HospitalInspections.org

A) From random observation, the surveyor finds that combustible materials have been used that are incompatible with the building's construction type and that are not permitted in Type I or Type II construction (19.1.6.2, 19.1.6.3). These deficiencies could contribute fuel load in a fire and cause earlier failure of the building structure.

Findings include:

1) The Basement Level of the Rogers and Concourse Wings have a Mechanical Room on the west side of the building that communicates to a vertical air intake shaft. The construction of this shaft has multiple deficiencies which include lack of compliance with 19.1.6.2:

a) Looking up the shaft from the bottom, there is a steel grate at the top of the shaft that supports a floor or roof assembly. No information was available and the floor of roof does not comply with the requirements of Type II (222) construction.

b) The air intake shaft communicates to a "doghouse" structure that sits on the roof of the 2nd Floor and includes the north wall of the 3rd Floor On-Call Rooms in the Center Wing. The doghouse has plywood on the north side of the north wall of the On-Call Rooms. The doghouse has an unprotected steel joist roof structure (unprotected steel) that is covered with plywood. The plywood and unprotected steel joists are not compatible with Type II (222) construction and/or Type I (332).


16339


A. Corrected 04/19/13
B. Corrected 04/19/13
C. Corrected 04/19/13







20224


A. Corrected 11/07/13

1) Corrected 04/19/13

2) Corrected 04/19/13

3) Corrected 11/07/13

4) (New 11/08/13): The 2nd Floor exit access corridor from surgery to PACU and further south has use areas which are open to the corridor and which lack smoke detection in accordance with 19.3.6.1, exception # 1. Cite Surgery/Recovery corridor


16339


A. Corrected 04/19/13

B. Corrected 04/19/13

C. Corrected 04/19/13



20224


A. Corrected 04/19/13

B. Corrected 11/07/13

C. Corrected 04/19/13

A) Based on random observation, the surveyor finds that corridor doors are not always positive latching in accordance with 19.3.6.3.2 and/or that corridor doors are not installed to maintain a smoke tight condition.

Findings include:

1) Corrected 11/07/13

2) Corrected 11/07/13

3) Corrected 11/07/13

4) Corrected 11/07/13

5) Corrected 11/07/13

6) Corrected 11/07/13

7) Corrected 11/07/13

8) Corrected 11/07/13

9) Corrected 11/07/13

10) (New 11/08/13): Two pairs of designated suite doors to the 1st Floor Carle Express Care Suite and one pair of designated suite doors to the Main ED Suite lack positive latching hardware.

11) (New 11/08/13): North Tower Patient Room 1006 had a latchset which was disabled with tape.




20224


Based on random observation and staff interview during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6..3.2 for a means to keep the door closed. This condition could affect patients, visitors and staff within an exit access corridor during a fire condition.

Findings include:

A. Corrected 11/07/13

B. Corrected 11/07/13

C. Corrected 04/19/13

D. Afternoon of 07/17/12, the 8th floor Parkview CVCU (not a designated suite) contains patient rooms which are not separated from the exit access corridor due to sliding glass doors which do not latch when in the closed position.

A) (New 11/07/13): North Clinic at the bridge, the designated 2-hour fire barrier (as shown on the Life Safety floor plans) (not sure what this was or what floor)?

B) (New 11/08/13) Multiple ducts penetrate the 4th Floor of the Conference Room along the south wall without fire dampers.


16339

Based on random observation during the survey walk-through, not all ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, as well as any staff and visitors because the failure to provide dampers and proper installation of shaft could result in smoke or fire passing from one part of the building to another.

Finding includes:

A. Corrected 04/18/13

B. North Clinic Building, 4th Floor, a shaft located in the North East Clinic was observed with ductworks that lack a two hour fire rated separation wall and the shaft is exposed from the remainder of the building.

11/08/13 Modified: The above shaft is part of a plenum return air system which is connected to multiple levels of the north clinic. There is a large antiquated 16" x 96" "fire damper" installed rough 12" below the bottom of the 3rd Floor concrete slab directly below the shaft cited. This fire damper is not installed in accordance with NFPA 101, and NFPA 90A. The fire damper is not maintained in accordance with NFPA 90A. The damper opening through the floor is unducted; a combination fire/smoke damper with a duct detector is not installed.

C. Corrected 04/18/13

D. North Clinic, First Floor - The surveyor finds that duct penetrations at shaft walls lack fire dampers in accordance with NFPA 90A. Locations include: Shaft located at the back wall of the Staff Only Room 1D023 near the Storage 1D019 as shown on the Life Safety drawings.

