. The smoke barrier wall contained an unsealed one inch hole.

4. The first floor corridor smoke barrier east of room 1313 but before the barrier goes to the south was observed on 10/13/10 at 2:15 p.m. Two unsealed holes were found within the first five feet from the corner of the wall as follows:
a) an approximately two inch by ten inch hole, and
b) one inch unsealed hole.

5. The first floor smoke barrier near the old radiology door was observed at 2:31 p.m. on 10/13/10. The wall contained several unsealed penetrations through the smoke barrier.

6. The first floor smoke barrier near room 1314 was reviewed at 2:41 p.m. on 10/13/10. A cut off, unsealed open ended conduit penetrated the smoke barrier.

7. The first floor smoke barrier near 1307 Restroom was observed on 10/13/10 at 2:45 p.m. Two copper pipes with a foam insulation on them penetrated the smoke barrier and were not sealed as they went through the barrier.

8. The first floor smoke barrier near room 1306 Cardio Rehabilitation was observed on 10/13/10 at 2:50 p.m. Three unsealed penetrations existed through the smoke barrier as follows:
a) an one inch copper pipe,
b) a two inch sewer pipe, and
c) an one inch open hole.

9. The first floor smoke barrier near room 1226 was observed on 10/13/10 at 2:51 p.m. A one inch unsealed penetration existed through the smoke barrier.

10. The first floor smoke barrier near room 1301 was observed on 10/13/10 at 2:55 p.m. A three quarter inch unsealed penetration existed through the smoke barrier were piping had been removed.

11. The first floor smoke barrier near room 1300 was observed on 10/13/10 at 3:00 p.m. Three unsealed penetrations were found in the smoke barrier as follows:
a) one open ended sleeve where wires passed through, and
b) two condensate lines where they penetrated the smoke barrier.

12. A waste water pipe penetrated the smoke barrier near the Rehabilitation Equipment Depot as observed on 10/13/10 at 3:29 p.m.

13. The Facilities Staff corridor smoke barrier was reviewed on 10/14/10 at 8:20 a.m. A pipe sleeve had been sealed in the past but the fire stop material was in need of a second application. The sleeve was directly about the double doors.

14. The smoke barrier near room G101 was reviewed at 8:25 a.m. on 10/14/10. A large electrical conduit was unsealed to the passage of smoke as wires entered the conduit.

15. The smoke barrier near room G038 was reviewed at 8:44 a.m. on 10/14/10. An electrical sleeve through the smoke barrier with no wires in it was unsealed to the passage of smoke.

16. The smoke barrier near room G037 was reviewed at 8:46 a.m. on 10/14/10. A 12 to 18 inch round duct was cut off at approximately six to 12 inches before it entered the smoke barrier. The ducting seemed to be abandoned.

17. The smoke barrier near room G022 was reviewed at 8:50 a.m. on 10/14/10. Four, two inch electrical sleeves with wires inside were not filled to resist the passage of smoke from one smoke barrier to another.

18. The smoke barrier near room G030 and in the corridor was reviewed at 8:46 a.m. on 10/14/10. Five open ended sleeves with wires inside were not filled to resist the passage of smoke from one smoke barrier to another.

Based on observation and exercising of the doors on October 12-14, 2010, the facility failed to ensure that smoke barrier doors closed tightly to resist the passage of smoke.

Findings included:

1. Elevator lobby doors with fire rating of 90 minutes and with a magnetic hold device were exercised at 8:21 a.m. on 10/13/10 at the north end of the PCU, surgical tower. The doors would not positively latch when released from the magnetic hold device. The doors were exercised several times. The doors were repaired during the course of the survey.

2. The fire rated smoke barrier doors with a magnetic hold device (interfaced with the fire alarm system) near the operating rooms 5 and 6 were blocked by a utility cart in the core of OR. At 10:11 a.m. on 10/13/10, the utility cart was removed by a staff member after being notified, and the doors were released from the magnetic hold device. The doors would not latch positively.

3. The fire rated smoke barrier doors with a magnetic hold device (interfaced with the fire alarm system), located near the operating rooms 6 and 7 in OR, would not positively latch when exercised at 10:15 a.m. on 10/13/10.

4. The fire rated smoke barrier doors with a magnetic hold device (interfaced with the fire alarm system), located near the operating rooms 4 and 5 in OR, would not latch positively when exercised at 10:40 a.m. on 10/13/10.

Based on observations made on October 12-14, 2010, the facility failed to maintain or establish the fire rated protection for hazardous areas.

Findings included:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

Hazardous areas must be separated from non-hazardous areas with one hour rated wall and ceiling assemblies.

1. The Soiled Laundry room was observed at 10:40 a.m. on 10/13/10. The southeast corner of this room had five conduits which were not sealed, two were pneumatic tubes, two were steam pipes, and the remaining was a smaller conduit.

2. The Boiler room was observed at 11:15 a.m. on 10/13/10.
a) The west wall of the mezzanine in this room had a penetration above the exit door into the second level of the hospital which was an open two inch conduit,
b) The north wall of the boiler room had four penetrations in the brick wall. One was at a brace which extended through the brick wall while one was a loose brick at about the midpoint of the mezzanine. Finally,there were two steam pipes which were not sealed in the northeast corner of the mezzanine.

3. The Chiller room was observed at 11:30 a.m. on 10/13/10. The door between the Chiller room and the Electrical room was not self-closing at the one-hour wall. The door was properly rated for the opening.

4. The enclosed catwalk room above the Electrical room was observed at 11:35 a.m. on 10/13/10. There were two unsealed conduits between the Chiller room and the room above the Electrical room. One was an unsealed two inch conduit and the remaining was a three quarter inch conduit.

5. The north wall of the Chiller room which separates the Chiller room from the Boiler room was observed at 11:45 a.m. on 10/13/10. There were seven penetrations in this wall, six were open conduits, and the remaining was at a brace.


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6. The west mechanical room on the 5th floor had an open ended conduit penetrating through the wall by ACH 5-3 at 4:10 p.m. on 10/12/10.

7. Room 391, the mechanical room on the 3rd floor, had an unsealed conduit penetrating through the corridor wall above the room door at 3:02 p.m. on 10/12/10.

Based on observations made on October 14, 2010, the facility failed to assure that a set of corridor doors to a hazardous area were self-closing.

Findings included:

In accordance with Section 3.2.1 of Chapter 38 (New Business Occupancies), hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4 of the Life Safety Code (LSC).

In accordance with Section 8.4.1.3 of the LSC, Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic closing in accordance with Section 7.2.1.8.

The corridor door to the soiled linen room was exercised at 8:10 a.m. on 10/14/10. There were no self-closing devices on the corridor doors to the hazardous area.

Based on observations made on October 12-14, 2010, the facility failed to maintain or establish the fire rated protection for hazardous areas.

Findings included:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 Edition; doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

1. Room 1343A was reviewed at 3:50 p.m. on 10/12/10. The room was empty with exception of two, five gallon containers of a corrosive liquid and nine lead acid type batteries. The room lacked self closures required of a hazardous storage area.

2. The Linear Accelerator Room 1387A was reviewed at 4:15 p.m. on 10/12/10. The control room door lacked a self closure mechanism as the room was being used for storage.

Based on observations made on October 12-14, 2010, all vertical openings such as stair towers are contained with a fire resistant rating.

Findings include:

In accordance with Section 7.1.3.2.1 of NFPA 101, 2000 Edition; where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.

1. The second floor level of the northeastern stair tower was observed at 2:01 p.m. on 10/12/10. A horizontal hole was created when piping was removed near room 211/212. The hole was repaired while the surveyor was still in the building.

2. The first floor level of the center stair tower near room 1502C was reviewed on 10/12/10 at 2:10 p.m. Two, three inch holes through the two hour construction of the stair tower were noted. Piping had been removed and the holes left unfilled. The holes were repaired while the surveyor was still in the building.

3. The ground level of the south stair well near room G035 was reviewed on 10/14/10 at 9:15 a.m. There were at least two open penetrations one inch square in size and some unsealed open ended conduits in the 2 hour barrier.

Based on observations made on October 12-14, 2010, the means of egress was reduced by items stored in the means of egress.

In accordance with Section 7.1.10.1 of NFPA 101, 2000 Edition, means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings include:

1. Outpatient Pediatric Therapy was observed on 10/12/10 at 3:09 p.m. Two exercise mats were found outside the egress door (12533). The mats were water soaked and were taking up approximately 1/3 to 1/4 of the egress path to the public way.

2. The Outpatient Pediatric Therapy corridor, labeled as 1135, was reviewed on 10/12/10. The exit was partially blocked with three items:
a) a gurney,
b) a toddler tricycle, and
c) a chair with wheels.
Note: The tricycle and chair were removed by a member of the staff at the time of survey.

3. The Mother Joseph Room was observed at 8:45 a.m. on 10/13/10. A microphone stand and a cork board (18 inches by 24 inches) were found located in the means of egress from the room near the internal stairs. These items were immediately removed by staff at the time of survey.

Based on observations and discussions with staff on October 14, 2010, the battery backup emergency lighting systems were not tested as required.

Findings included:

In accordance with NFPA 101 2000 Edition, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Although emergency lighting is not required in business occupancies such as this facility; NFPA 101, 2000 Edition, states the following in Section 4.6.12.2: "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed."

The battery operated emergency lighting of the facility was reviewed at 9:30 a.m. Staff in the area indicated that the batteries were recently replaced. The facility staff were asked about having the monthly 30 minute test and annual test for the emergency lighting. Upon further investigation, the facility staff could not locate documentation for either the 30 minute or 90 minute test.

Based on observations made on October 12-14, 2010, exit sign illumination must be maintained and doors that may be considered exits that re-enter the building should contain "No Exit" signs.

Findings include:

1. An exit sign labeled as 12242 was not illuminated in the first floor lab at 2:30 p.m. Attempts to determine if the exit sign self illuminated were not successful.

2. The "Old Lithotripsy Doctor's" office was reviewed at 3:25 p.m. on 10/12/10. The exit light appeared to be illuminated at approximately 1/2 of the exit sign. All letters of the exit sign must be illuminated completely.

In accordance with NFPA 101, 2000 Edition, section 7.10.8.1 No Exit;
any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.

3. The exit near the Lewis & Clark Conference rooms was reviewed on 10/13/10 at 4:25 p.m. The "Old Smoke Room" which can be accessed through the exit vestibule requires that staff re-enter the building to exit. This door to the corridor leading to this room that is inside the vestibule should be labeled as "NO EXIT".

Based on observations made on 10/13/10, manual fire alarm pull boxes shall be maintained free and clear from obstruction and smoke detectors shall be maintained.

Findings include:

In accordance with NFPA 72, 1999 Edition, Section 2-8.2.1; manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

1. The egress corridor from the Lewis and Clark Conference rooms was reviewed on 10/13/10. A manual fire alarm box was observed to be partially obstructed by a collapsible coat rack. The rack was later moved by staff at the time of survey.

2. The clean side of laundry was reviewed at 9:40 a.m. on 10/13/10. A cart overflowing with bags of laundry in it was blocking access to the manual fire alarm box.

3. The transfer switch room was observed on 10/13/10 at 10:41 a.m. A manual fire alarm box was observed without a cover in the hard lid ceiling.

4. Room G049 was observed on 10/13/10 at 10:57 a.m. The hard lid ceiling installed in the room contained an electrical box for a smoke detector. The smoke detector had been removed and no cover existed on the box.

