HospitalInspections.org

Based on observation and interview, the facility failed to ensure doors protecting corridor openings had means suitable for keeping closed. This has the potential to affect all patients, staff and visitors to the facility. The facility had a capacity of 448 patient beds and a census of 128 patients.

Findings include:

1. On 03/24/15 at 2:45 PM a tour was taken of the third floor. At 2:59 PM the door to the case manager's office was observed to open from the corridor. The door was observed to have a self closer that when activated did not keep the door closed.

On 03/24/15 at 2:49 PM in an interview, Staff QQ confirmed the observation.

2. On 03/25/15 at 10:58 AM a tour of the second floor was conducted with Staff QQ. At 11:04 AM observation of the door protecting the opening from the corridor to the room west of the labor clock revealed its self closer did not keep the door closed.

On 03/25/15 at 11:04 AM in an interview, Staff QQ confirmed the observation.

3. On 03/25/15 at 11:18 AM observation of the door protecting the opening from the corridor to room 217 revealed its self closer did not keep the door closed.

On 03/25/15 at 11:18 AM in an interview, Staff QQ confirmed the observation.

4. On 03/25/15 at 11:18 AM observation of the door protecting the opening from the corridor to room 219 revealed a wet floor sign in its path of travel that would stop the self closer from closing it.

On 03/25/15 at 11:18 AM in an interview, Staff QQ confirmed the observation.

Based on observation and interview, the facility failed to protect vertical openings between floors with construction having a fire resistive rating of at least one hour. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/23/15 at 2:22 PM a tour was taken of the facility's fifth floor with Staff QQ. On 03/23/15 at 2:37 PM, observation inside soiled utility room 564 revealed a circular hole in the ceiling occluded with a porcelain plumbing unit. The hole created an opening between the fifth and sixth floor which was not protected.

On 03/23/15 at 2:37 PM in an interview, Staff QQ confirmed the finding.

2. On 03/24/15 at 9:15 AM the tour of the fifth floor resumed with Staff QQ. On 03/24/15 at 10:34 AM observation of the two hour rated barrier above the drop down ceiling outside stairwell E, revealed a half inch open conduit with a blue wire traveling through it.

On 03/24/15 at 10:34 AM in an interview, Staff QQ confirmed the observation.

3. On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. At 11:16 AM observation of the chute room revealed the chute room door did not completely close.

On 03/24/15 at 11:16 AM in an interview, Staff QQ confirmed the observation.





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4. During tour of the sixth floor at 3:09 PM on 03/23/15 it was observed that on the vertical chase wall facing room 629 was seen an approximate two foot by two foot open into the chase with multiple pipes passing though the hole. This finding was confirmed at the time of discovery by Staff AA.

5. During the tour of the sixth floor at 3:09 PM on 03/23/15 it was observed that two, ½ inch cooper pipes and a 1 1/2 inch drain pipe passed vertically through the ceiling to the upper floor located to the right side of the door entering room 629. The pipes failed to have fire block around the pipes. This finding was confirmed at the time of discovery by staff AA.





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6. Observation above the entrance door, on the ground floor for KKO stairwell from the air handler room side, completed on 03/24/15 at 9:30 AM was observed to have 1/2 inch conduit with open annular space. This finding was verified by Staff FF at the time of the observation.

7. Observation of stairwell HHO's fire rated walls, on the ground floor, above the fire rated door on the corridor side completed on 03/24/15 at 10:05 AM revealed multiple penetrations varying in size and shape. This finding was verified by Staff FF at the time of the observation.

8. Observation of stairwell NNO's fire rated north wall, on the ground floor, on the corridor side completed on 03/24/15 at 10:10 AM revealed a 6 inch sprinkler water pipe penetrating the wall with a 1 inch annular space around the pipe. This finding was verified by Staff FF at the time of the observation.

9. Observation above the drop ceiling between elevators 4 and 5 doors located on the first floor in the South building completed on 03/24/15 at 3:15 PM revealed a 3/4 inch conduit with a gray ring and to gray data cables penetrating the two hour elevator shaft with open annular space and 1 1/2 inch by 1/4 inch open area just above the ceiling assembly. These findings were verified by Staff FF at the time of the observation.

10. Observation above the Fire exit door for Stairwell HH1 on the corridor side located on the first floor of the Ancillary building completed on 03/25/15 at 3:20 PM revealed a 2 inch by 8 inch hole. This finding was verified by Staff FF at the time of the observation.

Based on observation and interview, the facility failed to maintain the rating of its smoke barriers. This has the potential to affect all patients, staff and visitor to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/23/15 at 2:22 PM a tour was taken of the facility's fifth floor with Staff QQ. On 03/23/15 at 2:37 PM observation of the one hour rated barrier opposite the bank of service elevators above the drop down ceiling and near the stenciled words "1 hour" revealed a half inch conduit with two red wires coming out from it and was unstopped.

On 03/23/15 at 2:37 PM in an interview, Staff QQ confirmed the finding.

2. On 03/23/15 at 3:05 PM observation above the drop down ceiling of the one hour rated wall surrounding the equipment room revealed to the right of the door an open half inch conduit with a white wire traveling out of it.

On 03/23/15 at 3:05 PM in an interview, Staff QQ confirmed the observation.

3. On 03/24/15 at 9:15 AM the tour of the fifth floor resumed with Staff QQ. At 9:45 AM observation above the drop down ceiling of the one hour rated barrier between 586 and 587 revealed a two inch square penetration, with a depth of at least one foot (a one foot probe could not touch the back of the penetration).

On 03/24/15 at 9:45 AM in an interview, Staff QQ confirmed the observation.

4. On 03/24/15 at 10:08 AM observation above the drop down ceiling of the one hour rated wall over the double doors in room 589 revealed a half inch open conduit with a red wire coming out of it.

On 03/24/15 at 10:08 AM in an interview, Staff QQ confirmed the observation.

5. On 03/24/15 at 10:34 AM observation above the drop down ceiling of the one rated barrier over the double doors between rooms 558 and 559 revealed a half inch open conduit with two red wires coming out of it.

On 03/24/15 at 10:34 AM Staff QQ confirmed the observation.

6. On 03/24/15 at 10:49 AM observation of the one hour rated barrier over the double doors leading to the corridor from room 558 revealed a half inch open conduit with yellow, blue, and black wires.

On 03/24/15 at 10:49 AM in an interview, Staff QQ confirmed the observation.

7. On 03/24/15 at 11:05 AM observation above the drop down ceiling of the one hour barrier dividing room 559 from the corridor revealed a white tipped half inch conduit open to air, and a sprinkler line with an annular space.

On 03/24/15 at 11:05 AM in an interview, Staff QQ confirmed the observation.

8. On 03/24/15 at 2:45 PM a tour was taken of the third floor with Staff QQ. At 2:50 PM observation above the drop down ceiling outside the chute room of the one hour rated barrier separating the chute room from the corridor revealed just to the left of the door a medical gas copper line with an annular space.