A) From random observation the surveyors find that vertical openings and/or penetrations through fire rated floor assemblies are not installed and maintained in accordance 8.2.5 of NFPA 101.

Findings include:

1) Corrected 04/19/13

2) Corrected 04/19/13

3) 2nd Floor Center Wing - there is a rated shaft enclosure in the southeast corner of the Cardiology Waiting Area. The shaft wall is incomplete near the duct penetrations though the floor below.

4) 2nd Floor Center Wing - there is a shaft enclosure in the Southwest corner of the Cardiology Waiting Area. This shaft has three ducts that penetrate multiple floors from the Basement to the roof of a 4th Floor Mechanical Space.

a) Fire rated shaft enclosures for multiple
floors are not identified on the Life
Safety Plans for the 1st, 2nd, 3rd, and
possibly the 4th Floor, in accordance with
NFPA 101 and NFPA 90A.

b) Fire rated shaft enclosures for multiple
floors are not provided for the 1st, 2nd,
3rd, and possible the 4th Floor, in
accordance with NFPA 101 and NFPA
90A. In some cases that shaft does not
exist. On the 2nd and 3rd Floors, the
shafts are drywalled on one side only.

c) The three ducts have fire dampers in the
floor at some floors where fire dampers
would not be permitted under NFPA
90A. See also Item 5 below.

The PoC does not indicate what is proposed to
corrected the above items

5) 3rd Floor Center Building - Surgical Waiting Room: There is a duct shaft in the southeast corner of this room. The shaft does not comply:

a) The shaft enclosure is only drywalled on
one side; this shaft is not enclosed in fire
rated construction in accordance wish
19.3.1.1 and in accordance with NFPA
90A.

b) Three seamless 12" x 12" ducts
penetrate
the floor below and above without fire
dampers. The provider did not know
what these ducts connect to and had no
information that would indicate that the
ducts could comply with the rules for
hazardous ducts instead of the rules for
fire dampers under NFPA 90A.

6) Renumbered on 4/17/13: 3rd Floor Center Wing - Southeast Mechanical Room: The surveyor notes that that this space appears on plans to be part of the North Clinic at the 2nd and 3rd Floors. It is part of the Center Wing and is separated from the North Clinic by designated two hour fire barriers. This is not a deficiency.

7) Renumbered on 4/17/13: 4th Floor Center Wing West Mechanical Room - three seamless 12" x 12" ducts penetrate the floor below and the roof above without a fire rated shaft enclosure in this space in accordance with NFPA 90A.

Failure to protect openings in fire rated floors and failure to maintain vertical openings could allow fire to spread from floor to floor in a fire emergency.

End




16339


A. Corrected 04/19/13

B. Corrected 11/07/13

C. Corrected 11/07/13

D. Corrected 04/19/13

E. Corrected 04/19/13

F. Corrected 11/07/13







20224


A. Corrected 04/19/13

B. Corrected 04/19/13

C. Corrected 04/19/13

D. Corrected 11/07/13

A) Based on random the surveyor finds that hazardous areas are not protected in accordance with 19.3.2.1 and 8.4.1 of NFPA 101:

Findings include:

1) Corrected 11/07/13

2) 2nd Floor Center Building - Former procedures rooms have been converted to storage rooms and do not have one hour fire rated enclosures and 3/4 hour fire rated door assemblies:

a) EP Lab # 1

b) North IVS Storage Room

3) Corrected 11/07/13

Failure to maintain separations for hazardous areas will increase the fuel load in a fire emergency and allow fire and smoke to spread outside to the spaces with higher fuel loads.

End


16339


A. Corrected 11/07/13



20224

Based on random observation and staff interview during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access during a fire condition. Findings include:

A. Morning of 07/17/2012, 9th floor Parkview, contains mechanical rooms none of which are separated from occupied areas including:

1. The exit access corridors

2. Respiratory Care Staff area

3. Lodging Occupancy used on a 24/7 basis by EMT's and Life Flight personnel.

The Life Safety drawings indicate a fire resistance rating of 1-hour surrounding the Lodging occupancy from the mechanical rooms. The perimeter wall of the Lodging Suite does not exist above the suspended acoustical tile ceiling for the Lodging occupancy.

B. Morning of 07/18/12, 9th floor Parkview Respiratory Care Clean Storage was observed not separated from the occupied spaces including the corridor leading to offices, staff break and work rooms due to the lack of rated walls and doors.

