HospitalInspections.org

A) Based upon random observation, the surveyors find that fire doors and smoke doors throughout the building are held open or have automatic opening/hold open functions. While some of these doors close upon activation of the fire alarm system, none of the doors close upon activation of the sprinkler system in accordance with 7.2.1.8.2, 7.2.1.9.2 and 18.2.2.2.6.

2) c) (Modified 03/31/10): Pair of auto-open/auto hold open doors to the Ambulance Bay. These doors close and latch upon activation of the fire alarm and sprinkler system, but on 3/31/11 they unlatch again while the fire alarm system was still activated.

(New Item 3): Modified 03/31/11: The pair of fire doors to the Ambulance Bay have been modified; they are installed with continuous hinges. The hinges lack labeling that indicates that they are "listed" for use on fire doors and the documentation that was available does not clearly indicated that the hinges are listed for use on fire doors.

A) Based upon random observation the surveyor finds that exits are not enclosed and maintained as protected path to a public way in accordance with Chapter 7 of NFPA 101.

1) (Modified 04/16/10) Center Stair Lower Level. This stair is identified by the provider as a convenience stair on all floor levels.

b) Deleted 03/31/11

04/16/10: Based upon information
received for the provider's architect, the
stair is a required exit from the Lower
Level

d) Deleted 03/31/11

5) (Modified 04/01/11): The North Exit Stair discharges at the 1st Floor through a required exit passageway.

04/01/11: The Master Plan has not been modified to identify "Existing Exit Passageways" on the plans, as indicated in the last submitted PoC.

a) Corrected 04/16/10

b) Corrected 04/01/11

c) Corrected 04/01/11

6) The East Exit Stair discharges at the 1st Floor through a required exit passageway. This exit passageway is STILL not identified on any plans as an "Existing Exit Passageway.".

A) Sprinkler systems are not installed and maintained in accordance with NFPA 101, NFPA 13, and NFPA 25:

1) The Lower Level Cafeteria and Dining Room is part of a mixed use (Assembly, Business, Storage and Health Care) occupancy. This area was recently renovated but was not provided with sprinkler protection in accordance with 19.1.1.4.5.

4) 4 East is a fully sprinklered fire compartment or smoke compartment. The wardrobe units in each patient room lack sprinkler protection.

The PoC does not identify under K056 what is proposed for the above item

K056 to be cleared with the completion of IDPH Project 9041.

A) Corrected 08/04/10.

B) Corrected 11/18/09

3) All floors with medical gas vacuum outlets in patient rooms or recovery spaces. Medical gas shut off valves were not found. The provider was not able identify the location of the vacuum riser shut off valves for each floor. Locations include but are not limited to:

a) 5th Floor Stage II Recovery spaces.

b) 4 East Bronchoscopy Room and 4 East
patient rooms.

c) Patient rooms of 3 North

5) Deleted 04/01/11

A) 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) 03/31/11 - The provider failed to implement and document adequate interim life safety measures for the conditions cited below:

a) 4th Floor Exit Access Corridor: Bagged
waste full of shredded paper was left in
the corridor south of the OB Unit on the
afternoon of 3/31/11. The provider
failed to find and abate this condition.

b) At 1:00PM on 3/31/11, the surveyor
observed that the main fire alarm panel
was in trouble. The surveyor was
informed by the provider that the fire
alarm system for the entire building was
by-passed (that morning) to allow for
some "hot work" in one particular area.
The surveyor found no interim measures
in place for the following conditions.

*City Tie-in was bypassed; the automatic
functions of the fire alarm system to notify
the fire department was disabled. (19.3.4.3.2)

*Release of all door hold functions, release
of electronic locking devices in accordance
with 7.2.1.8 and 7.2.1.6 were disabled at the
fire alarm panel

*Release of all fire rated shutters was
disabled. (7.2.1.8)

*Automatic notification to building
occupants (horns and strobes) were disabled.
(19.3.4.3.1)

A) Based on random observation, the surveyor observed wiring and panel directories throughout the facility which were not installed and maintained in accordance with NFPA 70 1999.

3) Cables were observed throughout the facility which were not supported by the structure as required by 800-6.

The correction of the above item is on-going and will be cleared upon completion of all other citations.

A) Modified 3/31/11: Based upon random observation and document review that surveyors find that three elevators are not installed and/or tested in accordance with ANSI A17.3.

3) (New 11/18/07): Based upon direct observation the surveyor finds that Elevator 1, 2 and 3 lacks automatic recall to a designated alternate floor in accordance with ANSI A17.3. Activation of a 1st Floor Elevator Lobby smoke detect results in recall of the elevator to the 1st Floor with the doors opening to the floor of fire origin.