Based on observation and staff interview on October 14, 2010, the facility failed to ensure that the location of the dedicated power circuit branch servicing the fire alarm panel was permanently addressed on the alarm panel. Also, the circuit disconnecting means was not identified with a red marking.

Findings included:

In accordance with Section 1-5.2.5.2 of NFPA 72, 1999 edition; the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The main FACP for the Sletten Cancer Center was observed at 9:00 a.m. on 10/14/10. The FACP panel was labeled as to what electrical panel and breaker controlled it (Panel EG5, Breaker #14), but the circuit disconnecting means was not identified with a red marking.

Based on observation and staff interview on October 12-14, 2010, the facility failed to ensure that the location of the dedicated power circuit branch servicing the fire alarm panel was permanently addressed on the alarm panel. Also, the circuit disconnecting means was not identified with a red marking.

Findings included:

In accordance with Section 1-5.2.5.2 of NFPA 72, 1999 edition; the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

1. The main FACP for the east campus was observed at 1:45 p.m. on 10/12/10. The FACP panel was not labeled as to what electrical panel and breaker controlled it. Also, the circuit disconnecting means were not identified with a red marking.

2. The main FACP for the west campus which is located in the basement of the east campus was observed at 1:47 p.m. on 10/12/10. The FACP panel was labeled as to what electrical panel and breaker controlled it, which was panel EHP, breaker # 42, but the circuit disconnecting means were not identified with a red marking.

3. The Simplex 4100-U FACP located in room 1143 was observed at 9:25 a.m. on 10/13/10. The FACP panel was not labeled as to what electrical panel and breaker controlled it. Also, the circuit disconnecting means were not identified with a red marking.

Based on observations made on October 12-14, 2010, the fire alarm system and it's components were not being maintained per NFPA 72.

Findings include:

In accordance with NFPA 99, 1999 Edition, Section 2-1.3.2; in all cases, initiating devices shall be supported independently of their attachment to the circuit conductors.

1. A strobe and horn fire alarm device was found hanging from the alarm system wiring at 1:05 p.m. The strobe/horn device was labeled as A4 and was located on the backside of the roof penthouse.

2. During a test of the fire alarm system on 10/14/10 at 1:10 p.m., at least three strobes were found not working on the first floor. The following strobes did not flash when the alarm was silenced:
a) AV-1026,
b) AV-1012, and
c) AV-1001.

Based on staff interview and request for records on October 14, 2010, the facility failed to test the fire alarms system and conduct sensitivity tests for smoke detectors in accordance with NFPA 70, 1999 Edition and NFPA 72, 1999 Edition .

Findings included:

In accordance with 7-3.2, testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

In accordance with 7-3.2.1, detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

The fire alarm system the facility was as observed at 9:30 a.m. When asked if the fire alarm system had received inspections, testing and maintenance; the Facility Director could provide no documentation for such testing.

Based on observations made on October 12-14, 2010, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

Findings included:

In accordance with Section 19.1.1.3 of the Life Safety Code (LSC), All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities, adequate staffing, and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention and the planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building.

1. A closet in Neurodiagnostic Department was observed to be not sprinkled, as observed at 2:30 p.m. on 10/12/10.

2. Elevator #6 by the Neurodiagnostic Department was observed to be hydraulically controlled as observed at 2:35 p.m. on 10/12/10. The elevator pit was not sprinkled.

3. Room 1208-C, under the interior stairway was observed to be not sprinkled at 2:43 p.m. on 10/12/10.

4. The closet on the west wall of Registration/Admissions offices was observed at 8:10 a.m. on 10/13/10. This closet was without sprinkler coverage.

5. The closet enclosing the Automatic Teller Machine (ATM), was found to be non sprinkled as observed at 8:30 a.m. on 10/13/10.

6. The walk-in-cooler labeled C-37 was found to be eight feet by twenty feet and had one sprinkler head which was obstructed by a condenser as observed at 8:45 a.m. on 10/13/10.

7. The Transformer room by the Cameron Auditorium was not sprinkled as observed at 9:45 a.m. on 10/13/10.

8. The tunnels under the ground floor were observed at 1:06 p.m. on 10/13/10. A new section of the tunnel had been opened up by boring through the concrete wall, there were combustible materials in the area and no sprinkler coverage in this eight foot by twelve foot space.

Based on observations and interview of staff between October 12-14, 2010; the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

Findings included:

In accordance with Section 19.1.1.3 of NFPA 101, 2000 Edition; all health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities, adequate staffing, and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention and the planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building.

1. Communication Hub room 1316A was reviewed on 10/12/10 at 4:20 p.m. The room lacked sprinkler coverage. There was no lay in ceiling assembly in this room.

2. Room G236B of the Lewis Conference Room lacked full sprinkler coverage as observed on 10/13/10 at 8:30 a.m.

3. The closet across from room G047 in the Finance Center contained an insert shelving unit that blocked some of the spray pattern of the sprinkler head. The closet was approximately 3 feet wide by 10 feet long as observed on 10/13/10 at 11:03 a.m.

4. While observing the Finance Center, room G035 was reviewed on 10/13/10 at 11:11 a.m. The room was recently created with a remodel, contained a transformer, and was unsprinklered.

Based on observation made on October 12-14, 2010, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 13 and NFPA 25.

Findings included:

In accordance with Section 5-6.6 of NFPA 13 (1999 Edition), the clearance between the deflector of standard pendent and upright spray sprinklers and the top of storage shall be 18 inches or greater.

In accordance with 3-2.7.2 of NFPA 13 (1999 Edition) escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1. Soiled linen storage room 333, on the 3rd floor, had two sprinklers where there an annular space existed between the ceiling tiles and the escutcheon rings as observed at 2:06 p.m. on 10/12/10.

2. The magnetic door hold system components were tied to the sprinkler pipe above room 438 on the 4th floor at 7:30 a.m. on 10/13/10.

3. The sprinkler head in closet 450A (PT reception area closet) was blocked items placed on the top shelf of the closet. As soon as notified, the facility staff removed the items and the top shelf from the closet at 8:07 a.m. on 10/13/10.

4. The sprinkler head in ER room 18 (door marked 117) had a heavy accumulation of dust at 1:55 p.m. on 10/13/10.

5. Several chemical spray bottles were hanging from the sprinkler stand pipe/control valves in room 128, housekeeping in ER at 2:00 p.m. on 10/13/10.


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6. Room 1064-B, (a mechanical room), had a sprinkler head recessed into the corridor wall. The room was approximately five feet by five feet. The head was an upright pendant type and should have been a side pendant type for this location.

7. Room 1223 (storeroom for volunteers) had items stored which blocked spray pattern coverage for the room as observed at 2:15 p.m. on 10/12/10.

8. The Morgue walk-in-cooler had one escutcheon ring which was not tight to the ceiling tile as observed at 9:30 a.m. on 10/13/10.

9. The Compactor room had four escutcheon rings missing on the ceiling as observed at 12:40 p.m. on 10/13/10.

10. The South Tower stairwell had one sprinkler head taped over as observed at 12:50 p.m. on 10/13/10.

Based on observations made on October 14, 2010, the facility failed to maintain components of the sprinkler system in accordance with the standards of NFPA 13. And based on staff interview about the sprinkler service reports, the facility failed to maintain the automatic fire sprinkler system serving Sletten Cancer Institute in accordance with the standards of NFPA 13, 1999 Edition and NFPA 25, 1998 Edition.

Findings included:

Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution per 5-1.1(3) of NFPA 13. The removal or damage of one or more panels in a lay-in ceiling has the potential to hinder the ability of the sprinkler installed in that type of assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there due to the opening or failure of the ceiling tile, thus delaying the activation of the sprinkler to control the fire and the fire alarm system to activate.

The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary per section 2-3.4 of NFPA 25. The antifreeze solution shall be prepared with a freezing point below the expected minimum temperature for the locality per section 4-5.2.3 of NFPA 13.

1. Room 270 (Network room) was observed at 8:45 a.m. on 10/14/10. There was one two foot by two foot piece of ceiling tile out of place in this room.


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2. The facility staff reported at 11:15 a.m. on 10/13/10, that on 7/21/10, the antifreeze tested at -20 degrees Fahrenheit for Sletten Cancer Institute.

According to the National Oceanic and Atmospheric Administration (NOAA) the minimum low temperatures for Great Falls, Montana were -21 on December 7, 2009, -26 on December 8, 2009, and -23 on December 14, 2009. There was no documentation that the anti-freeze solution had been adjusted or replaced to ensure that the freezing point was below that expected for the minimum temperature for the locality.

3. The closet sprinkler head was blocked by storage in room 709, Image Recovery, at 8:10 a.m. on 10/13/10.

4. Room 435, soiled utility room, had a missing ceiling tile at 8:50 a.m. on 10/13/10.

Based on observations made on October 12-14, 2010; the automatic fire sprinkler system and components were not being maintained per NFPA 13 & 25.

Findings include:

In accordance with Section 2-2.1.1 of NFPA 25, 1998 Edition; sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

1. The elevator mechanical penthouse for the facility was reviewed at 12:55 p.m. on 10/12/10. A buildup of dust was observed on the sprinkler heads inside the room.

2. The kitchen was observed at 9:05 a.m. on 10/13/10. Two sprinkler heads near the center of the kitchen contained a buildup of link on them.

In accordance with Section 3-2.7.2 of NFPA 13, 1999 Edition; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

3. The supply room for Quick Care was reviewed at 1:50 p.m. An escutcheon ring inside the room was loosely fitted to the ceiling.

4. The first floor lab xylene distillery room was reviewed at 2:36 p.m. on 10/12/10. An escutcheon ring was loosely fitted to the sprinkler system.

5. Room 1525, a medical doctor's office, was reviewed on 10/12/20. A sprinkler head in the room lacked an escutcheon ring.

6. Room G214B, a computer training room, was reviewed on 10/13/20 at 8:15 a.m. A sprinkler head in the room had a loose escutcheon ring.

7. The Clark Conference Room was reviewed on 10/13/2010 at 8:37 a.m. The telephone closet sprinkler head was missing an escutcheon ring.

8. Clinical Engineering was inspected at 9:01 a.m. on 10/13/10. A sprinkler head in the ceiling lacked an escutcheon ring. The escutcheon was located on a table below the sprinkler head.

Based on observations made on October 12-14, 2010, the facility failed to ensure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Findings included:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 Edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 Edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

1. A free standing fire extinguisher was observed in the elevator equipment room located on the 5th floor at 4:45 p.m. on 10/12/10.

2. Fire extinguisher 44 located in 4th floor PT was manufactured in 1989. The 1995 date, the first 6-year testing of the device, could not be seen on the extinguisher. The 2001 hydrotesting and 2007 6-year maintenance testings were conducted and the labels were easily seen at 8:05 a.m. on 10/13/10.


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3. Air handling room 1088 in Accounting had one portable fire extinguisher which was not on a hanger as observed at 2:10 p.m. on 10/12/10.

4. A 3-A-40-BC portable fire extinguisher in room M-101-A (medical records storeroom) was last hydrotested in July of 2000, and received a six year maintenance test in July of 2007 as observed at 3:25 p.m. on 10/12/10. The six year maintenance should have been conducted in July of 2006 when it expired.

5. A 10-A-60 BC portable fire extinguisher in a wall cabinet in room 1801 received a six year maintenance test in July of 1999, but did not receive a hydotest until July 2006 as observed at 3:28 p.m. on 10/12/10. The hydrotest was due at the end of the sixth year in July of 2005.

6. The portable fire extinguisher (#232) located at GLS 106123, had the hydrotest maintenance sticker directly over the six year maintenance sticker, and one could not track the history for the extinguisher, as observed at 3:55 p.m. on 10/12/10.

Based on observations made on October 14, 2010, the facility failed to ensure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Findings included:

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

The portable fire extinguisher found in the pool water treatment room was manufactured in 1984. The hydrotest and 6-year maintenance stickers were directly on top of each other at 7:55 a.m. on 10/14/10. One could not track the history for the extinguisher.

Based on observations made on October 12-14, 2010; the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Findings included:

In accordance with Section 4-3.2 of NFPA 10, 1998 Edition; periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

1. The pharmacy was observed on 10/13/10 at 9:15 a.m. A portable fire extinguisher was not accessible because of items placed in front of it.

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

2. The portable fire extinguisher located in mechanical room #237 was observed at 1:34 p.m. on 10/14//10. The extinguisher had been placed in service in 1997 and a six year maintenance test was performed in March of 2003. The hydotesting on the portable extinguisher was not done until February of 2010, 11 months after the expiration date of March, 2009.

3. The cardboard bailer and bio hazard waste accumulation area in room 300 were observed on 10/13/10 at 10:00 a.m. There was no fire extinguisher in the room or within five feet of the room. The facility mounted a fire extinguisher at the time of survey.

Based on observation and interviews made on October 14, 2010, the facility failed to perform monthly inspections and maintain access to the portable fire extinguishers per there requirements of NFPA 10.

Findings included:

In accordance with NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, specific inspections must be done. Section 4-3.2 states that periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

While Section 4-3.1 states that fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

1. Two fire extinguishers in the egress path were reviewed for the facility at 9:50 p.m. Both extinguishers lacked proper monthly inspections. The annual inspection had been conducted by a fire protection contractor.

2. A cabinet mounted portable extinguisher was observed at 9:52 p.m. near the full size gym and racquetball courts. A "beer" dispensing machine was located directly in front of the fire extinguisher at the time of survey. The Facilities Director moved the cart at the time of survey.

Based on observations made on October 12-14, 2010; the facility failed to maintain the heating, ventilation, and air-conditioning system in accordance with Sections 19.5.2.1, and 9.2.1 of NFPA 101, Life Safety Code (LSC) and NFPA 90A.

Findings included:

In accordance with Section 5-3.1 of NFPA 90A, 1999 Edition; controls related to fan shut down and automatic damper operation shall be tested for compliance with the requirements of this standard.

A fire drill was conducted at 1:30 p.m. on 10/14/10 to check fire and smoke dampers on three floors of the West Campus building. A fire damper in the mechanical room #237 was observed for proper closure. The air handling system failed to shut down properly at this damper location.

Based on exercise of fire doors protecting gravity linen/trash chutes made on October 12-14, 2010, the facility failed to assure that there is a self-closing door at the discharge opening of the chute in accordance with NFPA 82, 1999 Edition.

In accordance with 3-2.2.9 of NFPA 82 gravity linen/trash chutes shall be protected at the discharge level by an approved automatic-closing or self-closing one-hour fire door suitable for Class B openings.

Findings included:

1. The trash chute room (1213) was observed at 2:20 p.m. on 10/12/10. The sliding door on the chute was not self-closing.

2. The laundry chute in room 1802 was observed at 3:30 p.m. on 10/12/10. The chute door was not self-closing.

3. The trash chute across from Medical Records was observed at 7:50 a.m. on 10/13/10. The chute doors were not self-closing.

4. The laundry chute across from Medical Records was observed at 7:51 a.m. on 10/13/10. The chute doors were not self-closing.

5. The laundry chute by Sterile Processing was observed at 10:20 a.m. on 10/13/10. The chute door was not self-closing, nor was it latched at the time it was observed.


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6. The laundry chute door on the south side of ER, with a self closure device (90 minute fire rated), would not positively latch when exercised at 2:11 p.m. on 10/13/10.

Based on observations made on October 12-14, 2010, the facility failed to ensure that items were not stored or left in the exit corridor system unattended for periods exceeding 30 minutes.

Findings included:

Items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor per Centers for Medicare and Medicaid Services Survey and Certification letter 04-41.

The exit corridor next to the Neurodiagnostic Department was observed at 2:22 p.m. on 10/12/10. The cardboard recycling bins were being stored in the exit corridor in this area.

Interview with facility staff regarding the storage in the exit corridor revealed that the bins have always been there.

Based on observation and interview with maintenance staff made on October 12-14, 2010, the facility failed to provide documentation that curtains in the basement met the Standards of NFPA 13, for flame spread ratings.

Findings included:

In accordance with Section 19.7.5.1 of NFPA 101, 2000 Edition; draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of Section 10.3.1 of NFPA 101.
Exception: Curtains at showers.

Room 1225 (Volunteer managers office) was observed at 2:10 p.m. on 10/12/10. There were sheer drapes hanging on the corridor windows to this office. There was no tag attesting that they carried a flame spread rating, nor any documentation that they had been treated with a material which was rated.

Interview with facility staff at a team meeting at 4:45 p.m. on 10/12/10 revealed that possibly the volunteer manager brought the drapes from home and hung them.

Based on observations made on October 12-14, 2010; the facility failed to provide curtains that were inherently fire retardant or had been treated with a spray to make them as such.

Findings include:

The Outpatient Childrens Therapy area was reviewed at 3:10 p.m. A set of white curtains used to conceal a storage area were found. The curtains did not contain information that they meet NFPA 701 or were inherently flame retardant nor were they treated with a fire retardant fabric spray.

Based on observation made on October 12-14, 2010, the facility failed to ensure that nonflammable gas cylinders were stored in accordance with the standards of NFPA 99.

Findings included:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99 (1999 Edition) freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

In accordance with NFPA 99, Sect. 4-3.1.1.2(a)(4) requires that the electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code (NEC), for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

1. An "E" size cylinder of oxygen was observed to be unsecured and in upright freestanding position in the ICU near room 5116 on the 5th floor of the surgical tower at 9:25 a.m. on 10/13/10.

2. A carbon dioxide cylinder was observed to be unsecured and in upright freestanding position in the medical gas room, marked 2517, in OR at 10:30 a.m. on 10/13/10. The cylinder was located in front of an electrical outlet approximately 14 inches from the floor.

3. The medical gas storage room door, marked 155B, was impeded by a cylinder rack and could not be closed at 2:13 p.m. on 10/13/10.

Based on observations made on October 12-14, 2010; compressed gas cylinders must be secured from falling and oxygen storage areas must have proper signage.

Findings include:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99 (1999 Edition) freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

1. At 3:30 p.m., room 1300 was reviewed. This mechanical room contained various electrical equipment and three "K" size or bigger helium tanks that were unsecured.

In accordance with NFPA 99, 1999 Edition, Section 8-3.1.11.3 Signs; a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

2. The oxygen storage room next to G120 was observed on 10/14/10 at 8:10 a.m. The door to the room did not contain signage in accordance to NFPA 99.

Based on observations made on October 12-14, 2010, the facility did not appropriately label a medical gas shut off valve as to its use.

Findings included:

In accordance with 4-3.5.4.2 of NFPA 99 (1999 Edition) shutoff valves for medical gases shall be labeled to reflect the rooms that are controlled by such valves.

1. The medical gas shutoff valve panel near room #6 in OR lacked labeling to address the rooms that it served at 10:21 a.m. on 10/13/10.

2. The medical gas shutoff valve panel near room #5 in OR lacked labeling to address the rooms that it served at 10:41 a.m. on 10/13/10.

Based on observations made on October 12 -14, 2010; the facility failed to properly designate the branch functions of each automatic transfer switch.

The findings include:

Type I essential electrical systems are comprised of two separate systems, being the emergency system and the equipment system per section 3-4.2.2.1 of NFPA 99, 1999 edition. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

The multiple transfer switches in electrical room G105F were examined at 10:40 a.m. on 10/13/10. Several transfer switches were housed in the room with the following numbers on them: 10-M3-084-0, 10-M3-085-0, 10-M3-086-0, 10-M3-087-0, 10-M3-088-0. There was no designation on any of the transfer switch denoting whether that particular switch served the emergency (life safety and critical functions) branch, the equipment branch or if the systems had been further isolated into separate Life Safety and Critical branches.

Based on observations made on October 12-14, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings included:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

1. A microwave was plugged into a surge protector in room 843, a staff kitchen as observed at 12:50 p.m. on 10/12/10 on the 8th floor. As soon as notified, the facility staff unplugged and removed the microwave from this location.

2. The electrical panel in room 393 on the 3rd floor was blocked by a clothes rack and furniture. As soon as notified, the facility staff removed the items blocking electrical panel OBL.

3. The Chief Risk Officer's office in Risk Management was observed at 1:35 p.m. on 10/12/10. Surge cords were found in series under one desk.

Note: One surge cord was removed from the location and the deficiency was corrected at the time of the survey process.

4. The Mercy Flight Dispatch room was observed at 1:40 p.m. on 10/12/10. A microwave and a small refrigerator were plugged into a surge cord.

5. The Map room was observed at 1:55 p.m. on 10/12/10. There were two APC units in use with surge cords plugged into them in series.

6. Room 1227 (air handling room) was observed at 2:08 p.m. on 10/12/10. One electrical box was found without its cover.

7. Room 1229 was observed at 2:50 p.m. on 10/12/10. Surge cords were found in series along the east and west walls.

8. Room 1801 was observed at 3:27 p.m. on 10/12/10. Three surge cords were found in series in this room.

9. The Patient Advocate office was observed at 7:35 a.m. on 10/13/10. There were two surge cords in series under a desk.

10. Medical Records break room was observed at 7:45 a.m. on 10/13/10. A microwave oven and refrigerator were plugged into a surge cord.

11. Room 1003 in Patient Registration was observed at 8:00 a.m. on 10/13/10. The Lexmark copier was plugged into an extension cord.

12. The Kitchen Chef's office was observed at 8:50 a.m. on 10/13/10. A surge cord was not flat on the floor or affixed to the wall, but dangling on the weight of the cord.

13. The Chief Clinical Officer's desk in Administration was observed at 9:55 a.m. on 10/13/10. There was an extension cord in use in this area.


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14. Breakers marked 40-42 were in on positions in the electrical panel L-OR1 in the operating room #1 at 10:09 a.m. on 10/13/10, however, they were marked as "spare" on the panel directory.

15. The warmer and the blood bank refrigeration units were plugged into a surge protector in the pump room in OR at 10:10 a.m. on 10/13/10.

16. A refrigerator was plugged into a surge protector in Am Admit/OR offices at 11:25 a.m. on 10/13/10.

17. A refrigerator was plugged into a surge protector in the OR staff lounge at 11:34 a.m. on 10/13/10.

18. Two toasters were plugged into an extension cord, then the extension cord was plugged into a surge protector in the OR staff lounge at 11:36 a.m. on 10/13/10.

19. The circuit breaker 41 in electrical panel ER 1C1L was in on position and marked as spare in the panel directory in ER at 1:47 p.m. on 10/13/10.

20. The receptacle with exposed electrical wires in the OR CT support equipment room, 211, had a missing cover at 1:43 p.m. on 10/13/10.

21. A refrigerator was plugged into a surge protector near the south exit of Laboratory on the second floor at 3:30 p.m. on 10/13/10.

22. A receptacle with exposed electrical wires in Pharmacy Informations, 2008, has a missing cover at 3:40 p.m. on 10/13/10.

23. Circuit breakers 6-12 were in the on position in panel L in the robot packaging room in Pharmacy. The panel directory was blank corresponding to these breakers.

Based on observations made on October 14, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, NFPA 99 or CMS interpretations.

Findings included:

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

The electrical panel in room 256 (housekeeping closet) was observed at 8:30 a.m. on 10/14/10. The panel was obstructed by a housekeeping cart.

Based on observations made on October 12-14, 2010, the facility failed to maintain the electrical system or its components in accordance with the standards of NFPA 70, 1999 Edition.

Findings included:

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

The store room in Endoscopy was observed at 3:50 p.m. on 10/13/2010. The electrical panel was blocked by stored items.

Note: The stored items were removed at the time of the survey process.

Based on observations made on October 12-14, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings included:

According to Article 384-13 of NFPA 70; all panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. NFPA 70, Article 110-22. Identification of Disconnecting Means states that each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

1. Electrical panel L5A was reviewed on 10/12/10 at 1:10 p.m. The panel contained two separate panel schedules. The correct panel schedule should be used and updated.

2. Electrical panel EM3A panel schedule was reviewed on 10/12/10. The panel schedule was not current to spare or circuits in use.

3. The panel schedule for electrical panel L3A was received on 10/12/10. Three circuits were in the off position, but were not labeled as spare.

4. Electrical panel CP1B was reviewed on 10/12/10. The panel is requiring an update to the current panel schedule.

5. Electrical panel 3P4HW 208Y/120V was reviewed on 10/12/10. The panel is requiring an update to the current panel schedule.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle. Power strips, if used, must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".


6. The first floor lab break room was observed on 10/12/10. The break room microwave was plugged into a surge protector. Microwaves and similar appliances must be directly plugged into a wall outlet.

7. The lab transcription area was reviewed on 10/12/10. The south west cubical in the room contained two surge protectors plugged in series or daisy chained.

8. The Medical Records/Transcription Dictation Area was reviewed at 8:15 a.m. on 10/13/10. An extension cord and multiple plug adapter were in used at computer station WMRPC21.

In accordance with 370.28(c) of NFPA 70 (1999 edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110.

10. The Rehabilitation bathroom was observed on 10/12/10 at 3:40 p.m. A call light in the bathroom lacked a cover plate where wiring for the call light originated.

11. Room 1342, which was recently changed into a medical doctors office, was missing 5 cover plates when observed at 3:56 p.m. on 10/12/10. One plate was for a four plug electrical outlet and the remaining four were for various single outlet or junction boxes.

12. Room 1345 was reviewed at 4:10 p.m. on 10/12/10. There were three electrical covers missing, two were for outlets and one for a light switch.

13. Room 1345A was observed at 4:12 p.m. on 10/12/10. Three electrical cover plates were missing in the room.

14. The Medical Records/Transcription Dictation Area was reviewed at 8:15 a.m. on 10/13/10. The room contains a low voltage junction box that was not covered.

15. The second floor bank of elevators were observed on 10/13/10 at 1:00 p.m. Elevator #1 had an electrical junction box that was missing a cover near the roll down door.

16. During inspection of the smoke barrier on second floor, an electrical box was found with two wires not connected coming out of apparently supporting the fire alarm. This observation was made on 10/13/10 at 1:31 a.m.

17. The first floor smoke barrier was reviewed on 10/13/10 at 2:10 p.m. An open junction box was found in the smoke barrier that was apparently part of the PROXY card system.

18. The smoke barrier near room G030 was reviewed at 8:46 a.m. on 10/14/10. Two uncovered junction boxes were found near the toilet in the room.

19. The smoke barrier near room G014 was reviewed at 8:46 a.m. on 10/14/10. An uncovered junction box for damper wiring was found near the supply and return air.

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

20. The laundry area was reviewed on 10/13/10 at 9:44 a.m. The main power disconnect for the washing machine was blocked with various supplied for laundry.

21. Electrical panel LXR was blocked by a wheeled cart as observed on 10/13/10 at 9:57 a.m. Facility staff moved the cart at the time of survey.

Based on observation and interview with staff on October 12-14, 2010; the facility failed to notify proper authorities when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period.

Findings include:

While touring the facility for life safety code compliance, facility staff indicated that various areas were under construction on the ground level. While in room G106 where construction staging was being done, it was noted that the facility had several ceiling tiles out of place. From discussion with staff, the construction project ran for 8 to 10 hours a day and then security would conduct fire watch on off hours. This fire watch was not report to the authority having jurisdiction at 406-444-4170 as is required.

Based on observations made on October 12-14, 2010, the facility failed to maintain the 2-hour fire resistance of fire barrier walls and doors in fire walls.

Findings included:

1. Room 1202-C (a locked closet) on the exit corridor in the Maintenance department was observed at 2:00 p.m. on 10/12/10. There was a six inch by twelve inch penetration above the corridor door into the space above the corridor which was not sealed.

2. The electrical subpanel on the north wall of room 1518 was observed at 3:00 p.m. on 10/12/10. The subpanel was not sealed for twelve penetrations through the 2-hour wall between the phone room and the mechanical room.

3. The exit stairwell by the Sterile Processing Department was observed at 10:30 a.m. on 10/13/10. New wiring had been installed in the stairwell for expanded cell phone coverage. The 2-hour wall between the exit corridor and the stairwell had a penetration where the wiring had not been sealed.

4. The room under the Cameron Auditorium was observed at 9:50 a.m. on 10/13/10. There were penetrations through the two hour ceiling in this room exposing wood construction in the interior spaces.

5. The door leading to the tunnels near the south tower was observed at 1:07 p.m. on 10/13/10. The fire wall above the door had two penetrations through it. One was for the sprinkler pipe and the remaining was for a half inch conduit which was not sealed.


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6. A 3-hour fire wall had an unsealed penetration around an open ended conduit above the rated double doors, where ER connecting tunnel met the South tower as observed at 1:30 p.m. on 10/13/10.

Based on observations on October 12-14, 2010, the facility failed to maintain the fire and smoke resistance rating of wall and ceiling assemblies.

Findings included:

1. Room 1202-B (a locked closet) on the exit corridor in the Maintenance department was observed at 1:40 p.m. on 10/12/10.
a) There were three open penetrations in the east wall of this room, and
b) three open penetrations in the west wall of this room.
All were penetrations from where conduits had been removed and the gypsum board had not been properly sealed.

2. Room 1202-A (a locked closet) on the exit corridor in the Maintenance department was observed at 1:55 p.m. on 10/12/10.
a) There were three penetrations in the east wall of this room,
b) There was one penetration in the west wall of this room, and
c) There were two penetrations in the south wall of this room which had not been properly sealed.

3. Room 1805 (a network server room) was observed at 4:00 p.m. on 10/12/10. There were two ceiling tiles missing in this server room.

4. The DuFresne classroom was observed at 4:30 p.m. on 10/12/10. The DaLite screen in this room was installed through a hole in the ceiling tile. There was no sprinkler or smoke detection above the ceiling tile in this room.

5. The Hub room in Medical Records was observed at 7:40 a.m. on 10/13/10. The following deficiencies were found:
a) a ceiling tile was missing, and
b) the wall in this room had a two inch hole.

6. The Audio/Video (AV) storeroom in the Cameron Auditorium was observed at 9:40 a.m. on 10/13/10. The walls and ceiling in this room were not finished and had no rating.

7. The corridor near the Nutrition office was observed at 2:35 p.m. on 10/13/10. One ceiling tile had a two inch penetration at this location.


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8. Room 570C had a missing ceiling tile at 4:10 p.m. on 10/12/10 on the 5th floor.

9. Rooms 515A and 515B had several missing ceiling tiles at 4:15 p.m. on 10/12/10 on the 5th floor.

10. Room 393 had two missing ceiling tiles at 3:01 p.m. on 10/12/10 on the 3rd floor.

11. Patient room 10 had a missing ceiling tile at 3:04 p.m. on 10/12/10.

12. The old open heart room had four missing ceiling tiles at 3:06 p.m. on 10/12/10 on the 3rd floor.

13. Elevator #17's lobby ceiling tile had a two inch by four inch hole on the 4th floor (PCU)of the surgical tower.

Based on observations on October 12-14, 2010, the facility failed to maintain the fire and smoke resistance rating of wall and ceiling assemblies.

Findings include:

1. The first floor east x-ray room was observed on 10/12/10 at 1:30 p.m. Two, two foot square tiles were missing in the suspended ceiling assembly.

2. The first floor lab blood draw area was reviewed at 3:20 p.m. on 10/12/10. A condensate drain was run through the tile ceiling and the ceiling tile was not notched to accommodate the drain. The tile was approximately 1/2 inch above the ceiling assembly where the drain passed through.

3. Mechanical room 1300 was observed on 10/12/10 at 3:30 p.m. Two ceiling tiles were out of place in the room.

4. The old MRI Computer Room was observed at 3:38 p.m. on 10/12/10. Several ceiling tile were out of place in the room.

5. Room 1344 was observed on 10/12/10 at 4:05 p.m. Some of the ceiling tile in the room was either missing or out of place.

6. Room 1369 was reviewed at 4:00 p.m. on 10/12/10. A ceiling tile in the room was incomplete where electrical service had been run through it.

7. The Lewis & Clark exit vestibule to the north was observed on 10/13/10 at 8:41 a.m. A ceiling tile was out of place at the time of survey and replaced by staff during the survey process.

8. Clinical Engineering was inspected at 9:01 a.m. on 10/13/10. The ceiling grid had one section of ceiling support hanging down from one end and two of the tiles not fitted tightly.

Based on observations which were made on October 12-14, 2010, the facility failed to maintain the fire resistive construction of all corridor walls in order that they would be resistant to the passage of smoke. In sprinklered buildings, wall partitions are only required to resist the passage of smoke, 19.3.6.1.

Findings included:

In accordance with Sections 19.3.6.1, 19.3.6.2.1, 19.3.6.5 of NFPA 101, 2000 edition; corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.)

The sprinkler chase room 472 on the 4th floor had an unsealed penetration that extended above the room door into exit corridor at 7:41 a.m. on 10/12/10.

Based on observations which were made on October 12-14, 2010, the facility failed to maintain the fire resistive construction of all corridor walls to prevent the passage of smoke. In fully sprinklered buildings, wall partitions are only required to resist the passage of smoke, 19.3.6.1.

Findings included:

In accordance with Sections 19.3.6.1, 19.3.6.2.1, 19.3.6.5 of NFPA 101, 2000 edition; corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.)

The maintenance shop G105 was reviewed at 10:30 a.m. on 10/13/10. An unsealed penetration to the corridor existed in the room.

Based on observation made on October 12-14, 2010, the facility failed to ensure that there were no impediments to closing or using a corridor door opening onto the exit corridor system.

Findings included:

Hold-open devices that release when the corridor door is pushed or pulled shall be permitted per Section 19.3.6.3.3 of NFPA 101 LSC, (2000 Edition). However, a hold-open device can not be used on doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, fire barrier or hazardous area enclosure unless they conform with Section 7.2.1.8.2 of NFPA 101 LSC, (2000 Edition). Doors cannot be blocked open by furniture, door stops, chocks, wedges, or devices that necessitate manual releasing action to close the door.

The self closure of the Equipment Depot corridor door on the 7th floor had a magnetic hold device that was interfaced with the fire alarm system (opened onto the exit corridor). When exercised, the door closure was inhibited by 4 sets of metal hooks over the door at 1:48 p.m. on 10/12/10. The facility staff removed all but one of the metal hooks and the door would positively latch and close.

Based on observation made on October 12-14, 2010, the facility failed to ensure that there were no impediments to closing or using a corridor door opening onto the exit corridor system.

Findings include:

The corridor door to room 311 was closed on 10/12/10. The door would not latch as required.

Based on observations made on October 12-14, 2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings included:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with Section 8.2.5 of NFPA 101. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101; pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The northwest corner of the Maintenance Shop was observed at 1:35 p.m. on 10/12/10. An electrical box cover was missing on a piece of conduit which extended to the level above.

2. Room 1200 (a mechanical room) in Maintenance was observed at 2:05 p.m. on 10/12/10. A copper pipe above an air-conditioning unit was not sealed as it passed through the ceiling to the level above.


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3. An unsealed floor penetration (open end of a two inch conduit) was observed in the north east corner of the Communications room on 8th floor at 12:44 p.m. on 10/12/10.

Based on observations made on October 14, 2010, the facility failed to seal penetrations through floors or in vertical shafts.

Findings included:

In accordance with Section 3.1.1 of Chapter 38 (New Business Occupancies) Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

In accordance with Section 8.2.5.2 of the Life Safety Code (LSC), Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance of the barrier.

Room 310 of the Sletten Cancer Center was observed at 8:15 a.m. on 10/14/10. The following unsealed penetrations were noted:
a) Three open penetrations from this room to the penthouse above which were all two inch conduits, and
b) One open two inch conduit between room 310 and the basement level which was not properly sealed.

Based on observations made on October 12-14, 2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

1. The Simulator Control Room was observed at 4:12 p.m. on 10/12/10. An electrical control box still in the room contains conduits from the floor below (Ground Floor). The penetrations were unsealed.

2. Mechanical Room MG001 was observed at 8:50 a.m. on 10/13/10. The room contained three unsealed vertical penetrations to the floor above. They consisted of one, two inch and two, two and one half inch unsealed holes.

3. The first floor smoke barrier was observed near the old radiology door at 2:31 p.m. on 10/13/10. At least two unsealed penetrations were seen to the second floor above.

4. Three vertical plumbing penetrations were seen to the floor above near the Rehabilitation Equipment Depot as observed on 10/13/10 at 3:29 p.m. Two were black sewer lines while the other was a copper water line.

Based on observation made on October 12-14, 2010, the facility failed to ensure that all access to exits were properly marked by readily visible signs.

Findings included:

In accordance with Section 7.10.1.2 of the LSC, exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

1. The DuFresne classroom was observed to be twenty four feet by forty six feet with only one exit to the east, at 4:32 p.m. on 10/12/10. There was another way out of this space to the west but the door did not have an exit sign.

2. The classroom identified as 5-A and 5-B was observed at 4:45 p.m. on 10/12/10. The classroom had an exit sign at the east end of the exit corridor but did not have an exit sign at the west door.

3. The north exit corridor directly behind Registration was observed at 8:20 a.m. on 10/13/10. The exit sign directed one to enter the stairway instead of exiting the outside double doors around the column.


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4. The court yard door at the surgery waiting area lacked a NO EXIT sign at 11:32 a.m. on 10/13/10. This enclosed court yard and the secondary door into it leads to a staff meeting lounge on the other side of the court yard.

5. The two exit doors on the west side of the OR core lacked an illuminating exit sign at 10:21 a.m. on 10/13/10.

6. The corridor exit location near the operating room 7 in OR was reviewed. At this juncture, this south stairway was identified as an exit stairway after the smoke barrier doors (interfaced with the fire alarm system). In an emergency event, these double doors would close and the occupants could not see the exit sign on the other side of the doors. There was no exit sign above these smoke barrier doors. Additionally, the exit sign after the smoke barrier doors pointing at the south stairway was not visible to the occupants traveling from the opposite side (north to south).

Based on observation made on October 12-14, 2010, the facility failed to ensure that all access to exits were properly marked by readily visible signs.

Findings include:

The first floor lab was reviewed at 2:30 p.m. on 10/12/10. Two signs were placed on the door marked with an exit sign as follows: "Please DO NOT OPEN when cold and/or windy" and "Do Not Open from 0500 to 1200". The door had an illuminated exit sign above it indicating it was a required exit.

Based on observations made on October 12-14, 2010, the facility failed to maintain the fire resistive rating of fire/smoke barrier walls.

Findings included:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The smoke barrier wall above the doctor's dictation on the 8th floor had an unsealed penetration around a conduit housing three data cables at 1:15 p.m. on 10/12/10.

2. The smoke barrier wall above the double doors on the West corridor of the 8th floor had an unsealed penetration around fiber communication cables at 1:20 p.m. on 10/12/10.

3. The smoke barrier wall above the double doors on the west corridor of the 7th floor had an unsealed penetration around a conduit housing communication cables at 1:45 p.m. on 10/12/10.

4. The smoke barrier wall above the fire rated double doors near room 369 on the 3rd floor had an unsealed penetration at 2:33 p.m. on 10/12/10. The penetration was unsealed on both sides.

5. The smoke barrier wall above fire rated (90 minute) door at Med-South nurse station on the 3rd floor had an unsealed conduit penetration at 2:36 p.m. on 10/12/10.

6. The smoke barrier wall above the ceiling tiles in cubicle #7 in the old observation area on the 3rd floor had an unsealed penetration around a conduit at 2:38 p.m. on 10/12/10.

7. The smoke barrier wall above the double doors near room 375 outside the old CCU had a penetration around a two inch open ended conduit at 2:53 p.m. on 10/12/10.

8. The smoke barrier wall near room marked 4109 on the 4th floor of the surgical tower had a two inch thick previously sealed penetration that required additional fire rated sealant at 8:50 a.m. on 10/13/10.

Note: All of these penetrations were sealed during the survey after the maintenance department was notified.

Based on observations made on October 12-14, 2010, the facility failed to maintain the fire resistive rating of fire/smoke barrier walls.

Findings included:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The second floor smoke barrier that runs along the east end portion of the north wall of room 217 Clean Utility was observed on 10/13/10 at 1:45 p.m. The smoke barrier was not complete around both a structural beam and duct work.

2. The first floor corridor smoke barrier across from room 1501 was observed on 10/30/10 at 1:55 p.m. An approximately one inch copper pipe passed through the smoke barrier and was unsealed as it passed through the gypsum wallboard.

3. The first floor corridor smoke barrier near the mens' and women's locker rooms was observed on 10/13/10 at 2:10 p.m. The smoke barrier wall contained an unsealed one inch hole.

4. The first floor corridor smoke barrier east of room 1313 but before the barrier goes to the south was observed on 10/13/10 at 2:15 p.m. Two unsealed holes were found within the first five feet from the corner of the wall as follows:
a) an approximately two inch by ten inch hole, and
b) one inch unsealed hole.

5. The first floor smoke barrier near the old radiology door was observed at 2:31 p.m. on 10/13/10. The wall contained several unsealed penetrations through the smoke barrier.

6. The first floor smoke barrier near room 1314 was reviewed at 2:41 p.m. on 10/13/10. A cut off, unsealed open ended conduit penetrated the smoke barrier.

7. The first floor smoke barrier near 1307 Restroom was observed on 10/13/10 at 2:45 p.m. Two copper pipes with a foam insulation on them penetrated the smoke barrier and were not sealed as they went through the barrier.

8. The first floor smoke barrier near room 1306 Cardio Rehabilitation was observed on 10/13/10 at 2:50 p.m. Three unsealed penetrations existed through the smoke barrier as follows:
a) an one inch copper pipe,
b) a two inch sewer pipe, and
c) an one inch open hole.

9. The first floor smoke barrier near room 1226 was observed on 10/13/10 at 2:51 p.m. A one inch unsealed penetration existed through the smoke barrier.

10. The first floor smoke barrier near room 1301 was observed on 10/13/10 at 2:55 p.m. A three quarter inch unsealed penetration existed through the smoke barrier were piping had been removed.

11. The first floor smoke barrier near room 1300 was observed on 10/13/10 at 3:00 p.m. Three unsealed penetrations were found in the smoke barrier as follows:
a) one open ended sleeve where wires passed through, and
b) two condensate lines where they penetrated the smoke barrier.

12. A waste water pipe penetrated the smoke barrier near the Rehabilitation Equipment Depot as observed on 10/13/10 at 3:29 p.m.

13. The Facilities Staff corridor smoke barrier was reviewed on 10/14/10 at 8:20 a.m. A pipe sleeve had been sealed in the past but the fire stop material was in need of a second application. The sleeve was directly about the double doors.

14. The smoke barrier near room G101 was reviewed at 8:25 a.m. on 10/14/10. A large electrical conduit was unsealed to the passage of smoke as wires entered the conduit.

15. The smoke barrier near room G038 was reviewed at 8:44 a.m. on 10/14/10. An electrical sleeve through the smoke barrier with no wires in it was unsealed to the passage of smoke.

16. The smoke barrier near room G037 was reviewed at 8:46 a.m. on 10/14/10. A 12 to 18 inch round duct was cut off at approximately six to 12 inches before it entered the smoke barrier. The ducting seemed to be abandoned.

17. The smoke barrier near room G022 was reviewed at 8:50 a.m. on 10/14/10. Four, two inch electrical sleeves with wires inside were not filled to resist the passage of smoke from one smoke barrier to another.

18. The smoke barrier near room G030 and in the corridor was reviewed at 8:46 a.m. on 10/14/10. Five open ended sleeves with wires inside were not filled to resist the passage of smoke from one smoke barrier to another.

Based on observation and exercising of the doors on October 12-14, 2010, the facility failed to ensure that smoke barrier doors closed tightly to resist the passage of smoke.

Findings included:

1. Elevator lobby doors with fire rating of 90 minutes and with a magnetic hold device were exercised at 8:21 a.m. on 10/13/10 at the north end of the PCU, surgical tower. The doors would not positively latch when released from the magnetic hold device. The doors were exercised several times. The doors were repaired during the course of the survey.

2. The fire rated smoke barrier doors with a magnetic hold device (interfaced with the fire alarm system) near the operating rooms 5 and 6 were blocked by a utility cart in the core of OR. At 10:11 a.m. on 10/13/10, the utility cart was removed by a staff member after being notified, and the doors were released from the magnetic hold device. The doors would not latch positively.

3. The fire rated smoke barrier doors with a magnetic hold device (interfaced with the fire alarm system), located near the operating rooms 6 and 7 in OR, would not positively latch when exercised at 10:15 a.m. on 10/13/10.

4. The fire rated smoke barrier doors with a magnetic hold device (interfaced with the fire alarm system), located near the operating rooms 4 and 5 in OR, would not latch positively when exercised at 10:40 a.m. on 10/13/10.

Based on observations made on October 12-14, 2010, the facility failed to maintain or establish the fire rated protection for hazardous areas.

Findings included:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

Hazardous areas must be separated from non-hazardous areas with one hour rated wall and ceiling assemblies.

1. The Soiled Laundry room was observed at 10:40 a.m. on 10/13/10. The southeast corner of this room had five conduits which were not sealed, two were pneumatic tubes, two were steam pipes, and the remaining was a smaller conduit.

2. The Boiler room was observed at 11:15 a.m. on 10/13/10.
a) The west wall of the mezzanine in this room had a penetration above the exit door into the second level of the hospital which was an open two inch conduit,
b) The north wall of the boiler room had four penetrations in the brick wall. One was at a brace which extended through the brick wall while one was a loose brick at about the midpoint of the mezzanine. Finally,there were two steam pipes which were not sealed in the northeast corner of the mezzanine.

3. The Chiller room was observed at 11:30 a.m. on 10/13/10. The door between the Chiller room and the Electrical room was not self-closing at the one-hour wall. The door was properly rated for the opening.

4. The enclosed catwalk room above the Electrical room was observed at 11:35 a.m. on 10/13/10. There were two unsealed conduits between the Chiller room and the room above the Electrical room. One was an unsealed two inch conduit and the remaining was a three quarter inch conduit.

5. The north wall of the Chiller room which separates the Chiller room from the Boiler room was observed at 11:45 a.m. on 10/13/10. There were seven penetrations in this wall, six were open conduits, and the remaining was at a brace.


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6. The west mechanical room on the 5th floor had an open ended conduit penetrating through the wall by ACH 5-3 at 4:10 p.m. on 10/12/10.

7. Room 391, the mechanical room on the 3rd floor, had an unsealed conduit penetrating through the corridor wall above the room door at 3:02 p.m. on 10/12/10.

Based on observations made on October 14, 2010, the facility failed to assure that a set of corridor doors to a hazardous area were self-closing.

Findings included:

In accordance with Section 3.2.1 of Chapter 38 (New Business Occupancies), hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4 of the Life Safety Code (LSC).

In accordance with Section 8.4.1.3 of the LSC, Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic closing in accordance with Section 7.2.1.8.

The corridor door to the soiled linen room was exercised at 8:10 a.m. on 10/14/10. There were no self-closing devices on the corridor doors to the hazardous area.

Based on observations made on October 12-14, 2010, the facility failed to maintain or establish the fire rated protection for hazardous areas.

Findings included:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 Edition; doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

1. Room 1343A was reviewed at 3:50 p.m. on 10/12/10. The room was empty with exception of two, five gallon containers of a corrosive liquid and nine lead acid type batteries. The room lacked self closures required of a hazardous storage area.

2. The Linear Accelerator Room 1387A was reviewed at 4:15 p.m. on 10/12/10. The control room door lacked a self closure mechanism as the room was being used for storage.

Based on observations made on October 12-14, 2010, all vertical openings such as stair towers are contained with a fire resistant rating.

Findings include:

In accordance with Section 7.1.3.2.1 of NFPA 101, 2000 Edition; where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.

1. The second floor level of the northeastern stair tower was observed at 2:01 p.m. on 10/12/10. A horizontal hole was created when piping was removed near room 211/212. The hole was repaired while the surveyor was still in the building.

2. The first floor level of the center stair tower near room 1502C was reviewed on 10/12/10 at 2:10 p.m. Two, three inch holes through the two hour construction of the stair tower were noted. Piping had been removed and the holes left unfilled. The holes were repaired while the surveyor was still in the building.

3. The ground level of the south stair well near room G035 was reviewed on 10/14/10 at 9:15 a.m. There were at least two open penetrations one inch square in size and some unsealed open ended conduits in the 2 hour barrier.

Based on observations made on October 12-14, 2010, the means of egress was reduced by items stored in the means of egress.

In accordance with Section 7.1.10.1 of NFPA 101, 2000 Edition, means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings include:

1. Outpatient Pediatric Therapy was observed on 10/12/10 at 3:09 p.m. Two exercise mats were found outside the egress door (12533). The mats were water soaked and were taking up approximately 1/3 to 1/4 of the egress path to the public way.

2. The Outpatient Pediatric Therapy corridor, labeled as 1135, was reviewed on 10/12/10. The exit was partially blocked with three items:
a) a gurney,
b) a toddler tricycle, and
c) a chair with wheels.
Note: The tricycle and chair were removed by a member of the staff at the time of survey.

3. The Mother Joseph Room was observed at 8:45 a.m. on 10/13/10. A microphone stand and a cork board (18 inches by 24 inches) were found located in the means of egress from the room near the internal stairs. These items were immediately removed by staff at the time of survey.

Based on observations and discussions with staff on October 14, 2010, the battery backup emergency lighting systems were not tested as required.

Findings included:

In accordance with NFPA 101 2000 Edition, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Although emergency lighting is not required in business occupancies such as this facility; NFPA 101, 2000 Edition, states the following in Section 4.6.12.2: "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed."

The battery operated emergency lighting of the facility was reviewed at 9:30 a.m. Staff in the area indicated that the batteries were recently replaced. The facility staff were asked about having the monthly 30 minute test and annual test for the emergency lighting. Upon further investigation, the facility staff could not locate documentation for either the 30 minute or 90 minute test.

Based on observations made on October 12-14, 2010, exit sign illumination must be maintained and doors that may be considered exits that re-enter the building should contain "No Exit" signs.

Findings include:

1. An exit sign labeled as 12242 was not illuminated in the first floor lab at 2:30 p.m. Attempts to determine if the exit sign self illuminated were not successful.

2. The "Old Lithotripsy Doctor's" office was reviewed at 3:25 p.m. on 10/12/10. The exit light appeared to be illuminated at approximately 1/2 of the exit sign. All letters of the exit sign must be illuminated completely.

In accordance with NFPA 101, 2000 Edition, section 7.10.8.1 No Exit;
any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.

3. The exit near the Lewis & Clark Conference rooms was reviewed on 10/13/10 at 4:25 p.m. The "Old Smoke Room" which can be accessed through the exit vestibule requires that staff re-enter the building to exit. This door to the corridor leading to this room that is inside the vestibule should be labeled as "NO EXIT".

Based on observations made on 10/13/10, manual fire alarm pull boxes shall be maintained free and clear from obstruction and smoke detectors shall be maintained.

Findings include:

In accordance with NFPA 72, 1999 Edition, Section 2-8.2.1; manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

1. The egress corridor from the Lewis and Clark Conference rooms was reviewed on 10/13/10. A manual fire alarm box was observed to be partially obstructed by a collapsible coat rack. The rack was later moved by staff at the time of survey.

2. The clean side of laundry was reviewed at 9:40 a.m. on 10/13/10. A cart overflowing with bags of laundry in it was blocking access to the manual fire alarm box.

3. The transfer switch room was observed on 10/13/10 at 10:41 a.m. A manual fire alarm box was observed without a cover in the hard lid ceiling.

4. Room G049 was observed on 10/13/10 at 10:57 a.m. The hard lid ceiling installed in the room contained an electrical box for a smoke detector. The smoke detector had been removed and no cover existed on the box.

Based on observation and staff interview on October 14, 2010, the facility failed to ensure that the location of the dedicated power circuit branch servicing the fire alarm panel was permanently addressed on the alarm panel. Also, the circuit disconnecting means was not identified with a red marking.

Findings included:

In accordance with Section 1-5.2.5.2 of NFPA 72, 1999 edition; the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The main FACP for the Sletten Cancer Center was observed at 9:00 a.m. on 10/14/10. The FACP panel was labeled as to what electrical panel and breaker controlled it (Panel EG5, Breaker #14), but the circuit disconnecting means was not identified with a red marking.

Based on observation and staff interview on October 12-14, 2010, the facility failed to ensure that the location of the dedicated power circuit branch servicing the fire alarm panel was permanently addressed on the alarm panel. Also, the circuit disconnecting means was not identified with a red marking.

Findings included:

In accordance with Section 1-5.2.5.2 of NFPA 72, 1999 edition; the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

1. The main FACP for the east campus was observed at 1:45 p.m. on 10/12/10. The FACP panel was not labeled as to what electrical panel and breaker controlled it. Also, the circuit disconnecting means were not identified with a red marking.

2. The main FACP for the west campus which is located in the basement of the east campus was observed at 1:47 p.m. on 10/12/10. The FACP panel was labeled as to what electrical panel and breaker controlled it, which was panel EHP, breaker # 42, but the circuit disconnecting means were not identified with a red marking.

3. The Simplex 4100-U FACP located in room 1143 was observed at 9:25 a.m. on 10/13/10. The FACP panel was not labeled as to what electrical panel and breaker controlled it. Also, the circuit disconnecting means were not identified with a red marking.

Based on observations made on October 12-14, 2010, the fire alarm system and it's components were not being maintained per NFPA 72.

Findings include:

In accordance with NFPA 99, 1999 Edition, Section 2-1.3.2; in all cases, initiating devices shall be supported independently of their attachment to the circuit conductors.

1. A strobe and horn fire alarm device was found hanging from the alarm system wiring at 1:05 p.m. The strobe/horn device was labeled as A4 and was located on the backside of the roof penthouse.

2. During a test of the fire alarm system on 10/14/10 at 1:10 p.m., at least three strobes were found not working on the first floor. The following strobes did not flash when the alarm was silenced:
a) AV-1026,
b) AV-1012, and
c) AV-1001.

Based on staff interview and request for records on October 14, 2010, the facility failed to test the fire alarms system and conduct sensitivity tests for smoke detectors in accordance with NFPA 70, 1999 Edition and NFPA 72, 1999 Edition .

Findings included:

In accordance with 7-3.2, testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

In accordance with 7-3.2.1, detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

The fire alarm system the facility was as observed at 9:30 a.m. When asked if the fire alarm system had received inspections, testing and maintenance; the Facility Director could provide no documentation for such testing.

Based on observations made on October 12-14, 2010, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

Findings included:

In accordance with Section 19.1.1.3 of the Life Safety Code (LSC), All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities, adequate staffing, and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention and the planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building.

1. A closet in Neurodiagnostic Department was observed to be not sprinkled, as observed at 2:30 p.m. on 10/12/10.

2. Elevator #6 by the Neurodiagnostic Department was observed to be hydraulically controlled as observed at 2:35 p.m. on 10/12/10. The elevator pit was not sprinkled.

3. Room 1208-C, under the interior stairway was observed to be not sprinkled at 2:43 p.m. on 10/12/10.

4. The closet on the west wall of Registration/Admissions offices was observed at 8:10 a.m. on 10/13/10. This closet was without sprinkler coverage.

5. The closet enclosing the Automatic Teller Machine (ATM), was found to be non sprinkled as observed at 8:30 a.m. on 10/13/10.

6. The walk-in-cooler labeled C-37 was found to be eight feet by twenty feet and had one sprinkler head which was obstructed by a condenser as observed at 8:45 a.m. on 10/13/10.

7. The Transformer room by the Cameron Auditorium was not sprinkled as observed at 9:45 a.m. on 10/13/10.

8. The tunnels under the ground floor were observed at 1:06 p.m. on 10/13/10. A new section of the tunnel had been opened up by boring through the concrete wall, there were combustible materials in the area and no sprinkler coverage in this eight foot by twelve foot space.

Based on observations and interview of staff between October 12-14, 2010; the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

Findings included:

In accordance with Section 19.1.1.3 of NFPA 101, 2000 Edition; all health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities, adequate staffing, and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention and the planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building.

1. Communication Hub room 1316A was reviewed on 10/12/10 at 4:20 p.m. The room lacked sprinkler coverage. There was no lay in ceiling assembly in this room.