C. Corrected 11/07/13

D. Corrected 11/07/13

E. Corrected 11/07/13

F. Corrected 11/07/13

A) Corrected 11/07/13



16339

Based on random observation, the surveyor find that requires exit stair enclosures do not provide a continuous path of escape and not provided protection against fire or smoke from other parts of the building to comply with Chapter 7. These deficiencies could affect any patients from this building and
as well as any staff and visitors because designated exit stairs are not protected against fire or smoke conditions to comply with 8.2.5.2.

Findings include:

1. Corrected 04/19/13

2. In the morning of 07/19/2012, North Tower Wing, First Floor - The survey finds that the Southwest stair does not discharge directly to the outside in accordance with 7.7.1. Multiple floors use and are provided with two hour horizontal exits. These horizontal exits are not continuous two hour fire barriers from foundation to roof in accordance with 7.2.4.3. The South West Stair 1AS3 serving North Tower Wing and Concourse Wing discharges into the interior of the Concourse Building which does not provide a complete fire separated exit path to the outside in accordance with 7.2.4.3.1 Exception (c).

11/08/13: The PoC indicates that the above exit path was approved. Approved as what? The PoC does not indicate whether and/or how the stair complies with 7.7.1 or 7.7.2. The 2nd half of the citation regarding horizontal exits is not addressed by the PoC.

3. Corrected 04/19/13

4. Deleted 04/19/13

A) Corrected 11/08/13

B) Corrected 11/07/13




16339


A. (Modified 11/07/13) North Tower Wing, 9th Floor, NICU the surveyor determines that the required exit access corridors from the elevator foyer lobby to the NICU Suite..... the dead-end condition has been corrected and the lobby has two exit paths; however, the new pair of doors to the suite do not always latch and/or latch when the fire alarm is activated.

B. Corrected 04/19/13

C. Corrected 11/07/13

D. Corrected 11/07/13

1. Corrected 11/07/13




20224

Based on random observation and staff interview during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all timesto comply with 19.2.1 and Chapter 7. These deficiencies could affect all patients, staff and visitors in the facility, by preventing occupants from reaching an exit from the building.

Findings include:

A. Corrected 11/07/13

B. Morning of 07/18/12, Parkview, all occupied levels 2nd - 8th floors contain a dead end corridor condition of approximately 70 feet. The dead end extends from a pair of cross corridor doors locked against egress within a south end corridor to the corridor where Rogers connects to Parkview.

04/19/13: The PoC for the item references attachments that are not attached to every PoC. A narrative indicating how each will be corrected is not provided.Corrected 04/19/13

C. Afternoon of 07/17/12 8th floor Parkview CVCU; the direction of egress, is indicated by an exit sign located above the inactive leaf of a pair of cross corridor exit access doors.

Based on random observation during the survey walk through the surveyor noted numerous designated suites which did not appear to comply with 18.2.5. The North Tower 2nd Floor was renovated in 2007 therefore this wing has been evaluated under Chapter 18. Four designated suites do not comply.

Findings include:

A. North Tower Wing, 2nd Floor, OR / Recovery Suites: The surveyor finds that multiple suites identified as S1, S2, and S3 are probably not suites and each suite lacks access to two remote exit access corridor doors in accordance with 18.2.5.3. All three suites must pass through adjoining suites to reach a corridor door. These suites do not comply with 18.2.5.8. The two hour fire barriers that are installed between the suits do not comply with 7.2.4.3.1; the fire compartments are part of the adjacent fire compartment. The two hour fire barriers define the boundaries between suites only and not horizontal exits.

B. North Tower Wing, 2nd Floor, OR Suite S3 identified 12,042 s.f. does not comply with 18.2.5.7 for the maximum allowable square footage for a non sleeping room suite, the maximum permitted is 10,000 square feet.

Failure to maintain suite boundaries and provide access to corridors doors from the suites will increase the travel distance to a corridor for horizontal evacuation during a fire emergency.

04/19/13: The PoC does not clearly indicate how and when the above items will be corrected and the RJA plans referenced are not attached to every PoC. The HVI project will be completed and occupied by 07/31/13. A detailed narrative/corrective action is not provided for each suite and/or for each part of Item A and Item B above. A detailed phasing schedule is not provided. Any changes will likely require submittal as a project. Compliance of th recently completed TAVR OR Project (Project 9709) will be confirmed with the correction of K042. What OR Project is proposed?

End










20224


Based on random observation and staff interview during the survey walk-through, not all designated suites are provided with exits in accordance with 19.2.5. Intervening rooms within a suite allow for a delay in becoming aware of a fire and to reach an exit access corridor. This condition could affect patients, visitors and staff on this floor level.

Findings include:

A. Afternoon of 07/18/12 3rd floor Rogers, Inpatient Therapy Services and Rehabilitation, deemed a suite by the facility, lacks the required arrangement of a means of egress to an exit access door and does not comply with 19.2.5.1 exception #2. Patient sleeping rooms have two intervening rooms to traverse in order to gain access to an exit access corridor. An example location is the semi-private room #3576 (as shown on the Life Safety floorplan) which must travel through room # 3377 and corridor #3385.

A) Based on random observation the surveyors find that designated two hour fire barriers are not installed or maintained in accordance with Chapter 8 of NFPA 101:

Findings include

1) Corrected 11/07/13

2) Corrected 11/07/13

3) Corrected 04/19/13

4) Corrected 04/19/13

5) Corrected 11/07/13

6) 3rd Floor Center Wing - Southeast Mechanical Room. The surveyor notes that this space appears on plans to be part of the North Clinic at the 2nd and 3rd Floors. It is part of the Center Wing and is separated from the North Clinic by designated two hour fire barriers.

a) Corrected 11/07/13

b) Two duct penetrations above the 3rd Floor corridor door above the ceiling have fire dampers; however, there is a void in the fire wall between the two ducts and the fire dampers are not installed in accordance with NFPA 90A..

11/08/13 - the above item was not corrected.

Failure to maintain fire barriers will allow smoke and fire to spread throughout the building more quickly in a fire emergency.

End


16339

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers as shown on the Life Safety drawings are constructed or maintained as fire resistive assemblies as required by NFPA 101, 8.2.3.2.4.1&2. These deficiencies could affect all persons in the facility, by preventing the barriers from providing the intended separation protection.

Findings include: See also K-042

A. Corrected 11/07/13

B. At 1:30PM, 07/18/2012 North Tower Wing 2nd Floor OR Based on observation all double egress doors to the the designated two hour fire rated horizontal exit which is also the OR suite boundary are not 90 minute fire doors with U L Labels and these fire doors are not self closing. One door was observed to have only a 45 minute rating.

C. In the afternoon, on 07/18/2012 North tower 2nd Floor Designated 2- hour separation
wall near the OR Pharmacy was observed with pipes and conduits penetration above the ceiling that are not fire sealed.


20224


A. Corrected 11/07/13

B. Corrected 11/07/13

A) Corrected 04/19/13

B) Written Fire Plan: The provider has indicated that the building fire alarm system does not activate globally but instead activates by zone of activation and in all zones adjacent to the zone of activation. The provider lacked specific information that identifies all fire alarm zones and sprinkler zones. This information is necessary to determine which zones are adjacent to the zone of activation and is necessary to determine whether fire alarm zones, sprinkler zones match to building separations, areas or wings that are defined by fire barriers, smoke barriers, suite boundaries, etc. All components and panels of the fire alarm and sprinkler system report to a monitoring location in the E R Security Room which is constantly attended. For any fire event, in addition to automatic notification to specific zones, an overhead announcement is made (manually initiated) that identifies the location of the fire to all portions of every building or wing. The written fire plan for the Hospital does not acknowledge the above conditions and does not clearly identify the staff response: for fire in that area of activation, for a fire in the adjacent zones and for a fire in the zones where the fire alarm does not automatically announce a fire (which could include two zones away from the fire and also remote locations).

Modified 04/19/13: The Provider has indicated that the fire alarm chimes and strobes activate globally; however they have not defined in writing which buildings are areas are included under global activation. The provider has indicate that a staff response is initiated in the zone of activation and in all adjacent zones. However, the fire alarm system and sprinkler system may not be designed or installed to annunciate the location of a fire automatically. The fire alarm and sprinkler zones may not match the building compartmentation as zones and only way to identify where the fire is in many of the zones is from a manually activated P A announcement. Use of the manually activated P A System is acceptable as a secondary protocol and for interim measures, only. It does not comply with NFPA 72 requirements for occupant notification in Health Care.

11/08/13: The PoC for the above items were reviewed onsite and will be reviewed further on the future onsite visits.

C) The survey was conducted using Life Safety Plans that were provided by the Hospital. These plans were dated 2010 and were created by SSR. The following deficiencies identify conflicts between the Life Safety Code (NFPA 101 - 2000) and these Life Safety Plans

1) Center Wing/North Clinic: The plans identify a two hour fire separation between the Center Wing and the North Clinic on the 1st, 2nd and 3rd Floors. The Life Safety Plans identify "exits" through these two hour barriers on the 1st, 2nd and 3rd Floors. From random observation, the surveyors observed exit signs above the 90 minute fire doors at these same locations.