On 03/24/15 at 2:50 PM in an interview, Staff QQ confirmed the observation.

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Based on observation and interview, the facility failed to ensure doors in smoke barrier openings were on self closer's and gaps between double doors were less than an eighth of an inch. This has the potential to affect all patients, staff and visitor to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/24/15 at 9:15 AM the tour of the fifth floor was conducted with Staff QQ. On 03/24/15 at 9:52 AM, observation of the double doors perpendicular to room 588 revealed about 70 percent of the gap between them was greater than one eighth of an inch.

On 03/24/15 at 9:52 AM, Staff QQ confirmed the observation.

2. On 03/24/15 at 11:06 AM observation of double doors perpendicular to room 559 and in a one hour smoke barrier revealed a gap of greater than one eighth of an inch for over 90 percent of the gap.

On 03/24/15 at 11:06 AM in an interview, Staff QQ confirmed the observation.

3. On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. At 2:04 PM observation of the door in the 30 minute barrier leading to room 413 revealed it was not on a self closer.

On 03/24/15 at 11:10 AM in an interview, Staff QQ confirmed the observation.

4. On 03/25/15 at 10:24 AM a tour of the third floor with Staff QQ was resumed. At 10:30 AM observation of the door in the 30 minute smoke barrier in the rest room in the east/west corridor between the intensive care unit and cardiovascular suite revealed it to have a self closer and a wooden wedge keeping it held open.

On 03/25/15 at 10:30 AM in an interview, Staff QQ confirmed the observation.

5. On 03/25/15, between 1:40 P.M. and 2:25 P.M., tour of the second floor was conducted with Staff CC and DDS. Observation of identified smoke barrier doors, located in the corridor near the pharmacy, revealed that upon release of the doors from the hold-open devices, the smoke barrier doors failed to close to impede the passage of smoke. Staff DDS and Staff QQ, who was present at the testing of the doors, confirmed the doors did not close to impede the passage of smoke.






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6. Observation of the Emergency Suite located on the first floor of the South Building completed on 03/24/15 at 4:20 PM revealed the self closing door in the smoke barrier between Emergency Suite and the Registration office being held open with a triangular piece of wood. This was verified by Staff FF at the time of the observation.

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Based on observation and interview, the facility failed to maintain the rating of the protective construction surrounding, and have doors on self closer's leading to, hazardous areas. This has the potential to affect all patients, staff and visitor to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/23/15 at 2:22 PM a tour was taken of the facility's fifth floor with Staff QQ. On 03/23/15 at 2:37 PM a six inch by six inch square was observed to be cut in the left corner of the one hour barrier above the drop down ceiling, as the soiled utility room is entered.

03/23/15 at 2:37 PM in an interview, Staff QQ confirmed the observation.

2. On 03/23/15 at 2:41 PM observation above the drop ceiling, to the left of the door of soiled utility room 564, of the one hour barrier revealed a half inch open conduit with a purple wire coming out. Next to that, a sprinkler line was observed to have an annular space. Next to that, a hot water pipe was observed to have an annular space within a metallic sleeve.

On 03/23/15 at 2:41 PM in an interview, Staff QQ confirmed the observation.

3. On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. At 1:45 PM observation of the door to the biohazard room next to room 412 revealed it was not on a self closer.

On 03/24/15 at 1:45 PM in an interview, Staff QQ confirmed the observation.

4. On 03/24/15 at 2:45 PM a tour was taken of the third floor. At 3:13 PM observation above the drop down ceiling of the one hour protective construction around the soiled utility room next to the case manager's office revealed an open junction box in the center. Leading to this open junction box were four one inch conduits. In the western wall a one inch square opening with two red wires leading from it was observed.

On 03/24/15 at 3:13 PM in an interview, Staff QQ confirmed the observation.

5. On 03/25/15 at 10:58 AM a tour of the second floor was conducted with Staff QQ. At 2:11 PM observation of the wall above the drop down ceiling surrounding the unsprinklered soiled utility room in the CMU suite revealed, as observed from the storage room, a one inch hole near the center of the wall, as observed from the corridor over the door, a one inch by one square hole, and as observed from the lounge, a L shaped hole in the middle part of the wall.

On 03/25/15 at 2:11 PM in an interview, Staff QQ confirmed the observation.

6. On 03/25/15, between 10:15 A.M. and 11:45 A.M., tour of the third floor was conducted with Staff CC, EE and EE. Observation of a soiled utility room, located in the recovery room, revealed the room was not provided automatic sprinkler protection. The door to the soiled utility room was wood with no fire resistance rating and no self-closing device. Observation above the ceiling tiles in the soiled utility room revealed there was no one hour fire rated construction that separated the room.

7. Further observation of the third floor with Staff CC, DDS and EE revealed a larger soiled utility room, located near an exit stairwell. The soiled utility room was used for trash and soiled linens collected from the operating rooms. Observation inside the soiled utility room revealed automatic sprinkler and smoke detection was present. Ceiling tiles within the soiled utility room, utilized as a smoke resistive partition, were observed in one corner of the room to be warped and displaced within the grid. The displaced ceiling tiles would not resist the passage of smoke. Staff DDS, present at the observation, confirmed the poor fitting ceiling tiles in that corner of the room, would not resist the passage of smoke.




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8. Observation of the ground floor boiler room's West wall on the side where the fire pump is located completed on 03/23/15 at 3:35 PM revealed an 8 inch by 8 inch electrical junction box penetrating the 1 hour rated wall without a protective cover present. This finding was verified by Staff FF at the time of the observation.

9. Observation of the ground floor boiler room's South wall on the side where the fire pump is located completed on 03/23/15 at 3:40 PM revealed an 8 inch round opening without any fire protection. This finding was verified by Staff FF at the time of the observation.

10. Observation of the North wall of the generator room on the ground floor by the corridor entrance completed on 03/24/15 at 9:30 AM revealed three copper water lines, with white insulation around them, ranging from 1/2 inch to 1 1/2 inches penetrating the 2 hour wall with open annular space. This finding was verified by Staff FF at the time of the observation.

11. Observation of the first floor gift shop storage room completed on 03/24/15 at 11:00 AM revealed sprinkler heads with rapid response heads and a non-rated door without a self closing device. This finding was verified by Staff FF at the time of the observation.

12. Observation of the trash room on the first floor completed on 03/24/15 at 1:45 PM revealed double 1 1/2 hour rated fire doors on an hydraulic self opening and closing mechanism identified as 1111D with the mechanism not allowing the fire doors to close. This finding was verified by Staff FF at the time of the observation.

13. Observation above the drop ceiling in the exit access corridor on the first floor by the trash room completed on 03/24/15 at 1:50 PM revealed a round 3 inch hole with a 1 1/2 inch water pipe passing through the fire rated west wall of the trash room. This finding was verified by Staff FF at the time of the observation.

14. Observation of the South 2 hour wall in the Boiler room located on the first floor of the Service Building completed on 03/24/15 at 2:55 PM revealed an open end on a 3/4 inch conduit with 2 red data cables passing through penetrating the wall. This finding was verified by Staff FF at the time of the observation.

15. Observation in the High Voltage Room located on the first floor of the Service Building completed on 03/24/15 at 3:00 PM revealed multiple penetrations varying in size and shape of the South 2 hour wall and the North and West 1 hour rated walls. These findings were verified by Staff FF at the time of the observation.

16. Observation of the Radiology file Storage area located on the first floor of the Service Building completed on 03/25/15 at 10:45 AM revealed the room was sprinklered and was attached to a general storage area with a door opening with no door in place. The general storage area had no sprinkler system in place. This finding was verified by Staff FF at the time of the observation.

Based on schematic review and staff verification the facility failed to maintain the fire rated walls of the exit access corridors. This has the potential to affect all patients, visitors, and staff in the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. Observation of the trash room on the first floor of the Service Building completed on 03/24/15 at 1:45 PM revealed double 1 1/2 hour rated fire doors (1111D), for access to the exit access corridor, on an hydraulic self opening and closing mechanism with the mechanism not allowing the fire doors to close. This finding was verified by Staff FF at the time of the observation.

2. Observation above the drop ceiling in the exit access corridor on the first floor of the Service Building by the trash room completed on 03/24/15 at 2:00 PM revealed a round 3 inch hole with a 1 1/2 inch water pipe passing through the fire rated west wall of the trash room. This finding was verified by Staff FF at the time of the observation.

3. Observation above the drop ceiling in the exit access corridor on the first floor of the Service Building by the trash room completed on 03/24/15 at 2:05 PM revealed a round 3 inch hole with a 1 1/2 inch water pipe passing through and a 2 inch whole penetrating the east wall of near the north fire rated double doors. This finding was verified by Staff FF at the time of the observation.

4. Observation above the South fire rated doors (1110R) in the exit access corridor on the first floor of the Service Building by the trash room completed on 03/24/15 at 2:22 PM revealed a 3/4 inch conduit open on the end and with open annular space penetrating the 2 hour rated wall. This was verified by Staff FF at the time of the observation.

5. Observation above the drop ceiling in the exit access corridor by the Ambulance Entrance to the Emergency Suite located on the first floor of the South Building completed on 03/24/15 at 3:30 PM revealed 2 feet by 6 feet opening in the 2 hour wall above the EMS supply room door. This was verified by Staff FF at the time of the observation.

6. Observation above the drop ceiling in the exit access corridor by doors 1100X on the first floor of the Ancillary Building completed on 03/25/15 at 11:30 AM revealed the 2 hour West wall had a 1/2 inch gap at the deck. This finding was verified by Staff FF at the time of the observation.

7. Observation above the drop ceiling in the exit access corridor above the Echo Lab sign on the first floor of the Ancillary Building completed on 03/25/15 at 11:35 AM revealed the one hour East wall had a 1 inch annular penetration and an 1 1/2 inch annular penetration with white data cables passing through. This finding was verified by Staff FF at the time of the observation.

8. Observation above the drop ceiling in the the Staff Lounge located in the Emergency PSCCU Suite of the South Building completed on 03/25/15 at 2:00 PM revealed multiple penetrations varying in size and shape in the 2 hour east wall. These findings were verified by Staff FF at the time of the observation.

9. Observation above the drop ceiling in the Joseph's Room located in the Emergency PSCCU Suite on the first floor of the South Building completed on 03/25/15 at 2:05 PM revealed two 3/4 inch conduits penetrating the 2 hour East wall with open annular space. These findings were verified by Staff FF at the time of the observation.

10. Observation above the doors 1018Z in the Emergency PSCCU Suite on the first floor of the South Building completed on 03/25/15 at 2:05 PM revealed multiple conduits with open ends varying in size penetrating the 2 hour wall. These findings were verified by Staff FF at the time of the observation.

11. Observation above the drop ceiling in the dictation room in the Emergency PSCCU Suite on the first floor of the South Building completed on 03/25/15 at 2:12 PM revealed the 2 hour East wall not sealed at the deck above and multiple penetrations varying in size and shape. These findings were verified by Staff FF at the time of the observation.

12. Observation above door 1016N on the office side of the Ancillary Building completed on 03/25/15 at 2:35 PM revealed 6 inch water pipe penetrating with 1 inch open annular space in the one hour East exit access corridor wall. This was verified by Staff FF at the time of the observation.

13. Observation above the drop ceiling of the 1 hour West wall of Waiting Room 135 of the Ancillary Building completed on 03/25/15 revealed a 3 inch by 4 inch penetration with open space below a junction box. This finding was verified by Staff FF at the time of the observation.

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. This could affect all persons utilizing the area. The hospital had a capacity of 448 patient beds with a census of 128 patients.

Findings include;

1. On 03/25/15, between 1:40 P.M. and 2:25 P.M., tour of the second floor was conducted with Staff CC and DDS. Observation of an exit stairwell to the point of exit discharge, at exit door 1147, revealed the discharge was on a cement pad approximately four feet by six feet in size. From the cement pad, travel to the public way was a distance of approximately 25 feet over grassy, uneven ground and mulch covered dirt.

Staff DDS present at the observation confirmed the finding.





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2. Observation outside the exit door from stairwell HH1 completed on 03/25/15 at 3:00 PM revealed a 3 foot by 10 foot side walk traveling from the exit door to the East beside the building, then a mulch covered area encompassing a 7 foot distance to the parking area. This was verified by Staff FF at the time of the observation.

Based on observation and interview, the facility failed to maintain an automatic sprinkler system in accordance with NFPA 25. This has the potential to affect all patients, staff and visitor to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. At 11:16 AM observation of the sprinkler head in the chute room revealed it to be covered with dust such that the bulb was difficult to observe.

On 03/24/15 at 11:16 AM in an interview, Staff QQ confirmed the observation.

2. On 03/25/15 at 10:58 AM a tour of the second floor was conducted with Staff QQ. At 10:58 AM observation of the sprinkler head in the chute room itself was observed covered in dust. Observation of the sprinkler head in the chute itself was covered in dust. In each instance, the color of the bulb fluid was difficult to see.

On 03/25/15 at 10:58 AM in an interview, Staff QQ confirmed the observation.






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3. Observation in the exit access corridor by the Ambulance entrance of the Emergency Suite in the South building completed on 03/24/15 at 3:30 PM revealed 3 quick response sprinkler heads with excessive amounts of foreign debris covering the bulb. This finding was verified by Staff FF at the time of the observation.

4. Observation in the CT Scan area located in the Ancillary building competed on 03/25/15 at 11:20 AM revealed multiple quick response sprinkler heads with excessive amounts of foreign debris covering the bulb. This finding was verified by Staff FF at the time of the observation.

Based observation and staff verification the facility failed to ensure fire extinguishers are inspected in accordance with National Fire Protection Association (NFPA) 10 section 1-6.3, and free from obstructions to access. This has the potential to affect all patients, visitors, and staff in the facility. The facility had a capacity of 448 beds and a census of 128 patients.
Findings include:

1. Observation in the receiving area located on the ground floor completed on 03/24/15 at 10:00 AM revealed fire extinguisher 104200 was obstructed by a pallet of cardboard boxes. This was verified by Staff FF at the time of the observation.

2. Observation of the CT suite corridor completed on 03/25/15 at 11:25 AM revealed a fire extinguisher (1018L) that had a plastic ring around the neck that showed the last hydrostatic pressure was completed on 02/2009. This was verified by Staff FF at the time of the observation.

3. Interview with Staff FF on 03/25/15 at 11:25 AM revealed that the facility was aware that there were a couple of fire extinguishers beyond the due date for the hydrostatic pressure testing.

4. During documentation review completed on 03/26/15 the facility failed to provide evidence that hydrostatic pressure testing was completed on fire extinguisher with identification 1018L.

Based on interview and record review, the facility failed to comply with section 9.2 and therefore section 9.2.1 that states the heating, ventilation and cooling and related equipment shall be in accordance with National Fire Protection Association 90A, which states at 2-1.1 equipment shall be arranged to afford access for inspection, maintenance, and repair. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

On 03/26/15 a review of a sample of the facility's fire/smoke damper maintenance documentation was completed. This sample included dampers inspected in April 2012 and November 2014.

On 03/26/15 at 3:45 PM in an interview, Staff QQ stated one-sixth of all dampers are tested every year so that every damper gets tested every six years.

The record review revealed the sample total was 405 dampers. Of those, 31, or 7.6 percent, were inaccessible and not tested. Fifteen of those sampled were described as appearing to not exist, or failed because "no damper, the wall is rated for two hours", such as at location code 1154Y, or "appears to have dampers but no access to confirm," at 1005B. Another 25 of those sampled, or 6.1 percent, were described as failed due to, for example, uneven spring tension (1126S), or because damper did not close completely when link was removed (1185Z). The inspection was performed by an outside company.

On 03/26/15 at 3:45 PM in an interview, Staff QQ explained he/she did not know when the inaccessible dampers were last tasted. He/she explained that if they would become accessible through future construction, they would then be tested.

On 03/26/15 at 4:30 PM in an interview, Staff QQ further explained the dampers are managed by an outside company, and was uncertain that all dampers that failed were fixed.

Based on observation and interview, the facility failed to ensure portable heating devices were not in an area with sleeping patients. This has the potential to affect all patients, staff and visitor to the facility. The hospital had a capacity of 448 patient beds and a census of 128 patients.

Findings include:

On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. On 11:25 AM observation in room 413B revealed a space heater. (Office 413B shares smoke compartment with sleeping patients.) The space heater was observed turned on with a stool next to it and papers hanging from a bulletin board over it. The stool and the papers were within three feet of it. The heater had a tag on it which said not to place furniture and other combustible items within three feet of the heater. In addition, the heater was observed unattended.

On 03/24/15 at 11:25 AM in an interview, Staff QQ confirmed the observation.

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Based on schematic review, observation, and staff verification the facility failed to maintain medical gas storage area protections. This has the potential to affect all patients, visitors, and staff in the facility. The facility census was 128.

Findings include:

1. Observation of a room located by the dock and Morgue area completed on 03/26/15 at 11:20 AM revealed 12 empty H medical gas tanks (2 of which were not secure with a chain), 8 full Nitrous Oxide H tanks, 1 Carbon Dioxide H tank (not secure), and 46 empty Oxygen E tanks. Review of the Schematic revealed the south wall without fire rating. The south wall of the room was noted to have multiple penetrations varying in size and shape and one of the two self closing non-rated doors was being held open by an hold open device not attached to the fire alarm system. This was verified by Staff QQ at the time of the observation.


2. On 03/25/15, between 10:15 A.M. and 11:45 A.M., tour of the third floor surgical area was conducted with Staff CC, DDS and EE. Observation of the back corridor of the surgical area revealed storage of H size and E size cylinders of various medical gases. The corridor storage area included four, H size cylinders of nitrogen, one, H size cylinder of medical air, nine, E size cylinders of carbon dioxide and seven ,E size cylinders of oxygen. Four of the seven E size cylinders of oxygen were labeled "empty". Additionally, located in the corridor outside operating room 12, were three, E size cylinders of oxygen, labeled as "empty". Interview of Staff EE, present at the observation, confirmed the storage of the medical gases in the corridor were for easy accessibility and the use in some surgical procedures.

Interview of Staff QQ, on 03/26/15, between 10:00 A.M. and 11:00 A.M. regarding the storage of medical gases in the back surgical corridor revealed that in addition to full tanks, the facility procedure was that if a tank is partially used, an empty tag will be placed on the tank for replacement and placed in the "empty" tank rack.

Based on observation and staff interview it was determined that the facility failed to supply all the styles of sprinkler heads used within the facility in the spare sprinkler head box according to NFPA 25, 2002 Edition, 5.2.1.3. This had a potential to affect all staff and patients within this facility.

Findings include:

During the tour of the facility at 9:38 AM on 03/25/15 it was observed that the facility spare sprinkler head box failed to contain all the styles of sprinkler heads used with the facility. During interview with Staff AA it was confirmed that the box failed to contain the sprinkler heads of all styles used in the facility. Staff AA confirmed the finding at the time of discovery.

Based on observation and staff interview it was determined that the facility failed to supply all the styles of sprinkler heads used within the facility in the spare sprinkler head box as required by the NFPA 25, 2002 edition, 5.2.1.3. This had a potential to affect all staff and patients within this facility.

Findings include:

During the tour of the facility at 8:58 AM on 03/24/15 it was observed that the facility spare sprinkler head box failed to contain all the styles of sprinkler heads used with the facility. During interview with Staff AA it was confirmed that the box failed to contain the sprinkler heads used in the air handler room. Staff AA confirmed the finding at the time of discovery.


Based on observation, document review, and staff interview it was determined that the facility failed to perform fire drills at least once per quarter according to NFPA 101, 2000 edition
21.7.1.2 . This had a potential to affect all staff and patients within the facility.
Findings include:
During the tour on 03/24/15 from 9:00 AM until 2:00 PM, the fire drill documentation was reviewed and revealed the facility performed a fire drill on 10/13/15 and 02/16/15.
During interview with Staff AA it was revealed the facility obtained occupancy on 07/14/2014 and from that time did only perform two fire drills until the time of survey. This failed to meet the requirement of fire drills to be performed at least every quarter. The finding was confirmed at the time of discovery by staff AA.

Based on observation and staff verification the facility failed to have all their medical gas storage areas marked with a precautionary sign, readable from a distance of 5 feet, that is conspicuously displayed on each door of the storage room or inclosure. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:


Observation of the gas storage area located by the Morgue completed on 03/26/15 at 11:20 AM revealed no sign on the entrance door from the corridor side or the door located on the dock area side to warn people of the gas storage area. This was verified by Staff QQ at the time of the observation.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings had means suitable for keeping closed. This has the potential to affect all patients, staff and visitors to the facility. The facility had a capacity of 448 patient beds and a census of 128 patients.

Findings include:

1. On 03/24/15 at 2:45 PM a tour was taken of the third floor. At 2:59 PM the door to the case manager's office was observed to open from the corridor. The door was observed to have a self closer that when activated did not keep the door closed.

On 03/24/15 at 2:49 PM in an interview, Staff QQ confirmed the observation.

2. On 03/25/15 at 10:58 AM a tour of the second floor was conducted with Staff QQ. At 11:04 AM observation of the door protecting the opening from the corridor to the room west of the labor clock revealed its self closer did not keep the door closed.

On 03/25/15 at 11:04 AM in an interview, Staff QQ confirmed the observation.

3. On 03/25/15 at 11:18 AM observation of the door protecting the opening from the corridor to room 217 revealed its self closer did not keep the door closed.

On 03/25/15 at 11:18 AM in an interview, Staff QQ confirmed the observation.

4. On 03/25/15 at 11:18 AM observation of the door protecting the opening from the corridor to room 219 revealed a wet floor sign in its path of travel that would stop the self closer from closing it.

On 03/25/15 at 11:18 AM in an interview, Staff QQ confirmed the observation.

Based on observation and interview, the facility failed to protect vertical openings between floors with construction having a fire resistive rating of at least one hour. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/23/15 at 2:22 PM a tour was taken of the facility's fifth floor with Staff QQ. On 03/23/15 at 2:37 PM, observation inside soiled utility room 564 revealed a circular hole in the ceiling occluded with a porcelain plumbing unit. The hole created an opening between the fifth and sixth floor which was not protected.

On 03/23/15 at 2:37 PM in an interview, Staff QQ confirmed the finding.

2. On 03/24/15 at 9:15 AM the tour of the fifth floor resumed with Staff QQ. On 03/24/15 at 10:34 AM observation of the two hour rated barrier above the drop down ceiling outside stairwell E, revealed a half inch open conduit with a blue wire traveling through it.

On 03/24/15 at 10:34 AM in an interview, Staff QQ confirmed the observation.

3. On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. At 11:16 AM observation of the chute room revealed the chute room door did not completely close.

On 03/24/15 at 11:16 AM in an interview, Staff QQ confirmed the observation.





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4. During tour of the sixth floor at 3:09 PM on 03/23/15 it was observed that on the vertical chase wall facing room 629 was seen an approximate two foot by two foot open into the chase with multiple pipes passing though the hole. This finding was confirmed at the time of discovery by Staff AA.

5. During the tour of the sixth floor at 3:09 PM on 03/23/15 it was observed that two, ½ inch cooper pipes and a 1 1/2 inch drain pipe passed vertically through the ceiling to the upper floor located to the right side of the door entering room 629. The pipes failed to have fire block around the pipes. This finding was confirmed at the time of discovery by staff AA.





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6. Observation above the entrance door, on the ground floor for KKO stairwell from the air handler room side, completed on 03/24/15 at 9:30 AM was observed to have 1/2 inch conduit with open annular space. This finding was verified by Staff FF at the time of the observation.

7. Observation of stairwell HHO's fire rated walls, on the ground floor, above the fire rated door on the corridor side completed on 03/24/15 at 10:05 AM revealed multiple penetrations varying in size and shape. This finding was verified by Staff FF at the time of the observation.

8. Observation of stairwell NNO's fire rated north wall, on the ground floor, on the corridor side completed on 03/24/15 at 10:10 AM revealed a 6 inch sprinkler water pipe penetrating the wall with a 1 inch annular space around the pipe. This finding was verified by Staff FF at the time of the observation.

9. Observation above the drop ceiling between elevators 4 and 5 doors located on the first floor in the South building completed on 03/24/15 at 3:15 PM revealed a 3/4 inch conduit with a gray ring and to gray data cables penetrating the two hour elevator shaft with open annular space and 1 1/2 inch by 1/4 inch open area just above the ceiling assembly. These findings were verified by Staff FF at the time of the observation.

10. Observation above the Fire exit door for Stairwell HH1 on the corridor side located on the first floor of the Ancillary building completed on 03/25/15 at 3:20 PM revealed a 2 inch by 8 inch hole. This finding was verified by Staff FF at the time of the observation.

Based on observation and interview, the facility failed to maintain the rating of its smoke barriers. This has the potential to affect all patients, staff and visitor to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/23/15 at 2:22 PM a tour was taken of the facility's fifth floor with Staff QQ. On 03/23/15 at 2:37 PM observation of the one hour rated barrier opposite the bank of service elevators above the drop down ceiling and near the stenciled words "1 hour" revealed a half inch conduit with two red wires coming out from it and was unstopped.

On 03/23/15 at 2:37 PM in an interview, Staff QQ confirmed the finding.

2. On 03/23/15 at 3:05 PM observation above the drop down ceiling of the one hour rated wall surrounding the equipment room revealed to the right of the door an open half inch conduit with a white wire traveling out of it.

On 03/23/15 at 3:05 PM in an interview, Staff QQ confirmed the observation.

3. On 03/24/15 at 9:15 AM the tour of the fifth floor resumed with Staff QQ. At 9:45 AM observation above the drop down ceiling of the one hour rated barrier between 586 and 587 revealed a two inch square penetration, with a depth of at least one foot (a one foot probe could not touch the back of the penetration).

On 03/24/15 at 9:45 AM in an interview, Staff QQ confirmed the observation.

4. On 03/24/15 at 10:08 AM observation above the drop down ceiling of the one hour rated wall over the double doors in room 589 revealed a half inch open conduit with a red wire coming out of it.

On 03/24/15 at 10:08 AM in an interview, Staff QQ confirmed the observation.

5. On 03/24/15 at 10:34 AM observation above the drop down ceiling of the one rated barrier over the double doors between rooms 558 and 559 revealed a half inch open conduit with two red wires coming out of it.

On 03/24/15 at 10:34 AM Staff QQ confirmed the observation.

6. On 03/24/15 at 10:49 AM observation of the one hour rated barrier over the double doors leading to the corridor from room 558 revealed a half inch open conduit with yellow, blue, and black wires.

On 03/24/15 at 10:49 AM in an interview, Staff QQ confirmed the observation.

7. On 03/24/15 at 11:05 AM observation above the drop down ceiling of the one hour barrier dividing room 559 from the corridor revealed a white tipped half inch conduit open to air, and a sprinkler line with an annular space.

On 03/24/15 at 11:05 AM in an interview, Staff QQ confirmed the observation.

8. On 03/24/15 at 2:45 PM a tour was taken of the third floor with Staff QQ. At 2:50 PM observation above the drop down ceiling outside the chute room of the one hour rated barrier separating the chute room from the corridor revealed just to the left of the door a medical gas copper line with an annular space.

On 03/24/15 at 2:50 PM in an interview, Staff QQ confirmed the observation.

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Based on observation and interview, the facility failed to ensure doors in smoke barrier openings were on self closer's and gaps between double doors were less than an eighth of an inch. This has the potential to affect all patients, staff and visitor to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/24/15 at 9:15 AM the tour of the fifth floor was conducted with Staff QQ. On 03/24/15 at 9:52 AM, observation of the double doors perpendicular to room 588 revealed about 70 percent of the gap between them was greater than one eighth of an inch.

On 03/24/15 at 9:52 AM, Staff QQ confirmed the observation.

2. On 03/24/15 at 11:06 AM observation of double doors perpendicular to room 559 and in a one hour smoke barrier revealed a gap of greater than one eighth of an inch for over 90 percent of the gap.

On 03/24/15 at 11:06 AM in an interview, Staff QQ confirmed the observation.

3. On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. At 2:04 PM observation of the door in the 30 minute barrier leading to room 413 revealed it was not on a self closer.

On 03/24/15 at 11:10 AM in an interview, Staff QQ confirmed the observation.

4. On 03/25/15 at 10:24 AM a tour of the third floor with Staff QQ was resumed. At 10:30 AM observation of the door in the 30 minute smoke barrier in the rest room in the east/west corridor between the intensive care unit and cardiovascular suite revealed it to have a self closer and a wooden wedge keeping it held open.

On 03/25/15 at 10:30 AM in an interview, Staff QQ confirmed the observation.

5. On 03/25/15, between 1:40 P.M. and 2:25 P.M., tour of the second floor was conducted with Staff CC and DDS. Observation of identified smoke barrier doors, located in the corridor near the pharmacy, revealed that upon release of the doors from the hold-open devices, the smoke barrier doors failed to close to impede the passage of smoke. Staff DDS and Staff QQ, who was present at the testing of the doors, confirmed the doors did not close to impede the passage of smoke.






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6. Observation of the Emergency Suite located on the first floor of the South Building completed on 03/24/15 at 4:20 PM revealed the self closing door in the smoke barrier between Emergency Suite and the Registration office being held open with a triangular piece of wood. This was verified by Staff FF at the time of the observation.

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Based on observation and interview, the facility failed to maintain the rating of the protective construction surrounding, and have doors on self closer's leading to, hazardous areas. This has the potential to affect all patients, staff and visitor to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/23/15 at 2:22 PM a tour was taken of the facility's fifth floor with Staff QQ. On 03/23/15 at 2:37 PM a six inch by six inch square was observed to be cut in the left corner of the one hour barrier above the drop down ceiling, as the soiled utility room is entered.

03/23/15 at 2:37 PM in an interview, Staff QQ confirmed the observation.

2. On 03/23/15 at 2:41 PM observation above the drop ceiling, to the left of the door of soiled utility room 564, of the one hour barrier revealed a half inch open conduit with a purple wire coming out. Next to that, a sprinkler line was observed to have an annular space. Next to that, a hot water pipe was observed to have an annular space within a metallic sleeve.

On 03/23/15 at 2:41 PM in an interview, Staff QQ confirmed the observation.

3. On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. At 1:45 PM observation of the door to the biohazard room next to room 412 revealed it was not on a self closer.

On 03/24/15 at 1:45 PM in an interview, Staff QQ confirmed the observation.

4. On 03/24/15 at 2:45 PM a tour was taken of the third floor. At 3:13 PM observation above the drop down ceiling of the one hour protective construction around the soiled utility room next to the case manager's office revealed an open junction box in the center. Leading to this open junction box were four one inch conduits. In the western wall a one inch square opening with two red wires leading from it was observed.

On 03/24/15 at 3:13 PM in an interview, Staff QQ confirmed the observation.

5. On 03/25/15 at 10:58 AM a tour of the second floor was conducted with Staff QQ. At 2:11 PM observation of the wall above the drop down ceiling surrounding the unsprinklered soiled utility room in the CMU suite revealed, as observed from the storage room, a one inch hole near the center of the wall, as observed from the corridor over the door, a one inch by one square hole, and as observed from the lounge, a L shaped hole in the middle part of the wall.

On 03/25/15 at 2:11 PM in an interview, Staff QQ confirmed the observation.

6. On 03/25/15, between 10:15 A.M. and 11:45 A.M., tour of the third floor was conducted with Staff CC, EE and EE. Observation of a soiled utility room, located in the recovery room, revealed the room was not provided automatic sprinkler protection. The door to the soiled utility room was wood with no fire resistance rating and no self-closing device. Observation above the ceiling tiles in the soiled utility room revealed there was no one hour fire rated construction that separated the room.

7. Further observation of the third floor with Staff CC, DDS and EE revealed a larger soiled utility room, located near an exit stairwell. The soiled utility room was used for trash and soiled linens collected from the operating rooms. Observation inside the soiled utility room revealed automatic sprinkler and smoke detection was present. Ceiling tiles within the soiled utility room, utilized as a smoke resistive partition, were observed in one corner of the room to be warped and displaced within the grid. The displaced ceiling tiles would not resist the passage of smoke. Staff DDS, present at the observation, confirmed the poor fitting ceiling tiles in that corner of the room, would not resist the passage of smoke.




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8. Observation of the ground floor boiler room's West wall on the side where the fire pump is located completed on 03/23/15 at 3:35 PM revealed an 8 inch by 8 inch electrical junction box penetrating the 1 hour rated wall without a protective cover present. This finding was verified by Staff FF at the time of the observation.

9. Observation of the ground floor boiler room's South wall on the side where the fire pump is located completed on 03/23/15 at 3:40 PM revealed an 8 inch round opening without any fire protection. This finding was verified by Staff FF at the time of the observation.

10. Observation of the North wall of the generator room on the ground floor by the corridor entrance completed on 03/24/15 at 9:30 AM revealed three copper water lines, with white insulation around them, ranging from 1/2 inch to 1 1/2 inches penetrating the 2 hour wall with open annular space. This finding was verified by Staff FF at the time of the observation.

11. Observation of the first floor gift shop storage room completed on 03/24/15 at 11:00 AM revealed sprinkler heads with rapid response heads and a non-rated door without a self closing device. This finding was verified by Staff FF at the time of the observation.

12. Observation of the trash room on the first floor completed on 03/24/15 at 1:45 PM revealed double 1 1/2 hour rated fire doors on an hydraulic self opening and closing mechanism identified as 1111D with the mechanism not allowing the fire doors to close. This finding was verified by Staff FF at the time of the observation.

13. Observation above the drop ceiling in the exit access corridor on the first floor by the trash room completed on 03/24/15 at 1:50 PM revealed a round 3 inch hole with a 1 1/2 inch water pipe passing through the fire rated west wall of the trash room. This finding was verified by Staff FF at the time of the observation.

14. Observation of the South 2 hour wall in the Boiler room located on the first floor of the Service Building completed on 03/24/15 at 2:55 PM revealed an open end on a 3/4 inch conduit with 2 red data cables passing through penetrating the wall. This finding was verified by Staff FF at the time of the observation.

15. Observation in the High Voltage Room located on the first floor of the Service Building completed on 03/24/15 at 3:00 PM revealed multiple penetrations varying in size and shape of the South 2 hour wall and the North and West 1 hour rated walls. These findings were verified by Staff FF at the time of the observation.

16. Observation of the Radiology file Storage area located on the first floor of the Service Building completed on 03/25/15 at 10:45 AM revealed the room was sprinklered and was attached to a general storage area with a door opening with no door in place. The general storage area had no sprinkler system in place. This finding was verified by Staff FF at the time of the observation.

Based on schematic review and staff verification the facility failed to maintain the fire rated walls of the exit access corridors. This has the potential to affect all patients, visitors, and staff in the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. Observation of the trash room on the first floor of the Service Building completed on 03/24/15 at 1:45 PM revealed double 1 1/2 hour rated fire doors (1111D), for access to the exit access corridor, on an hydraulic self opening and closing mechanism with the mechanism not allowing the fire doors to close. This finding was verified by Staff FF at the time of the observation.

2. Observation above the drop ceiling in the exit access corridor on the first floor of the Service Building by the trash room completed on 03/24/15 at 2:00 PM revealed a round 3 inch hole with a 1 1/2 inch water pipe passing through the fire rated west wall of the trash room. This finding was verified by Staff FF at the time of the observation.

3. Observation above the drop ceiling in the exit access corridor on the first floor of the Service Building by the trash room completed on 03/24/15 at 2:05 PM revealed a round 3 inch hole with a 1 1/2 inch water pipe passing through and a 2 inch whole penetrating the east wall of near the north fire rated double doors. This finding was verified by Staff FF at the time of the observation.

4. Observation above the South fire rated doors (1110R) in the exit access corridor on the first floor of the Service Building by the trash room completed on 03/24/15 at 2:22 PM revealed a 3/4 inch conduit open on the end and with open annular space penetrating the 2 hour rated wall. This was verified by Staff FF at the time of the observation.

5. Observation above the drop ceiling in the exit access corridor by the Ambulance Entrance to the Emergency Suite located on the first floor of the South Building completed on 03/24/15 at 3:30 PM revealed 2 feet by 6 feet opening in the 2 hour wall above the EMS supply room door. This was verified by Staff FF at the time of the observation.

6. Observation above the drop ceiling in the exit access corridor by doors 1100X on the first floor of the Ancillary Building completed on 03/25/15 at 11:30 AM revealed the 2 hour West wall had a 1/2 inch gap at the deck. This finding was verified by Staff FF at the time of the observation.

7. Observation above the drop ceiling in the exit access corridor above the Echo Lab sign on the first floor of the Ancillary Building completed on 03/25/15 at 11:35 AM revealed the one hour East wall had a 1 inch annular penetration and an 1 1/2 inch annular penetration with white data cables passing through. This finding was verified by Staff FF at the time of the observation.

8. Observation above the drop ceiling in the the Staff Lounge located in the Emergency PSCCU Suite of the South Building completed on 03/25/15 at 2:00 PM revealed multiple penetrations varying in size and shape in the 2 hour east wall. These findings were verified by Staff FF at the time of the observation.

9. Observation above the drop ceiling in the Joseph's Room located in the Emergency PSCCU Suite on the first floor of the South Building completed on 03/25/15 at 2:05 PM revealed two 3/4 inch conduits penetrating the 2 hour East wall with open annular space. These findings were verified by Staff FF at the time of the observation.

10. Observation above the doors 1018Z in the Emergency PSCCU Suite on the first floor of the South Building completed on 03/25/15 at 2:05 PM revealed multiple conduits with open ends varying in size penetrating the 2 hour wall. These findings were verified by Staff FF at the time of the observation.

11. Observation above the drop ceiling in the dictation room in the Emergency PSCCU Suite on the first floor of the South Building completed on 03/25/15 at 2:12 PM revealed the 2 hour East wall not sealed at the deck above and multiple penetrations varying in size and shape. These findings were verified by Staff FF at the time of the observation.

12. Observation above door 1016N on the office side of the Ancillary Building completed on 03/25/15 at 2:35 PM revealed 6 inch water pipe penetrating with 1 inch open annular space in the one hour East exit access corridor wall. This was verified by Staff FF at the time of the observation.

13. Observation above the drop ceiling of the 1 hour West wall of Waiting Room 135 of the Ancillary Building completed on 03/25/15 revealed a 3 inch by 4 inch penetration with open space below a junction box. This finding was verified by Staff FF at the time of the observation.

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. This could affect all persons utilizing the area. The hospital had a capacity of 448 patient beds with a census of 128 patients.

Findings include;

1. On 03/25/15, between 1:40 P.M. and 2:25 P.M., tour of the second floor was conducted with Staff CC and DDS. Observation of an exit stairwell to the point of exit discharge, at exit door 1147, revealed the discharge was on a cement pad approximately four feet by six feet in size. From the cement pad, travel to the public way was a distance of approximately 25 feet over grassy, uneven ground and mulch covered dirt.

Staff DDS present at the observation confirmed the finding.





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2. Observation outside the exit door from stairwell HH1 completed on 03/25/15 at 3:00 PM revealed a 3 foot by 10 foot side walk traveling from the exit door to the East beside the building, then a mulch covered area encompassing a 7 foot distance to the parking area. This was verified by Staff FF at the time of the observation.

Based on observation and interview, the facility failed to maintain an automatic sprinkler system in accordance with NFPA 25. This has the potential to affect all patients, staff and visitor to the facility. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

1. On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. At 11:16 AM observation of the sprinkler head in the chute room revealed it to be covered with dust such that the bulb was difficult to observe.

On 03/24/15 at 11:16 AM in an interview, Staff QQ confirmed the observation.

2. On 03/25/15 at 10:58 AM a tour of the second floor was conducted with Staff QQ. At 10:58 AM observation of the sprinkler head in the chute room itself was observed covered in dust. Observation of the sprinkler head in the chute itself was covered in dust. In each instance, the color of the bulb fluid was difficult to see.

On 03/25/15 at 10:58 AM in an interview, Staff QQ confirmed the observation.






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3. Observation in the exit access corridor by the Ambulance entrance of the Emergency Suite in the South building completed on 03/24/15 at 3:30 PM revealed 3 quick response sprinkler heads with excessive amounts of foreign debris covering the bulb. This finding was verified by Staff FF at the time of the observation.

4. Observation in the CT Scan area located in the Ancillary building competed on 03/25/15 at 11:20 AM revealed multiple quick response sprinkler heads with excessive amounts of foreign debris covering the bulb. This finding was verified by Staff FF at the time of the observation.

Based observation and staff verification the facility failed to ensure fire extinguishers are inspected in accordance with National Fire Protection Association (NFPA) 10 section 1-6.3, and free from obstructions to access. This has the potential to affect all patients, visitors, and staff in the facility. The facility had a capacity of 448 beds and a census of 128 patients.
Findings include:

1. Observation in the receiving area located on the ground floor completed on 03/24/15 at 10:00 AM revealed fire extinguisher 104200 was obstructed by a pallet of cardboard boxes. This was verified by Staff FF at the time of the observation.