2. Room G236B of the Lewis Conference Room lacked full sprinkler coverage as observed on 10/13/10 at 8:30 a.m.

3. The closet across from room G047 in the Finance Center contained an insert shelving unit that blocked some of the spray pattern of the sprinkler head. The closet was approximately 3 feet wide by 10 feet long as observed on 10/13/10 at 11:03 a.m.

4. While observing the Finance Center, room G035 was reviewed on 10/13/10 at 11:11 a.m. The room was recently created with a remodel, contained a transformer, and was unsprinklered.

Based on observation made on October 12-14, 2010, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 13 and NFPA 25.

Findings included:

In accordance with Section 5-6.6 of NFPA 13 (1999 Edition), the clearance between the deflector of standard pendent and upright spray sprinklers and the top of storage shall be 18 inches or greater.

In accordance with 3-2.7.2 of NFPA 13 (1999 Edition) escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1. Soiled linen storage room 333, on the 3rd floor, had two sprinklers where there an annular space existed between the ceiling tiles and the escutcheon rings as observed at 2:06 p.m. on 10/12/10.

2. The magnetic door hold system components were tied to the sprinkler pipe above room 438 on the 4th floor at 7:30 a.m. on 10/13/10.

3. The sprinkler head in closet 450A (PT reception area closet) was blocked items placed on the top shelf of the closet. As soon as notified, the facility staff removed the items and the top shelf from the closet at 8:07 a.m. on 10/13/10.

4. The sprinkler head in ER room 18 (door marked 117) had a heavy accumulation of dust at 1:55 p.m. on 10/13/10.

5. Several chemical spray bottles were hanging from the sprinkler stand pipe/control valves in room 128, housekeeping in ER at 2:00 p.m. on 10/13/10.


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6. Room 1064-B, (a mechanical room), had a sprinkler head recessed into the corridor wall. The room was approximately five feet by five feet. The head was an upright pendant type and should have been a side pendant type for this location.

7. Room 1223 (storeroom for volunteers) had items stored which blocked spray pattern coverage for the room as observed at 2:15 p.m. on 10/12/10.

8. The Morgue walk-in-cooler had one escutcheon ring which was not tight to the ceiling tile as observed at 9:30 a.m. on 10/13/10.

9. The Compactor room had four escutcheon rings missing on the ceiling as observed at 12:40 p.m. on 10/13/10.

10. The South Tower stairwell had one sprinkler head taped over as observed at 12:50 p.m. on 10/13/10.

Based on observations made on October 14, 2010, the facility failed to maintain components of the sprinkler system in accordance with the standards of NFPA 13. And based on staff interview about the sprinkler service reports, the facility failed to maintain the automatic fire sprinkler system serving Sletten Cancer Institute in accordance with the standards of NFPA 13, 1999 Edition and NFPA 25, 1998 Edition.

Findings included:

Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution per 5-1.1(3) of NFPA 13. The removal or damage of one or more panels in a lay-in ceiling has the potential to hinder the ability of the sprinkler installed in that type of assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there due to the opening or failure of the ceiling tile, thus delaying the activation of the sprinkler to control the fire and the fire alarm system to activate.

The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary per section 2-3.4 of NFPA 25. The antifreeze solution shall be prepared with a freezing point below the expected minimum temperature for the locality per section 4-5.2.3 of NFPA 13.

1. Room 270 (Network room) was observed at 8:45 a.m. on 10/14/10. There was one two foot by two foot piece of ceiling tile out of place in this room.


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2. The facility staff reported at 11:15 a.m. on 10/13/10, that on 7/21/10, the antifreeze tested at -20 degrees Fahrenheit for Sletten Cancer Institute.

According to the National Oceanic and Atmospheric Administration (NOAA) the minimum low temperatures for Great Falls, Montana were -21 on December 7, 2009, -26 on December 8, 2009, and -23 on December 14, 2009. There was no documentation that the anti-freeze solution had been adjusted or replaced to ensure that the freezing point was below that expected for the minimum temperature for the locality.

3. The closet sprinkler head was blocked by storage in room 709, Image Recovery, at 8:10 a.m. on 10/13/10.

4. Room 435, soiled utility room, had a missing ceiling tile at 8:50 a.m. on 10/13/10.

Based on observations made on October 12-14, 2010; the automatic fire sprinkler system and components were not being maintained per NFPA 13 & 25.

Findings include:

In accordance with Section 2-2.1.1 of NFPA 25, 1998 Edition; sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

1. The elevator mechanical penthouse for the facility was reviewed at 12:55 p.m. on 10/12/10. A buildup of dust was observed on the sprinkler heads inside the room.

2. The kitchen was observed at 9:05 a.m. on 10/13/10. Two sprinkler heads near the center of the kitchen contained a buildup of link on them.

In accordance with Section 3-2.7.2 of NFPA 13, 1999 Edition; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

3. The supply room for Quick Care was reviewed at 1:50 p.m. An escutcheon ring inside the room was loosely fitted to the ceiling.

4. The first floor lab xylene distillery room was reviewed at 2:36 p.m. on 10/12/10. An escutcheon ring was loosely fitted to the sprinkler system.

5. Room 1525, a medical doctor's office, was reviewed on 10/12/20. A sprinkler head in the room lacked an escutcheon ring.

6. Room G214B, a computer training room, was reviewed on 10/13/20 at 8:15 a.m. A sprinkler head in the room had a loose escutcheon ring.

7. The Clark Conference Room was reviewed on 10/13/2010 at 8:37 a.m. The telephone closet sprinkler head was missing an escutcheon ring.

8. Clinical Engineering was inspected at 9:01 a.m. on 10/13/10. A sprinkler head in the ceiling lacked an escutcheon ring. The escutcheon was located on a table below the sprinkler head.

Based on observations made on October 12-14, 2010, the facility failed to ensure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Findings included:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 Edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 Edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

1. A free standing fire extinguisher was observed in the elevator equipment room located on the 5th floor at 4:45 p.m. on 10/12/10.

2. Fire extinguisher 44 located in 4th floor PT was manufactured in 1989. The 1995 date, the first 6-year testing of the device, could not be seen on the extinguisher. The 2001 hydrotesting and 2007 6-year maintenance testings were conducted and the labels were easily seen at 8:05 a.m. on 10/13/10.


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3. Air handling room 1088 in Accounting had one portable fire extinguisher which was not on a hanger as observed at 2:10 p.m. on 10/12/10.

4. A 3-A-40-BC portable fire extinguisher in room M-101-A (medical records storeroom) was last hydrotested in July of 2000, and received a six year maintenance test in July of 2007 as observed at 3:25 p.m. on 10/12/10. The six year maintenance should have been conducted in July of 2006 when it expired.

5. A 10-A-60 BC portable fire extinguisher in a wall cabinet in room 1801 received a six year maintenance test in July of 1999, but did not receive a hydotest until July 2006 as observed at 3:28 p.m. on 10/12/10. The hydrotest was due at the end of the sixth year in July of 2005.

6. The portable fire extinguisher (#232) located at GLS 106123, had the hydrotest maintenance sticker directly over the six year maintenance sticker, and one could not track the history for the extinguisher, as observed at 3:55 p.m. on 10/12/10.

Based on observations made on October 14, 2010, the facility failed to ensure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Findings included:

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

The portable fire extinguisher found in the pool water treatment room was manufactured in 1984. The hydrotest and 6-year maintenance stickers were directly on top of each other at 7:55 a.m. on 10/14/10. One could not track the history for the extinguisher.

Based on observations made on October 12-14, 2010; the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Findings included:

In accordance with Section 4-3.2 of NFPA 10, 1998 Edition; periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

1. The pharmacy was observed on 10/13/10 at 9:15 a.m. A portable fire extinguisher was not accessible because of items placed in front of it.

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

2. The portable fire extinguisher located in mechanical room #237 was observed at 1:34 p.m. on 10/14//10. The extinguisher had been placed in service in 1997 and a six year maintenance test was performed in March of 2003. The hydotesting on the portable extinguisher was not done until February of 2010, 11 months after the expiration date of March, 2009.

3. The cardboard bailer and bio hazard waste accumulation area in room 300 were observed on 10/13/10 at 10:00 a.m. There was no fire extinguisher in the room or within five feet of the room. The facility mounted a fire extinguisher at the time of survey.

Based on observation and interviews made on October 14, 2010, the facility failed to perform monthly inspections and maintain access to the portable fire extinguishers per there requirements of NFPA 10.

Findings included:

In accordance with NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, specific inspections must be done. Section 4-3.2 states that periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

While Section 4-3.1 states that fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

1. Two fire extinguishers in the egress path were reviewed for the facility at 9:50 p.m. Both extinguishers lacked proper monthly inspections. The annual inspection had been conducted by a fire protection contractor.

2. A cabinet mounted portable extinguisher was observed at 9:52 p.m. near the full size gym and racquetball courts. A "beer" dispensing machine was located directly in front of the fire extinguisher at the time of survey. The Facilities Director moved the cart at the time of survey.

Based on observations made on October 12-14, 2010; the facility failed to maintain the heating, ventilation, and air-conditioning system in accordance with Sections 19.5.2.1, and 9.2.1 of NFPA 101, Life Safety Code (LSC) and NFPA 90A.

Findings included:

In accordance with Section 5-3.1 of NFPA 90A, 1999 Edition; controls related to fan shut down and automatic damper operation shall be tested for compliance with the requirements of this standard.

A fire drill was conducted at 1:30 p.m. on 10/14/10 to check fire and smoke dampers on three floors of the West Campus building. A fire damper in the mechanical room #237 was observed for proper closure. The air handling system failed to shut down properly at this damper location.

Based on exercise of fire doors protecting gravity linen/trash chutes made on October 12-14, 2010, the facility failed to assure that there is a self-closing door at the discharge opening of the chute in accordance with NFPA 82, 1999 Edition.

In accordance with 3-2.2.9 of NFPA 82 gravity linen/trash chutes shall be protected at the discharge level by an approved automatic-closing or self-closing one-hour fire door suitable for Class B openings.

Findings included:

1. The trash chute room (1213) was observed at 2:20 p.m. on 10/12/10. The sliding door on the chute was not self-closing.

2. The laundry chute in room 1802 was observed at 3:30 p.m. on 10/12/10. The chute door was not self-closing.

3. The trash chute across from Medical Records was observed at 7:50 a.m. on 10/13/10. The chute doors were not self-closing.

4. The laundry chute across from Medical Records was observed at 7:51 a.m. on 10/13/10. The chute doors were not self-closing.

5. The laundry chute by Sterile Processing was observed at 10:20 a.m. on 10/13/10. The chute door was not self-closing, nor was it latched at the time it was observed.


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6. The laundry chute door on the south side of ER, with a self closure device (90 minute fire rated), would not positively latch when exercised at 2:11 p.m. on 10/13/10.

Based on observations made on October 12-14, 2010, the facility failed to ensure that items were not stored or left in the exit corridor system unattended for periods exceeding 30 minutes.

Findings included:

Items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor per Centers for Medicare and Medicaid Services Survey and Certification letter 04-41.

The exit corridor next to the Neurodiagnostic Department was observed at 2:22 p.m. on 10/12/10. The cardboard recycling bins were being stored in the exit corridor in this area.

Interview with facility staff regarding the storage in the exit corridor revealed that the bins have always been there.

Based on observation and interview with maintenance staff made on October 12-14, 2010, the facility failed to provide documentation that curtains in the basement met the Standards of NFPA 13, for flame spread ratings.