The only exit designation that can be used at these locations is as a horizontal exit. However, the designated exits do not comply with the rules of horizontal exits under 7.2.4.3.1 (NFPA 101). The two hour fire separation between the Center Wing and the North Clinic does not continue through the Basement Level.

Revised 11/07/13: The above locations may have two hour barriers that are not horizontal exits which means that travel distance cannot be measured to them but must continue through them to a legitimate exit.

The issues is not just the two hour separations but also travel distance to a legtimate exit. Not all two hour barriers are exits. Revised PoC statement

2) Corrected 04/19/13

D) (New 04/19/13) Based on an onsite review of RJA Life Safety Plans dated 01/31/13, the surveyor finds the life safety components are missing or are not identified.

1) 1st Floor Exit Stair 1AS1 is not shown with two hour fire rated enclosures and the 1st Floor (new) discharge for this stair is not identified on all plans as an Exit Passageway.

2) 3rd Floor Concourse Level - Mechanical Room with Kitchen Exhaust Ducts. The Life Safety Plans show a shaft enclosure at this 3rd Floor location where no shaft exists on this level.

End

A) The surveyor notes that the Hospital has personnel that work eight hour shifts and some personnel that work twelve hour shifts. Based upon a review of fire alarm documentation for the previous 12 months in multiple buildings, 07/20/12 with the facility safety officer, the surveyor finds that the provider conducts and observes fire drills in the zone of activation and typically in two adjacent zones.

1) The provider lacked specific information that identifies each zone and the boundaries of each zone that is being included in the zones to be observed during a fire drill.

4/19/13: Although the above item is essentially the same citation that is part of K048, the information required is not currently available and the correction date needs to be revised.

2) Corrected 04/19/13

3) Corrected 04/19/13

4) Corrected 04/19/13

11/08/13: The PoC for the above items were reviewd onsite and will be reviewed further on the next onsite visit.

A) From random observation, the surveyor finds that the fire alarm system that serves the clinical spaces, the Surgery Center and the Recovery Center are not installed, tested and maintained in accordance with NFPA 72-1999. Findings include:

1) The main fire alarm panel is located in the adjacent Clinic Building. (information only)

a) Corrected 04/17/13.

b) Corrected 04/17/13

c) Corrected 04/17/13.

2) Corrected 11/08/13

3) Corrected 11/08/13

4) (Revised 04/17/13): Documentation for testing, maintenance and service of the sprinkler system was not immediately available and is not maintained on site for the past 12 months in accordance with NFPA 25.

a. Although other documents may identify complying testing and maintenance, such documents are not identified as the "annual testing and maintenance" that is required by NFPA 25. The annual inspection report is left blank for the section provided for the annual main drain test.

b. The documentation for 2012-1013 available onsite does not clearly distinguish between the "main drain" test and the quarterly or semi-annual testing of inspector's test valves.

End

A) Based on random observation through the Hospital, the surveyors find the sprinkler system is not installed and maintained in accordance with NFPA 13. This includes sprinkler system deficiencies that are identified on quarterly sprinkler system inspection reports.

Examples include but are not limited to:

1) Corrected 04/19/13
2) Corrected 04/19/13
3) Corrected 04/19/13
4) Corrected 04/19/13
5) Corrected 04/19/13
6) Corrected 04/19/13

7) Basement Level Rogers South Mechanical Room has an electrical room that lacks sprinkler protection.

8) Corrected 04/19/13
9) Corrected 04/19/13
10) Corrected 04/19/13
11) Corrected 04/19/13
12) Corrected 04/19/13
13) Corrected 04/19/13

14) 1st Floor Center Wing Walgreens Space - The shelving in the back of this space is closer than 18" below the sprinkler heads installed. Some of the sprinkler heads are obstructed and not installed in accordance with NFPA 13 (obstructions and/or sprinkler head spacing does not comply).

11/07/13: The modified installation includes sprinkler heads which are closer that 6' and not installed to prevent cold soldering.

15) Corrected 04/19/13
16) Corrected 04/19/13
17 Corrected 04/19/13

End


14416


A. Parkview:
1. Corrected 04/19/13
2. Corrected 04/19/13
3. Corrected 04/19/13

B. Corrected 11/08/13



16339


A. Corrected 04/19/13

B. Corrected 04/19/13

C. Corrected 04/19/13



17659

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

A. Five of five fire pump locations were surveyed.

1. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7 for any of the fire pumps. 4/18/13: The provider has documentation for testing of only two of four points

2. Corrected 04/19/13

3. The transfer switch for the fire pump in the Parkview Wing is not located in the pump room as required by NFPA 20-6-6.4.





20224

Based on random observation and staff interview during the survey walk through not all portions of the building are sprinkler protected. This could result in delayed activation of the sprinkler system. This condition may affect patients, staff and visitors within the building.
Findings include:

A. Corrected 11/08/13

B. Morning of 07/18/2012, The facility failed to provide fire suppression for the following areas:

1. Corrected 04/19/13

2. Modified 04/19/13: 9th floor Parkview,
Mechanical room #911 (as shown on
Life Safety floor plan) lacks sprinkler
protection below ductwork greater than
48 inches in width. Example location -
entry located north of corridor #910
contains an aisle to the left which dead
ends and is surrounded by ductwork
overhead.
04/19/13: Sprinkler protection was not
provided at the north end of S-2

3. Corrected 11/08/13

4. 6th floor Parkview, patient room closets
(floor to ceiling) lack sprinkler coverage,
example location room #6616 (as shown
on Life Safety floor plan). The closest
sprinkler head is located more than 5
feet away beyond the privacy curtain.

5. Corrected 04/19/13

A) Based on document review of sprinkler maintenance and testing for reports dated 5/14/20012, the surveyor finds that the sprinkler system in multiple buildings is not being tested, serviced and maintained in accordance with NFPA 25 - 1999.

Examples include:

1) Corrected 11/08/13

2) Corrected 11/08/13

3) (Modified 11/08/13): The main drain test and quarterly flow tests are typically documented on the same form.

a) The main drain test for each system is not clearly documented on the annual test and maintenance inspection for each system.

b) The documentation on the combined forms does not clearly identify a "Main Drain" test in accordance with NFPA 25. Any other terminology will not be acceptable.

c) A combined form dated 5/6/13 indicated that a "main flow" test took 1:15 to activate the fire alarm. It is not clear what this test was or was not.

d) The documentation of quarterly flow testing does not include the specific location of each inspector's test valve.

The sprinkler system may not perform correctly in a fire emergency if it is not tested and maintained in accordance with NFPA 13/NFPA 25.

End


16339


A. Corrected 04/19/13

B. Corrected 04/19/13

C. Corrected 11/08/13

A) Based on document review of sprinkler maintenance and testing for reports dated 5/14/20012, the surveyor finds that the sprinkler system in multiple buildings is not being tested, serviced and maintained in accordance with NFPA 25 - 1999.

See also K062 for Building 01.

Examples include:

1) The sprinkler inspection report dated 5/14/2012, for the North Clinic sprinkler system identifies eight deficiencies identified in the report that include previously cited main drain deficiencies and also deficiencies with tamper switches that did not report to the fire alarm and sprinkler heads that were not installed in accordance with NFPA 13.

2) The sprinkler inspection report dated 5/14/2012, for the North Clinic sprinkler system identifies under item "4 c" that visible sprinkler piping is not in good condition. There was no further explanation for this condition.

The sprinkler system may not perform correctly in a fire emergency if it is not tested and maintained in accordance with NFPA 13/NFPA 25.

End

A) Based on random observation, the surveyors find that mechanical systems are not installed, tested and maintained in accordance with NFPA 101 and NFPA 90A:

Findings include:

1) Corrected 04/19/13

2) Basement Level CDU Mechanical Room (across from Cafeteria): Two ducts penetrate the fire rated floor above. Fire dampers were not found in accordance with NFPA 90A.

3) Basement Level Rogers and Center Wing: There is a north and south Mechanical Room in the east side of the building. One or both rooms are open to a vertical shaft enclosure. These mechanical rooms are defined on the Life Safety Plans with two hour fire barriers.

a) Multiple ducts penetrate these two hour
barriers without fire dampers and do not
comply with NFPA 90A.

4) Basement Level Rogers and Center Wing: The north and south Mechanical Room in the east side of the building has a tee shaped room in the middle of the Mechanical Rooms that is part of an air intake plenum and air intake shaft that extends to the 3rd Floor Roof above.

a) All portions of the air intake shaft
enclosure on multiple floors are not
identified as fire rated enclosures on the
Life Safety Plan. Not enough
information is not provided to
demonstrate how this shaft complies
with NFPA 101 and NFPA 90A The
shaft location is missing on the 1st and
2nd Floors.

b) These air intake shaft are required to be
enclosed from the Basement Level to the
roof (minimum - one hour shaft
enclosure). Fire dampers were not found
at air intake louvers or openings in the
Basement Level Mechanical Room in
accordance with NFPA 90. Fire
dampers were not found on all floors
where ducts or openings penetrate this
shaft.

c) A fire rated shaft enclosure was not
found at the 1st Floor (with multiple
sealed penetrations into the shaft. Also,
The door to this shaft at the 1st Floor
is not a fire rated B Label fire door
and it lacks self closing hardware.

d) No fire rated shaft enclosure was found
on the 2nd Floor. The shaft appears to
be open to adjacent ceiling cavities,
assess doors are not fire rated and ducts
lack fire dampers.

5) There is a 1st Floor Mechanical Room on the north side of the west Wing of the North Clinic. The mechanical space is separated from portions of the 1st Floor of the North Clinic and the Center Wing of the Hospital by two hour fire barriers. However, in the Basement Level the North Clinic is only separated from the Center Wing by a one hour smoke barrier. This does not constitute a building separation. Multiple duct penetrations through the 1st Floor two hour fire barriers (3 ducts at the north wall and 2 ducts at the south wall) lack fire dampers in accordance with NFPA 90A.

6) 1st Floor Center Wing - The is a large duct shaft in the Northwest corner of the Walgreens Pharmacy. The shaft has multiple ducts with fire dampers at the floor. The access panel for one of the ducts was left open. Access to this shaft for inspection and maintenance is through an shaft access door that is three feet above the floor and that is mostly blocked by a shelf in the Walgreens space. Access to the fire dampers was not provided in accordance with NFPA 90A. An inspection of the fire dampers and shaft could not be conducted; access could not be provided.

Failure to maintain vertical openings and failure to install and maintain fire dampers where required will allow fire to spread from floor to floor in a fire emergency.

End




20224


A. Corrected 04/19/13

A) Corrected 04/19/13


14416


North Tower:
By direct observation in the 3rd Floor Mechanical Room on the morning of 7/17/12 while in the company of the Central Plant Supervisor, the surveyor finds the facility failed to install the kitchen grease hood ventilation systems in compliance with NFPA 96, 1998:

1. Corrected 04/19/13

2. The four grease laden vapor exhaust ducts, for the Kitchen Hoods, from the enclosing shaft to the utility fan sets (Fan Nos. 21, 22, 23 & 24) and from the fan sets to the exterior are not separated with rated construction from other parts of the facility's mechanical systems located within this mechanical room (i.e. air handlers, pumps and compressors). The ducts were covered with thermal insulation. (NFPA 96, 1998, 4-7.1)

3. Corrected 04/19/13

A) Corrected 04/18/13




16339


A. Corrected 04/18/13



20224


Based on random observation and staff interview during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. or 39.2.3.2. These deficiencies could affect any patients, staff, or visitors attempting to utilize these corridors under emergency conditions by impeding egress.

Findings include:

A. Corrected 04/18/13

B. (Modified 04/19/13): 8th floor Parkview, CVCU (Cardio-Vascular Critical Care Unit which is not a designated suite) Through staff interview, and observation there is no designated clean utility and all materials are stored on multiple shelving units within the centrally located nurses station. This condition also does not comply with 19.3.2.1 whether it is part of a corridor or within a suite.

11/08/13: to be reviewed further onsite

C. (Modified 04/19/13): Afternoon of 07/18/2012, 7th floor Parkview, ICU (which is not a designated suite) Through staff interview, and observation there are numerous materials stored on multiple shelving units and in many Pixis Units within the centrally located nurses station. This condition also does not comply with 19.3.2.1 whether it is part of a corridor or within a suite.

11/08/13: to be reviewed further onsite

D. Corrected 11/08/13

E. Corrected 04/19/13

Parkview 2nd Floor Suite 8 as shown on the Life Safety documents provided:

By direct observation the surveyor finds not all medical gas zone valves are labeled to reflect the outlets/inlets they serve (NFPA 99, 1999, 4-3.1.2.14 (b) 3) and in some cases depending on correct labeling the valve location may not meet NFPA 99, 1999, 4-3.1.2.3 in that the zone valves are not separated by an intervening wall from the outlets/inlets they serve.

A) K130 Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction PoC and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1) The facility does not comply with NFPA 101 and lacks adequate interim measures for all cited deficiencies.

4/17/13: Interim measures will be reviewed until all corrective actions have been completed.

