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Based on observations made on September 13, 2011, the facility failed to provide for positive latching hardware on a set of one and one-half hour fire doors located in a two-hour barrier.

The findings include:

Communicating openings in dividing fire barriers required by 19.1.1.4.1 of the Life Safety Code shall be protected by approved self-closing fire doors per section 19.1.1.4.2 of the Life Safety Code. Self-closing mechanisms shall operate properly to assure that positive latching is achieved on each fire door operation per section 2-1.4.1 of NFPA 80, 1999 Edition.

The set of one and one-half rated fire doors in the two-hour fire barrier between the Bio-Med service room and the corridor of the building commonly referred to as MOB4 on the first floor were exercised at 8:02 a.m. on September 13, 2011. The set of fire doors did have self-closing mechanisms that could be held open by devices interconnected to the fire alarm system. Each door had a sliding dead bolt lock that served as the means for keeping the doors closed. Sliding dead bolt locks are not considered as positive latching hardware per the interpretations of NFPA 80 for a fire rated door assembly.

Based on observations made during a survey on September 12 and 13, 2011, it has been determined that the facility did not maintain the fire resistive rating of wall and ceiling assemblies.

Findings include:

1. X-Ray room #4 on second floor was observed at 1:00 p.m. on September 12, 2011. An electrical bus panel along the northwest wall was missing a cover along the floor.

2. The office area for Radiology on second floor was observed at 1:45 p.m. on September 12, 2011. There were three ceiling tiles which were missing or had been cut exposing holes through them, which could allow smoke to filtrate to the unprotected level above the ceiling tiles.

Based on observations made on September 12, 2011, the facility failed to assure that corridor doors were provided with a means suitable for keeping the doors closed.

The findings include:

The first floor chapel room had a set of doors facing the exit corridor and entry way of the building. These doors were exercised at 11:29 a.m. on September 12, 2011. The automatic flush bolts on the inactive leaf of the set of doors did not engage when the both doors were in the closed position. The triggers for the automatic bolt mechanism on the inactive leaf were not in the proper alignment thus preventing the inactive door from latching properly.

Based on observations made on September 12 and 13, 2011, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by self-closing fire resistive doors.

The findings include:

1. The soiled dumbwaiter in the central core of Surgery was observed at 3:00 p.m. on September 12, 2011. The self-closing spring was unhooked from the mechanical fire rated door directly above the soiled dumbwaiter doors.

Note: The springs were re-installed during the survey process.

2. The clean dumbwaiter in the central core of Surgery was observed at 3:10 p.m. on September 12, 2011. The self-closing spring was unhooked from the mechanical fire rated door directly above the clean dumbwaiter doors.

Note: The springs were re-installed during the survey process.

Based on observations made on September 12, 2011, the facility failed to place a NO EXIT or similar sign at a door that may be mistaken as a means of egress to the public way.

The findings include:

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 NO EXIT or similar language per section 7.10.8.1 of the Life Safety Code .

The first floor family room was examined at 11:37 a.m. on September 12, 2011. The room was open to the corridor system and had a glass door from it to a patio area. The patio area did not lead directly to the public way due to a lack of a hard surface path from the patio to the sidewalk or parking lot visible from the doorway. This doorway had the potential to be mistaken for an exit as it did lead to the outside of the building but lacks the complete components necessary to be considered an exit. No sign such as NO EXIT or NOT AN EXIT was posted at the glass door to the patio to prevent being mistaken as a means of egress.

Based on observations made on September 13, 2011, the facility failed to appropriately identify which door in a means of egress lead to the public way.

The findings include:

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants per sections 7.10.1.4 and 39.2.10 of the Life Safety Code.

The north (rear) exit door from the building was examined at 10:42 a.m. on September 13, 2011. The corridor from the exam suite leading to this means of egress opens onto an enclosed delivery area. The delivery area consists of four doors, only one of which leads to the public way. There was no exit sign over the set of double doors leading to the public way in this area to ensure that the exit is readily apparent to the occupants using that means of egress.

Based on observations made on September 13, 2011, the facility failed to prevent an exit sign from being obstructed from vision by an informational sign.

The findings include:

No decorations, furnishings, or equipment that impairs visibility of an exit sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted per sections 39.2.10 and 7.10.1.7 of the Life Safety Code.

The north entrance/exit doorway into the building from the parking lot was examined at 11:13 a.m. on September 13, 2011. The door had an illuminated exit sign above it. However, the addition of an informational sign for the reception desk impaired the ability of occupants to clearly see the exit sign.

Based on observations made on September 12 and 13, 2011, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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 as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

The north smoke barrier wall of Endo Exam room #1 was observed at 4:45 p.m. on September 12, 2011. There were two open conduits in the north wall of this room, both were 3/4 inch conduits which had not been sealed with a material to resist the passage of smoke through the barrier.

Note: The smoke barrier was filled with a smoke resistive material during the survey process.

Based on observation, the facility failed to provide self-closing doors on all hazardous areas and to keep all hazardous areas properly protected.

Findings include:

In accordance with NFPA 101 and section 19.3.2.1 Hazardous Areas, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Section 8.4.1.3 of NFPA 101, Life Safety Code states: Doors in barriers required to have a fire resistance rating shall have a 3/4 hour fire protection rating and shall be self-closing in accordance with 7.2.1.8.

The soiled utility room in Labor and Delivery was examined at 11:45 a.m. on September 12, 2011. The door to this room was not self-closing.

Based on observations made on September 13, 2011, the facility failed to assure that exit doors were unlocked and readily available for exiting purposes during periods of occupancy.

The findings include:

Doors shall be arranged to be opened readily from the egress side whenever the building is occupied per sections 7.2.1.5.1 and 39.2.2.2.2 of the Life Safety Code.

The exterior door identified as an exit in the corridor adjacent to the Laboratory suite was examined at 10:17 a.m. on September 13, 2011. When an attempt was made to open the door it was determined that the door was locked during this time of occupancy.

Based on observations made on September 12 and 13, 2011, the facility failed to properly denote and mark the location of the means of disconnect service for the fire alarm control panel (FACP).

The findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s) per section 1-5.2.5.2 of NFPA 72, 1999 edition. 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 or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The Simplex 4100U fire alarm control panel was examined at 2:52 p.m. on September 12, 2011. The panel did not denote the location as to the electrical panel board and breaker that controlled the power to the FACP. A representative of the FACP manufacturer did confirm the location of the power service to be in electrical panel board ELL1 at 8:30 a.m. on September 13, 2011. Upon examination of panel board ELL1, it was determined per the listing that breaker number 10 was the power source for the FACP but was not properly marked in red.

Note: The disconnecting location of the electrical service for the FACP was noted at the fire alarm panel and the proper marking of the breaker in the panel board were performed by the manufacturer's representative after the observations were made.

Based on observations made on September 12 and 13, 2011, the facility failed to maintain the sprinkler system and its components in accordance with the standards of NFPA 101; NFPA 13, 1999 Edition; and NFPA 25, 1998 Edition.

The findings include:

Sprinklers shall be free of corrosion, foreign material, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall) per section 2-2.1.1 of NFPA 25.

1. The Operating Room aid room was observed at 2:30 p.m. on September 12, 2011. There was an escutcheon ring missing on one of the sprinkler pipes on the ceiling.

Note: The escutcheon ring was installed on the sprinkler pipe during the survey process, correcting the problem.



04703

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) per section 2-2.1.1 of NFPA 25, 1998 Edition. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2. The first floor environmental services closet adjacent to the Nurse Manager office was examined at 1:29 p.m. on September 12, 2011. The sprinkler located in this closet exhibited signs of corrosion.

The clearance between the deflector of standard pendent and upright spray sprinklers and the top of storage shall be 18 inches or greater per section 5-6.6 of NFPA 13, 1999 Edition.

3. The mechanical room on the first floor housing the heating, ventilation and air conditioning (HVAC) system for the surgery suite was examined at 1:06 p.m. on September 12, 2011. Due to the size of the duct work in the system sprinkler heads had been placed under those ducts exceeding 4 feet in width. One of these sprinkler heads had boxes of filters stacked within 12 inches of the sprinkler head.

Based on observations made on September 12 and 13, 2011, the facility failed to maintain the means of egress, including exit corridors, free from obstructions that would interfere with their instant use in case of fire or other emergency and also failed to prevent the means of egress from being used for storage purposes.

The findings include:

In accordance with Centers for Medicare and Medicaid Services Survey and Certification letters S&C-04-41 and S&C-10-18 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.

The exit corridors in the immediate area of the laundry room on the first floor were observed over the course of the survey to contain two to three wheeled carts parked in the corridor system. The initial observation during the course of the survey at 2:22 p.m. on September 12, 2011, found that three wheeled carts used for laundry or other purposes had been parked in the exit corridor to the north of the laundry room. At 7:20 a.m. on September 13, 2011 two wheeled carts were parked in the exit corridor to the north of the laundry room. At approximately 9:35 a.m. on September 13, 2011 during the fire alarm and smoke damper testing, two wheeled carts were parked in the exit corridor to the north of the laundry room and one in the exit corridor immediately outside of the laundry room door. Finally, at 12:30 p.m. on September 13, 2011, there were two wheeled carts parked in the exit corridor to the north of the laundry room and one in the exit corridor immediately outside of the laundry room door. These observations concluded that the wheeled carts were being stored in the exit corridors during times of non-use.

Based on review of maintenance records and logs on September 13, 2011, the facility failed to document that one of the two emergency generators serving the facility was subject to a weekly inspection.

The findings include:

The maintenance records and logs for the two emergency generators were reviewed at the facility on September 13, 2011. A maintenance record for the Detroit diesel type generator did note that a weekly inspection was conducted by the maintenance staff. No similar documentation was available verifying that the Caterpillar diesel type generator was subject to a weekly inspection.

Based on observation made on September 12 and 13, 2011, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 National Electrical Code, 1999 Edition; NFPA 99, 1999 Edition; and the Centers for Medicare and Medicaid Services (CMS).

Findings include:

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, 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; 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and interpretations from the CMS.

1. The waiting room for Patient Registration on second floor was observed at 2:00 p.m. on September 12, 2011. The east wall where two soda and candy dispensing machines were plugged into an electrical outlet had a multi-plug in use. These machines were considered large machines as the electrical demand exceeded 12 watts. There was also a water cooler being plugged into the same electrical outlet in the room which was why the multi-plug adaptor was in-use at the wall outlet.

Note: An electrician installed a four-gang outlet for the large machines at this area, and the multi-plug adaptor was no longer required.


04703


Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70. Unused openings in boxes, raceways, auxiliary gutters, cabinets (panel boards), equipment cases or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment per Article 110-12(a) of NFPA 70.

2. The first floor electrical room (located across from the nurse's station) was examined at 1:10 p.m. on September 12, 2011. Three panel boards located within this room did not have a complete listing or marking as to what each breaker serviced. These were:
a) Panel Board EEL1B did not have a listing for breakers 17 and 19.
b) Panel Board ECL1 did not have a listing for breakers 10, 17, 21 and 24.
c) Panel Board L1B did not have a listing for breaker 9.
All of the above breakers were observed to be in the on position.

3. The first floor telephone room was examined at 2:15 p.m. on September 12, 2011. Three panel boards located within this room did not have a complete listing or marking as to what each breaker serviced and one panel board was missing protective plates to prevent contact with the bus bar. These were:
a) Panel Board L1A Section 1 did not have a listing for breaker 21.
b) Panel Board L1A Section 2 did not have a listing for breaker 25.
c) Panel Board KL did not have a listing for breakers 6, 14, 16, 18, 20, 25, 29, 31, 33, 37, 38, 39 and 41.
All of the above breakers were observed to be in the on position.
d) Panel Board KL was missing two protective plates for unused openings in the panel board.

4. The first floor main electrical room that houses the transfer switches for the generator was examined at 2:40 p.m. on September 12, 2011. Panel board ELL1 located within this room was missing two protective plates to prevent contact with the bus bar.

Based on review of the fire watch policy and interview on September 13, 2011, the facility failed to have a fire watch policy which included contacting the authority having jurisdiction (State Certification Bureau at 406-444-4170) whenever a fire watch was instituted.

In accordance with the 2000 Edition of NFPA 101 Section 9.7.6.1, where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the automatic sprinkler system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire policy was provided to the Certification Bureau on September 13, 2011 for review. The fire watch policy did not addressed contacting the Certification Bureau at 406-444-4170 when a fire watch was required.

An interview with the maintenance staff during the exit interview included a question of whether the current fire watch policy contains that the "State Surveying Agency" is to be called when the automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. The maintenance staff members indicated the policy did not include contacting the State Surveying Agency at 406-444-4170.

Based on and interview and review of the fire plan on September 13, 2011, the facility failed to have a fire watch policy which included contacting the authority having jurisdiction (State Certification Bureau at 406-444-4170) whenever a fire watch was instituted for the fire alarm system.

In accordance with the 2000 Edition of NFPA 101 Section 9.7.6.1, where a required automatic fire alarm system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire watch policy was provided to the Certification Bureau on September 13, 2011 for review. After review, the fire watch policy did not specifically include notification of the State Certification Bureau at 406-444-4170 whenever the fire alarm system was out of service for longer than 4 hours in 24 hour period.

An interview with the maintenance staff members included a question of whether the current fire watch policy contains that the "State Surveying Agency" is to be called when the fire alarm system is out of service for more than 4 hours in a 24 hour period. The maintenance staff members indicated that the fire watch policy did not include contacting the State Surveying Agency at 406-444-4170.