2. Observation of the CT suite corridor completed on 03/25/15 at 11:25 AM revealed a fire extinguisher (1018L) that had a plastic ring around the neck that showed the last hydrostatic pressure was completed on 02/2009. This was verified by Staff FF at the time of the observation.

3. Interview with Staff FF on 03/25/15 at 11:25 AM revealed that the facility was aware that there were a couple of fire extinguishers beyond the due date for the hydrostatic pressure testing.

4. During documentation review completed on 03/26/15 the facility failed to provide evidence that hydrostatic pressure testing was completed on fire extinguisher with identification 1018L.

Based on interview and record review, the facility failed to comply with section 9.2 and therefore section 9.2.1 that states the heating, ventilation and cooling and related equipment shall be in accordance with National Fire Protection Association 90A, which states at 2-1.1 equipment shall be arranged to afford access for inspection, maintenance, and repair. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:

On 03/26/15 a review of a sample of the facility's fire/smoke damper maintenance documentation was completed. This sample included dampers inspected in April 2012 and November 2014.

On 03/26/15 at 3:45 PM in an interview, Staff QQ stated one-sixth of all dampers are tested every year so that every damper gets tested every six years.

The record review revealed the sample total was 405 dampers. Of those, 31, or 7.6 percent, were inaccessible and not tested. Fifteen of those sampled were described as appearing to not exist, or failed because "no damper, the wall is rated for two hours", such as at location code 1154Y, or "appears to have dampers but no access to confirm," at 1005B. Another 25 of those sampled, or 6.1 percent, were described as failed due to, for example, uneven spring tension (1126S), or because damper did not close completely when link was removed (1185Z). The inspection was performed by an outside company.

On 03/26/15 at 3:45 PM in an interview, Staff QQ explained he/she did not know when the inaccessible dampers were last tasted. He/she explained that if they would become accessible through future construction, they would then be tested.

On 03/26/15 at 4:30 PM in an interview, Staff QQ further explained the dampers are managed by an outside company, and was uncertain that all dampers that failed were fixed.

Based on observation and interview, the facility failed to ensure portable heating devices were not in an area with sleeping patients. This has the potential to affect all patients, staff and visitor to the facility. The hospital had a capacity of 448 patient beds and a census of 128 patients.

Findings include:

On 03/24/15 at 11:10 AM a tour was taken of the fourth floor with Staff QQ. On 11:25 AM observation in room 413B revealed a space heater. (Office 413B shares smoke compartment with sleeping patients.) The space heater was observed turned on with a stool next to it and papers hanging from a bulletin board over it. The stool and the papers were within three feet of it. The heater had a tag on it which said not to place furniture and other combustible items within three feet of the heater. In addition, the heater was observed unattended.

On 03/24/15 at 11:25 AM in an interview, Staff QQ confirmed the observation.

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Based on schematic review, observation, and staff verification the facility failed to maintain medical gas storage area protections. This has the potential to affect all patients, visitors, and staff in the facility. The facility census was 128.

Findings include:

1. Observation of a room located by the dock and Morgue area completed on 03/26/15 at 11:20 AM revealed 12 empty H medical gas tanks (2 of which were not secure with a chain), 8 full Nitrous Oxide H tanks, 1 Carbon Dioxide H tank (not secure), and 46 empty Oxygen E tanks. Review of the Schematic revealed the south wall without fire rating. The south wall of the room was noted to have multiple penetrations varying in size and shape and one of the two self closing non-rated doors was being held open by an hold open device not attached to the fire alarm system. This was verified by Staff QQ at the time of the observation.


2. On 03/25/15, between 10:15 A.M. and 11:45 A.M., tour of the third floor surgical area was conducted with Staff CC, DDS and EE. Observation of the back corridor of the surgical area revealed storage of H size and E size cylinders of various medical gases. The corridor storage area included four, H size cylinders of nitrogen, one, H size cylinder of medical air, nine, E size cylinders of carbon dioxide and seven ,E size cylinders of oxygen. Four of the seven E size cylinders of oxygen were labeled "empty". Additionally, located in the corridor outside operating room 12, were three, E size cylinders of oxygen, labeled as "empty". Interview of Staff EE, present at the observation, confirmed the storage of the medical gases in the corridor were for easy accessibility and the use in some surgical procedures.

Interview of Staff QQ, on 03/26/15, between 10:00 A.M. and 11:00 A.M. regarding the storage of medical gases in the back surgical corridor revealed that in addition to full tanks, the facility procedure was that if a tank is partially used, an empty tag will be placed on the tank for replacement and placed in the "empty" tank rack.

Based on observation and staff interview it was determined that the facility failed to supply all the styles of sprinkler heads used within the facility in the spare sprinkler head box according to NFPA 25, 2002 Edition, 5.2.1.3. This had a potential to affect all staff and patients within this facility.

Findings include:

During the tour of the facility at 9:38 AM on 03/25/15 it was observed that the facility spare sprinkler head box failed to contain all the styles of sprinkler heads used with the facility. During interview with Staff AA it was confirmed that the box failed to contain the sprinkler heads of all styles used in the facility. Staff AA confirmed the finding at the time of discovery.

Based on observation and staff interview it was determined that the facility failed to supply all the styles of sprinkler heads used within the facility in the spare sprinkler head box as required by the NFPA 25, 2002 edition, 5.2.1.3. This had a potential to affect all staff and patients within this facility.

Findings include:

During the tour of the facility at 8:58 AM on 03/24/15 it was observed that the facility spare sprinkler head box failed to contain all the styles of sprinkler heads used with the facility. During interview with Staff AA it was confirmed that the box failed to contain the sprinkler heads used in the air handler room. Staff AA confirmed the finding at the time of discovery.


Based on observation, document review, and staff interview it was determined that the facility failed to perform fire drills at least once per quarter according to NFPA 101, 2000 edition
21.7.1.2 . This had a potential to affect all staff and patients within the facility.
Findings include:
During the tour on 03/24/15 from 9:00 AM until 2:00 PM, the fire drill documentation was reviewed and revealed the facility performed a fire drill on 10/13/15 and 02/16/15.
During interview with Staff AA it was revealed the facility obtained occupancy on 07/14/2014 and from that time did only perform two fire drills until the time of survey. This failed to meet the requirement of fire drills to be performed at least every quarter. The finding was confirmed at the time of discovery by staff AA.

Based on observation and staff verification the facility failed to have all their medical gas storage areas marked with a precautionary sign, readable from a distance of 5 feet, that is conspicuously displayed on each door of the storage room or inclosure. The facility had a capacity of 448 beds and a census of 128 patients.

Findings include:


Observation of the gas storage area located by the Morgue completed on 03/26/15 at 11:20 AM revealed no sign on the entrance door from the corridor side or the door located on the dock area side to warn people of the gas storage area. This was verified by Staff QQ at the time of the observation.