B) Corrected 11/08/13

C) Corrected 04/18/13

A) K130 Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction PoC and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1) The facility does not comply with NFPA 101 and lacks adequate interim measures for all cited deficiencies.

The above item will remain until all deficiencies are corrected in this building.

Based on random observation during the survey walk-through the building emergency the surveyor finds that the emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517.

Findings include:

1. Life Safety Panels such as XLA8A, XLA7A, XLA6A in the electrical closet on each floor of the North Tower are all serving loads that include: nurse call, comm room receptacles, hall receptacles, time clocks, cameras and cart lifts that should be served by other branches to meet the requirements of NFPA70, Section 517-32 through 34.

2. The Parkview Wing of the main building has Life Safety and Critical Panels in the electrical closets on each floor, including the elevator equipment room that are serving loads that should be served by other branches in accordance with NFPA-70, Section 517-32 through 34. Panels R-1C-8RE1 and R-1C-7RE1 are examples of critical panels that are serving fire alarms that should be served by the life safety panels, and life safety panels L-1S-8RE and L-1S-7RE, and the life safety panels on each floor are serving loads such as nurse call, and room receptacles that should be served by critical panels.

3. The Rogers Wing of the main building has a single emergency panel on each floor serving a mixture of life safety, critical, and in some cases equipment which does not meet the requirements of NFPA-70, Section 517-30 through 34.

4. The Center Wing of the main building had critical panels XCD3A, and XCD1B serving med gas alarms that are required by NFPA-70, Section 517-32 to be served by the life safety branch, and life safety panel XLD2A was serving the nurse call system which is required by NFPA-70, Section 517-33 to be served by the critical branch of the emergency power system.

A) Based on random observation throughout multiple floors and multiple buildings or wings, the surveyors find that data cables above the ceiling area supported by ceiling tiles, sprinkler piping, conduit, ductwork, etc. above ceilings.

The data cables are not supported independently in accordance with NFPA 70 1999 800-52(e). The non-complying supporting elements above ceilings (ceiling tiles, conduit, ducts, sprinkler piping, etc.) are not designed to support data cables. This condition was observed and confirmed by the VP of Facilities and Support Services on 7/17/12.

Examples include but are not limited to:

1) 3rd Floor Center Building - corridor near vending machines

2) 1st Floor Center Building in corridor in front of EVS Closet (near Walgreens)

3) North Tower Wing, 11th Floor - Part of Elevator Lobby leading to OB Unit

4) Corrected 11/08/13

5) Corrected 11/08/13

6) North Tower Wing, 4th Floor exit access corridor by Patient Room 4143

7) North Tower Wing Lower Level CPD Storage exit access corridor near the Electrical Closet

B) Based upon random observation on multiple floors and in multiple buildings or wings, the surveyors find that switch gear and electrical panels are not installed and maintained in accordance with NFPA 70:

1) Corrected 04/18/13

2) Corrected 11/08/13

C) Corrected 11/08/13

End


16339

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. The deficiencies may lead to a lack of power for critical care areas which could affect patients, staff and visitors during a fire event.

Findings include:

A. Corrected 11/07/13

C. In the afternoon, 07/18/2012 North Tower Wing, 2nd Floor near the OR Supervisor's Room - Electrical panels A2D, A2S and CA2S were observed that are being blocked with a chair and a cart which the required 3'-0" clear space is not being maintained to comply with NFPA 70 1999 110-26(a)

A) Corrected 04/18/13




17659

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. Corrected 04/18/13

2. The surveyor did not find a single lockable disconnect for each elevator's emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

3. The surveyor did not find that the disconnect for the emergency lighting and controls for the elevators were properly labeled in accordance with NFPA-70, Section 620-53.

4. Added 11/08/13: it will also be necessary to confirm compliance with NFPA-70, Section 517-32, relative to elevator lighting, etc.

A) Multiple elevators are not installed and tested in accordance with 19.5.3 and 9.4.3.2 of NFPA 101 and ASME/ANSI A17.3, Safety Code for Existing Elevators.

1) Corrected 04/18/13

2) Corrected 11/08/13

B) (New 11/08/13) The existing elevator machine room for multiple elevators at the top of the North Clinic does not comply with 19.5.3 and 9.4.3.2 of NFPA 101 and ASME/ANSI A17.3, Safety Code for Existing Elevators.

1) No smoke detector is installed in the elevator machine room for automatic recall.

2) A shunt trip relay is not installed for each elevator and heat detectors are not installed within two feet of each and every sprinkler heat.

3) This machine room will also be surveyed for compliance with 620-53 and 517-32 of NFPA 70-1999.