Findings included:

In accordance with Section 19.7.5.1 of NFPA 101, 2000 Edition; draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of Section 10.3.1 of NFPA 101.
Exception: Curtains at showers.

Room 1225 (Volunteer managers office) was observed at 2:10 p.m. on 10/12/10. There were sheer drapes hanging on the corridor windows to this office. There was no tag attesting that they carried a flame spread rating, nor any documentation that they had been treated with a material which was rated.

Interview with facility staff at a team meeting at 4:45 p.m. on 10/12/10 revealed that possibly the volunteer manager brought the drapes from home and hung them.

Based on observations made on October 12-14, 2010; the facility failed to provide curtains that were inherently fire retardant or had been treated with a spray to make them as such.

Findings include:

The Outpatient Childrens Therapy area was reviewed at 3:10 p.m. A set of white curtains used to conceal a storage area were found. The curtains did not contain information that they meet NFPA 701 or were inherently flame retardant nor were they treated with a fire retardant fabric spray.

Based on observation made on October 12-14, 2010, the facility failed to ensure that nonflammable gas cylinders were stored in accordance with the standards of NFPA 99.

Findings included:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99 (1999 Edition) freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

In accordance with NFPA 99, Sect. 4-3.1.1.2(a)(4) requires that the electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code (NEC), for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

1. An "E" size cylinder of oxygen was observed to be unsecured and in upright freestanding position in the ICU near room 5116 on the 5th floor of the surgical tower at 9:25 a.m. on 10/13/10.

2. A carbon dioxide cylinder was observed to be unsecured and in upright freestanding position in the medical gas room, marked 2517, in OR at 10:30 a.m. on 10/13/10. The cylinder was located in front of an electrical outlet approximately 14 inches from the floor.

3. The medical gas storage room door, marked 155B, was impeded by a cylinder rack and could not be closed at 2:13 p.m. on 10/13/10.

Based on observations made on October 12-14, 2010; compressed gas cylinders must be secured from falling and oxygen storage areas must have proper signage.

Findings include:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99 (1999 Edition) freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

1. At 3:30 p.m., room 1300 was reviewed. This mechanical room contained various electrical equipment and three "K" size or bigger helium tanks that were unsecured.

In accordance with NFPA 99, 1999 Edition, Section 8-3.1.11.3 Signs; a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

2. The oxygen storage room next to G120 was observed on 10/14/10 at 8:10 a.m. The door to the room did not contain signage in accordance to NFPA 99.

Based on observations made on October 12-14, 2010, the facility did not appropriately label a medical gas shut off valve as to its use.

Findings included:

In accordance with 4-3.5.4.2 of NFPA 99 (1999 Edition) shutoff valves for medical gases shall be labeled to reflect the rooms that are controlled by such valves.

1. The medical gas shutoff valve panel near room #6 in OR lacked labeling to address the rooms that it served at 10:21 a.m. on 10/13/10.

2. The medical gas shutoff valve panel near room #5 in OR lacked labeling to address the rooms that it served at 10:41 a.m. on 10/13/10.

Based on observations made on October 12 -14, 2010; the facility failed to properly designate the branch functions of each automatic transfer switch.

The findings include:

Type I essential electrical systems are comprised of two separate systems, being the emergency system and the equipment system per section 3-4.2.2.1 of NFPA 99, 1999 edition. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

The multiple transfer switches in electrical room G105F were examined at 10:40 a.m. on 10/13/10. Several transfer switches were housed in the room with the following numbers on them: 10-M3-084-0, 10-M3-085-0, 10-M3-086-0, 10-M3-087-0, 10-M3-088-0. There was no designation on any of the transfer switch denoting whether that particular switch served the emergency (life safety and critical functions) branch, the equipment branch or if the systems had been further isolated into separate Life Safety and Critical branches.

Based on observations made on October 12-14, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings included:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

1. A microwave was plugged into a surge protector in room 843, a staff kitchen as observed at 12:50 p.m. on 10/12/10 on the 8th floor. As soon as notified, the facility staff unplugged and removed the microwave from this location.

2. The electrical panel in room 393 on the 3rd floor was blocked by a clothes rack and furniture. As soon as notified, the facility staff removed the items blocking electrical panel OBL.

3. The Chief Risk Officer's office in Risk Management was observed at 1:35 p.m. on 10/12/10. Surge cords were found in series under one desk.

Note: One surge cord was removed from the location and the deficiency was corrected at the time of the survey process.

4. The Mercy Flight Dispatch room was observed at 1:40 p.m. on 10/12/10. A microwave and a small refrigerator were plugged into a surge cord.

5. The Map room was observed at 1:55 p.m. on 10/12/10. There were two APC units in use with surge cords plugged into them in series.

6. Room 1227 (air handling room) was observed at 2:08 p.m. on 10/12/10. One electrical box was found without its cover.

7. Room 1229 was observed at 2:50 p.m. on 10/12/10. Surge cords were found in series along the east and west walls.

8. Room 1801 was observed at 3:27 p.m. on 10/12/10. Three surge cords were found in series in this room.

9. The Patient Advocate office was observed at 7:35 a.m. on 10/13/10. There were two surge cords in series under a desk.

10. Medical Records break room was observed at 7:45 a.m. on 10/13/10. A microwave oven and refrigerator were plugged into a surge cord.

11. Room 1003 in Patient Registration was observed at 8:00 a.m. on 10/13/10. The Lexmark copier was plugged into an extension cord.

12. The Kitchen Chef's office was observed at 8:50 a.m. on 10/13/10. A surge cord was not flat on the floor or affixed to the wall, but dangling on the weight of the cord.

13. The Chief Clinical Officer's desk in Administration was observed at 9:55 a.m. on 10/13/10. There was an extension cord in use in this area.


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14. Breakers marked 40-42 were in on positions in the electrical panel L-OR1 in the operating room #1 at 10:09 a.m. on 10/13/10, however, they were marked as "spare" on the panel directory.

15. The warmer and the blood bank refrigeration units were plugged into a surge protector in the pump room in OR at 10:10 a.m. on 10/13/10.

16. A refrigerator was plugged into a surge protector in Am Admit/OR offices at 11:25 a.m. on 10/13/10.

17. A refrigerator was plugged into a surge protector in the OR staff lounge at 11:34 a.m. on 10/13/10.

18. Two toasters were plugged into an extension cord, then the extension cord was plugged into a surge protector in the OR staff lounge at 11:36 a.m. on 10/13/10.

19. The circuit breaker 41 in electrical panel ER 1C1L was in on position and marked as spare in the panel directory in ER at 1:47 p.m. on 10/13/10.

20. The receptacle with exposed electrical wires in the OR CT support equipment room, 211, had a missing cover at 1:43 p.m. on 10/13/10.

21. A refrigerator was plugged into a surge protector near the south exit of Laboratory on the second floor at 3:30 p.m. on 10/13/10.

22. A receptacle with exposed electrical wires in Pharmacy Informations, 2008, has a missing cover at 3:40 p.m. on 10/13/10.

23. Circuit breakers 6-12 were in the on position in panel L in the robot packaging room in Pharmacy. The panel directory was blank corresponding to these breakers.

Based on observations made on October 14, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, NFPA 99 or CMS interpretations.

Findings included:

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

The electrical panel in room 256 (housekeeping closet) was observed at 8:30 a.m. on 10/14/10. The panel was obstructed by a housekeeping cart.

Based on observations made on October 12-14, 2010, the facility failed to maintain the electrical system or its components in accordance with the standards of NFPA 70, 1999 Edition.

Findings included:

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

The store room in Endoscopy was observed at 3:50 p.m. on 10/13/2010. The electrical panel was blocked by stored items.

Note: The stored items were removed at the time of the survey process.

Based on observations made on October 12-14, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings included:

According to Article 384-13 of NFPA 70; all panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. NFPA 70, Article 110-22. Identification of Disconnecting Means states that each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

1. Electrical panel L5A was reviewed on 10/12/10 at 1:10 p.m. The panel contained two separate panel schedules. The correct panel schedule should be used and updated.

2. Electrical panel EM3A panel schedule was reviewed on 10/12/10. The panel schedule was not current to spare or circuits in use.

3. The panel schedule for electrical panel L3A was received on 10/12/10. Three circuits were in the off position, but were not labeled as spare.

4. Electrical panel CP1B was reviewed on 10/12/10. The panel is requiring an update to the current panel schedule.

5. Electrical panel 3P4HW 208Y/120V was reviewed on 10/12/10. The panel is requiring an update to the current panel schedule.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle. Power strips, if used, must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".


6. The first floor lab break room was observed on 10/12/10. The break room microwave was plugged into a surge protector. Microwaves and similar appliances must be directly plugged into a wall outlet.

7. The lab transcription area was reviewed on 10/12/10. The south west cubical in the room contained two surge protectors plugged in series or daisy chained.

8. The Medical Records/Transcription Dictation Area was reviewed at 8:15 a.m. on 10/13/10. An extension cord and multiple plug adapter were in used at computer station WMRPC21.

In accordance with 370.28(c) of NFPA 70 (1999 edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110.

10. The Rehabilitation bathroom was observed on 10/12/10 at 3:40 p.m. A call light in the bathroom lacked a cover plate where wiring for the call light originated.

11. Room 1342, which was recently changed into a medical doctors office, was missing 5 cover plates when observed at 3:56 p.m. on 10/12/10. One plate was for a four plug electrical outlet and the remaining four were for various single outlet or junction boxes.

12. Room 1345 was reviewed at 4:10 p.m. on 10/12/10. There were three electrical covers missing, two were for outlets and one for a light switch.

13. Room 1345A was observed at 4:12 p.m. on 10/12/10. Three electrical cover plates were missing in the room.

14. The Medical Records/Transcription Dictation Area was reviewed at 8:15 a.m. on 10/13/10. The room contains a low voltage junction box that was not covered.

15. The second floor bank of elevators were observed on 10/13/10 at 1:00 p.m. Elevator #1 had an electrical junction box that was missing a cover near the roll down door.

16. During inspection of the smoke barrier on second floor, an electrical box was found with two wires not connected coming out of apparently supporting the fire alarm. This observation was made on 10/13/10 at 1:31 a.m.

17. The first floor smoke barrier was reviewed on 10/13/10 at 2:10 p.m. An open junction box was found in the smoke barrier that was apparently part of the PROXY card system.

18. The smoke barrier near room G030 was reviewed at 8:46 a.m. on 10/14/10. Two uncovered junction boxes were found near the toilet in the room.

19. The smoke barrier near room G014 was reviewed at 8:46 a.m. on 10/14/10. An uncovered junction box for damper wiring was found near the supply and return air.

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

20. The laundry area was reviewed on 10/13/10 at 9:44 a.m. The main power disconnect for the washing machine was blocked with various supplied for laundry.

21. Electrical panel LXR was blocked by a wheeled cart as observed on 10/13/10 at 9:57 a.m. Facility staff moved the cart at the time of survey.

Based on observation and interview with staff on October 12-14, 2010; the facility failed to notify proper authorities when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period.

Findings include:

While touring the facility for life safety code compliance, facility staff indicated that various areas were under construction on the ground level. While in room G106 where construction staging was being done, it was noted that the facility had several ceiling tiles out of place. From discussion with staff, the construction project ran for 8 to 10 hours a day and then security would conduct fire watch on off hours. This fire watch was not report to the authority having jurisdiction at 406-444-4170 as is required.