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Based on observation, the common wall separating the hospital from the adjacent outpatient building was not properly maintained as a fire barrier.

Findings:

Observed on 10/5/16 at 2:15 PM: The common wall between the hospital and the adjacent outpatient building, located within the connecting corridor, contained improperly sealed penetrations. The observation was made above the drop ceiling at the corridor doors. The penetrations were cables and conduit, and appeared to be filled with common drywall spackle. They did not appear to be sealed with a product consistent with a listed through penetration firestop system.

Staff I, who was present at the time the above observation was made, verified this finding.

Based on observation, a cable shaft and an elevator shaft were not properly enclosed with a fire barrier.

Findings:

Observed on 10/5/16 at 10:45 AM: A cable shaft was missing a piece of drywall. This created an unprotected opening in the shaft enclosure. The space where the drywall was missing measured approximately 2ft x 1ft. The access point where the observations were made is located on the 6th floor, in a small closet near room 610. This shaft passes through multiple floors.

Staff I, who was present at the time the above observation was made, verified this finding.

Observed on 10/6/16 at 10:45 AM: The elevator control room for elevator #1 contained an unsealed penetration through the wall, with a metal cable passing through. This control room is open to the elevator shaft and therefore must be enclosed with the shaft.

Staff L, who was present at the time the above observation was made, verified this finding. The finding was later verified with Staff I.

Based on observation, a door assembly in an elevator shaft was not of an approved type with appropriate fire protection rating.

Findings:

Observed on 10/6/16 at 10:45 AM: The door assembly for elevator control room #1 was only fire rated for 20 minutes, as noted on the door tag. The control room is open to the elevator shaft and therefore is considered part of the shaft enclosure. NFPA 101 section 19.3.1.1 requires a minimum 1-hour fire resistance rating for vertical openings. Section 8.2.3.2.1(2) requires openings in a 1-hour fire barrier to also have a 1-hour fire protection rating where used for vertical openings.

Staff L, who was present at the time the above observation was made, verified this finding. The finding was later verified with the Staff I.

Based on observation, several walls separating smoke compartments on the third floor were not properly maintained as a fire rated smoke barrier.

Findings:

Observed on 10/5/16 at 2:45 PM: The wall above the drop ceiling in the elevator lobby near room 314 contained unsealed penetrations, with data cables passing through.

Unsealed penetrations were also observed in the same area near room 341 above the drop ceiling, with various conduits and cables passing through, and a missing piece of corner wall.

These observations were made in a renovated section of the facility. Staff I, who was present at the time the above observation was made, verified these findings.

Based on observation, several stairway exit enclosures were not maintained to protect against fire and smoke.

Findings:

Observed on 10/4/16 at 3:20 PM: The floor 1A rear stairwell contained an unsealed penetration through the fire rated enclosure, with telemetry wires passing through.

Observed on 10/5/16 at 10:45 AM: The floor 6 stairwell near room 629 contained several unsealed penetrations through the fire rated enclosure, with conduit and wires passing through.

Staff I, who was present at the time the above observation was made, verified these findings.

Based on interview and document review the facility did not maintain the fire alarm system as required.

Findings are:

Review of Simplex Grinnell Fire Alarm Inspection Reports dated May 2015, October 2015, and May 2016 documented several deficiencies. The 4 deficiencies noted below were on all 3 reports reviewed.

"Upon arrival and departure there was an earth ground trouble at node #2"
"In the crawl space of subbasement mech room there is a missing heat detector"
"The key switch for duct detector 1M1-99 for AHU-8 is no longer wired in"
"The heat detector in the compressor room in the basement is missing"

On all 3 reports, there were a total of 22 deficiencies noted, including the 4 repeated items stated above. When Staff J was asked for documentation of action regarding the deficiencies, there were only work orders for 3 of the 22 items. There was no documentation regarding the remaining 19 items.

Alarm Systems NFPA 72 states:
"14.2.1.2.2 System defects and malfunctions shall be corrected."

Based on observation, interview and document review the facility did not test and maintain the Automatic Sprinkler System as required.

Findings are:

During the facility tour on 10/3/2016 at 1:30 PM with Staff I it was observed that some of the sprinkler heads in the linen receiving and laundry area were loaded with dust. Several of the sprinkler heads appeared to be more than 50 years old. When asked about the age of the sprinkler heads, Staff I said that the building was built in the 1940s and the sprinkler heads were probably part of the original system.

The Simplex Grinnell Sprinkler Inspection Reports dated 1/8/2015, 5/7/2015, 8/28/2015, and 5/5/2016 were reviewed. The reports documented the items observed and several other deficiencies, such as:

"All gauges are outdated"
"4 Tamper switches (solarium and storage tanks) do not report to alarm system"
"The flow switch in the ABS building is not working, water motor gong for
sub-basement is not working"
"10 Heads in laundry area are corroded, loaded or painted"

NFPA 25 states:

2-3.2* Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-3.1 Sprinklers.

2-3.1.1* Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. Test procedures shall be repeated at 10-year intervals.

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

The 4 deficiencies above were noted on each of the 4 reports reviewed. Surveyors requested documentation from Staff J of the actions taken regarding the reports. There is no evidence to indicate that these reports have been acted on by the facility.

Based on observation the facility did not maintain the oxygen shut off valves to be readily accessible at all times for use in an emergency.

Findings are:

During the tour of the operating suite it was noted on 10/4/2016 at 11:25AM that there were 3 C-arms blocking access to the oxygen shut off valves in an alcove outside the anesthesia storage room. This observation was confirmed by Staff K at the time of observation.

Based on interview the facility failed to conduct routine testing and inspection of elevators. The facility also failed to maintain records related to elevator maintenance.

Findings are:

During interview on 10/6/2016 at 2:30 PM with Staff I a copy of the facilities elevator inspections was requested. Staff I stated that the elevator maintenance contractor kept those reports, and that he would get them from them and forward them to the surveyors.

On 10/11/2016 at 10:46 AM, after the onsite survey, an email was sent to Staff I again requesting the documents. On 10/12/2016 at 3:26 PM the documents were received via email. Review of the documents showed preventive maintenance and service reports done by the contractor, but did not indicate any inspections were completed.

NFPA 101 states:

9.4.6 Elevator Testing. Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and
Escalators.

9.4.3.2 All existing elevators having a travel distance of 25 ft (7.6 m) or more above or below the level that best serves the needs of emergency personnel for firefighting or rescue purposes shall conform to the Fire Fighters' Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators.