HospitalInspections.org

Based on observation and interview, the facility failed to maintain a two hour rated fire barrier between itself and adjacent business occupancies. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

On 05/11/15 at 3:08 PM a tour was taken of the fourth floor with Staff Q and R.

1. On 05/11/15 at 3:14 PM observation near the door and above the drop down ceiling of the two hour fire barrier between the building and an existing business occupancy revealed an open one inch conduit.

On 05/11/15 at 3:14 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

2. On 05/12/15 at 3:42 PM observation above the drop down ceiling in the room perpendicular to the nurse executive office, next to stair A3, of the two hour fire barrier separating the facility from an administrative area (existing business occupancy), revealed an open one inch by one inch square with two conduits running out of it.

On 05/12/15 at 3:42 PM in an interview, Staff Q confirmed the observation.

3. On 05/12/15 at 3:55 PM observation above the drop down ceiling in the conference lounge of the two hour fire barrier separating the facility from an administrative area (existing business occupancy), revealed a one inch square in the drywall with a conduit traveling through it.

On 05/12/15 at 3:55 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 4:00 PM a tour was conducted of the second floor with Staff Q and R.

4. On 05/12/15 at 4:19 PM observation above the drop down ceiling of the two hour fire rated barrier over double doors leading to an existing business occupancy (administrative space for respiratory therapy) revealed a four finger-width opening with a conduit traveling through it.

On 05/12/15 at 4:19 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure all doors protecting corridor openings were free of impediments to their closing. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

1. In the critical care area of compartment 2.1, on 05/13/15 at 11:50 AM Staff X was asked in an interview to close the door to room one and three (thereby protecting the rooms from the corridor). Staff X was unable to close either door completely. Having difficulty getting the latching hardware to work, he/she needed the help of management to close the doors such that it took two people to close each door.

The two individuals and Staff Q were then unable to reopen the door to patient room 3 and required a family member who happened to be visiting the patient, to open the door from within.

Based on observation and interview, the facility failed to maintain the stated rating of its fire barriers protecting its stairways and other vertical openings. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

1. On 05/11/15 at 11:40 AM observation above the drop down ceiling of the two hour rated wall at the northwest corner of the single elevator bank revealed a half inch open conduit.

On 05/11/15 at 11:40 AM in an interview, Staff Q confirmed the observation.

2. On 05/11/15 at 12:00 PM observation above the drop down ceiling in the nurse assistant manager office, of the two hour fire rated barrier surrounding a chaise, that traveled through at least five floors, revealed a half inch conduit and rebar with annular spaces

On 05/11/15 at 12:00 PM in an interview, Staff Q confirmed the observation.

On 05/11/15 at 3:08 PM a tour was taken of the fourth floor with Staff Q and R.

3. On 05/11/15 at 3:38 PM observation above the drop down ceiling of the two hour rated fire barrier surrounding a chase in the northeast corner of the locker room revealed two heating, ventilation and cooling ducts with a space between them creating a penetration in the barrier.

On 05/11/15 at 3:38 PM in an interview, Staff Q confirmed the observation.

4. On 05/11/15 at 3:56 PM observation above the drop down ceiling of the two hour fire barrier surrounding stair B4 revealed a two inch sprinkler line with an annular space.

On 05/11/15 at 3:56 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

5. On 05/12/15 at 9:51 AM observation above the drop down ceiling of the two hour fire barrier surrounding a chase next to the northern bank of elevators revealed, as seen from its middle, a half inch hole.

On 05/12/15 at 9:51 AM in an interview, Staff R confirmed the observation.

On 05/12/15 at 4:00 PM a tour was conducted of the second floor with Staff Q and R.

6. On 05/12/15 at 4:12 PM observation above the drop down ceiling of the two hour fire rated barrier surrounding stair 4b revealed a half inch conduit traveling to metal plate which had an annular space around it.

On 05/12/15 at 4:12 PM in an interview, Staff R confirmed the observation.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

7. On 05/13/15 at 8:39 AM observation above the drop down ceiling of the two hour fire barrier protecting stair B1 revealed a half inch penetration and a two inch by two inch opening above an old exit sign.

On 05/13/15 at 8:39 AM in an interview, Staff R confirmed the observation.

8. On 05/13/15 at 10:05 AM observation above the drop down ceiling of the two hour fire barrier protecting stairway B3 revealed grey wires traveling through a one foot by one foot square opening.

On 05/13/15 at 10:05 AM in an interview, Staff R confirmed the observation.

9. On 05/13/15 at 11:22 AM observation above the drop down ceiling of the two hour rated fire barrier protecting stair A4 revealed a half inch opening in the drywall.

On 05/13/15 at 11:22 AM in an interview, Staff Q confirmed the observation.

10. On 05/13/15 at 11:24 AM observation above the drop down ceiling, as seen from the corridor, of the two hour fire rated barrier protecting the chase in compartment 2.1 revealed a three inch by six inch rectangular penetration near an heating, ventilation and cooling damper, with heating, ventilation and cooling duct traveling to stair A4.

On 05/13/15 at 11:24 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure each door in stairway completely self closed. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

On 05/11/15 at 11:45 AM the door to exit stairway B4 was observed to not close and latch.

On 05/11/15 at 11:45 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain the ratings of its smoke barriers. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

1. On 05/11/15 at 2:52 PM observation above the drop down ceiling of the 30 minute smoke barrier separating the north compartment from the south compartment revealed to the right of the double doors and facing the nursing station, a one inch conduit open to air.

On 05/11/15 at 2:52 PM in an interview, Staff Q confirmed the observation.

2. On 05/11/15 at 2:58 PM observation above the drop down ceiling of the 30 minute smoke barrier separating the north compartment from the south compartment as seen from within the medication room revealed the word "DATA" written on the wall and three one inch circles with blue wires traveling into the word.

On 05/11/15 at 2:58 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was taken of the third floor with Staff Q and R.

3. On 05/12/15 at 10:34 AM observation above the drop down ceiling of the smoke barrier in the clean utility room and bordering compartments 3.2, 3.3, and 3.4, revealed a half inch conduit, running east/west, with an open joint that had been held together with duct tape. Coming out of the conduit was grey wiring.

On 05/12/15 at 10:34 AM in an interview, Staff Q confirmed the observation.

4. On 05/12/15 at 11:55 AM observation above the drop down ceiling of the two hour rated fire barrier toward the back of the bathroom revealed a conduit traveling to an open junction box.

On 05/12/15 at 11:55 AM in an interview, Staff R confirmed the observation.

5. On 05/12/15 at 1:48 PM observation above the drop down ceiling of the two hour rated fire barrier located to the left of the copier in the fast track area revealed a one foot by one foot square cut from the drywall.

On 05/12/15 at 1:48 PM in an interview, Staff Q confirmed the observation.

6. On 05/12/15 at 1:56 PM observation above the drop down ceiling of the two hour fire rated barrier around the corner from the previous finding in the fast track area revealed an open 0.75 inch conduit near where two I-beams meet.

On 05/12/15 at 1:56 PM in an interview, Staff Q confirmed the observation.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

7. On 05/13/15 at 9:45 AM observation above the drop down ceiling of the smoke barrier separating compartment 2.4 from 2.3, and perpendicular to audiology office, revealed a half inch open conduit with a blue wire traveling from it.

On 05/13/15 at 9:45 AM in an interview, Staff Q confirmed the observation.

8. On 05/13/15 at 10:38 AM observation above the drop down ceiling over double doors in a two hour fire rated barrier protecting an electric room in the southern part of compartment 2.1, as seen from within the compartment (called colloquially as new peds), revealed a half inch flex conduit leading to an open junction box with an opening within the box itself from where the conduit enters.

On 05/13/15 at 10:38 AM in an interview, Staff Q confirmed the observation.

9. On 05/13/15 at 10:44 AM observation above the drop down ceiling of the two hour fire rated barrier as seen from the corridor just north of the electrical closet revealed at the right angle formed by a room into the corridor a one and a half plumbing pipe with an annular space around it.

On 05/13/15 at 10:44 AM in an interview, Staff Q confirmed the observation.

10. Continuing north along the same corridor, on 05/13/15 at 10:55 AM observation above the drop down ceiling of the two hour rated fire barrier protecting a nearby data closet revealed above the double doors a one inch open conduit with a blue wire traveling out of it, and a pale blue flex conduit with an annular space.

On 05/13/15 at 10:55 AM in an interview, Staff Q confirmed the observation.

On 05/15/15 at 9:52 AM a tour was taken of the first floor of the facility with Staff Q and R.

11. On 05/15/15 at 11:03 AM observation above the drop down ceiling of the two hour fire rated barrier over the double doors that protect the southeast north/south corridor from a east/west intersecting corridor (near an industrial storage area), revealed a junction box with the words "fire alarm" written on it that had a missing circular knock out. Traveling to the box was a conduit from the area of the doors.

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

12. On 05/15/15 at 1:29 PM observation above the drop down ceiling of the northwest part of the one hour rated fire barrier in dietary storage in compartment 1b.3 revealed a half inch open conduit.

On 05/15/15 at 1:29 PM in an interview, Staff Q confirmed the observation.





29377

On 05/14/15 at beginning at 8:45 AM a tour of the first floor was conducted with Staff Q and Staff R.

13. At 8:55 AM observation of the two hour rated wall above the drop down ceiling in the Family Lounge revealed a one inch conduit open to air.

Staff Q confirmed the finding at that time by interview and observation.

14. At 9:00 AM observation of the two hour rated wall above the drop down ceiling in Triage Room 26 revealed an open 2 inch black pipe with black cables running through it.

Staff Q confirmed the finding at that time by interview and observation.

15. At 9:03 AM observation of the two hour rated wall above the drop down ceiling in Triage Room 25 revealed a one inch circular penetration in the barrier.

Staff Q confirmed the finding at that time by interview and observation.

16. At 9:09 AM observation of the two hour rated wall above the drop down ceiling in Triage Room 24 revealed an open 2 inch drain pipe traveling through the barrier.

Staff Q confirmed the finding at that time by interview and observation.

17. At 9:14 AM observation of the two hour rated wall above the drop down ceiling in Triage Room 23 revealed annular spaces around blue wires, a one inch conduit and a metal junction box.

Staff Q confirmed the findings at that time by interview and observation.

18. At 9:20 AM observation of the two hour rated wall above the drop down ceiling as seen within the soiled utility room of the Triage area was conducted. Two three inch circular penetrations in the barrier were observed as well as an annular opening around the heating, ventilation and cooling duct work.

Staff Q confirmed the findings at that time by interview and observation.

19. At 9:24 AM observation facing the south two hour rated wall above the drop down ceiling as seen in the clean utility room of the Triage area revealed a one inch conduit open to air.

Staff Q confirmed the finding at that time by interview and observation.

20. At 9:30 AM observation facing the east two hour rated wall above the drop down ceiling as seen in the same clean utility room revealed one, one inch copper pipe open to air and a circular opening around a one inch conduit traveling through the barrier.

Staff Q confirmed the findings at that time by interview and observation.

21. At 9:50 AM observation of the two hour rated wall above the drop down ceiling outside of the mammography waiting area revealed circular openings around three, one inch conduits traveling through the barrier.

Staff Q confirmed the findings at that time by interview and observation.

22. At 10:23 AM observation of the two hour rated wall within the electrical closets located adjacent to the gift shop revealed the separation between the two spaces did not fully extend up to the ceiling above as indicated on the building schematics.

Staff Q confirmed the finding at that time by interview and observation.

23. At 11:07 AM observation of the two hour rated wall above the drop down ceiling in the corridor outside of the clinical dietician's office revealed one inch conduit open to air.

Staff Q confirmed the finding at that time by interview and observation.

24. At 1:19 PM observation of the two hour rated wall above the drop down ceiling in the northwest corner of the pharmacy revealed two circular penetrations in the barrier.

Staff Q confirmed the findings at that time by interview and observation.

25. At 1:26 PM observation of the two hour rated wall above the drop down ceiling in the pharmacy narcotic vault revealed one circular penetration in the barrier.

Staff Q confirmed the finding at that time by interview and observation.

26. At 2:34 PM observation of the two rated wall in the drop down ceiling outside of the data room revealed the barrier did not fully extend up to the floor above. The entire room was noted to be a two hour rated space as indicated on the plan.

Staff Q confirmed the finding at that time by interview and observation.

Based on observation and interview, the facility failed to ensure that the coordinator to double doors in smoke barriers coordinated the doors to close completely, that each door in a smoke barrier had a self closer, and that each door in a smoke barrier equipped with latching hardware latched shut. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

1. On 05/12/15 at 2:15 PM the double doors, in the smoke barrier, and leading to the endoscopy area were observed to have a coordinator that did not coordinate the doors' closing, leaving a gap between the two.

On 05/12/15 at 2:15 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 4:00 PM a tour was conducted of the second floor with Staff Q and R.

2. On 05/12/15 at 4:33 PM double doors with latching hardware in a smoke barrier leading to maternity, were observed to not completely close and latch.

On 05/12/15 at 4:33 PM in an interview, Staff R confirmed the observation explaining the latching hardware was broken.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

3. On 05/13/15 at 10:31 AM observation of the double doors in the smoke barrier leading to level two new pediatric area revealed they had latching hardware, but when closed, the latching hardware did not completely close and latch the doors.

On 05/13/15 at 10:31 AM in an interview, Staff Q confirmed the observation.

On 05/15/15 at 9:52 AM a tour was taken of the first floor of the facility with Staff Q and R.

4. On 05/15/15 at 10:48 AM observation of the main door to enter the pharmacy and in a one hour fire rated barrier revealed it did not have a self closer.

On 05/15/15 at 10:48 AM in an interview, Staff Q confirmed the observation.

5. On 05/15/15 at 1:25 PM double doors in a one hour fire rated barrier in the central sterile corridor leading to dietary storage were observed to have a coordinator that did not coordinate the doors to close completely.

On 05/15/15 at 1:25 PM in an interview, Staff Q confirmed the observation.

6. On 05/15/15 at 2:11 PM observation of the double doors in the two hour fire rated barrier, near the southeast exit, near an industrial storage area, and perpendicular to the quality assurance office, revealed when tested they failed to completely close.

On 05/15/15 at 2:11 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure doors to hazardous areas completely self closed. This has the potential to affect all patients, staff, and visitors to the sleep clinic.

Findings include:

On 05/15/15 at 2:50 PM a tour was conducted of the facility with Staff Q and another surveyor. Observation of the soiled utility room door revealed it to have a self closer with latching hardware. Observation of the complete self closing system revealed the door would close but not completely as the latching hardware did not latch.

On 05/15/15 at 2:50 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure the building's hazardous area, a laboratory, was separated from other parts of the building with one hour fire resistive rating construction. This has the potential to affect all patients, staff, and visitors.

Findings include:

On 05/13/15 at 2:25 PM a tour was taken of the building with Staff Q. During the tour a laboratory was observed in use for the emergency department. The laboratory had unprotected openings to an exit corridor and to the nursing station.

On 05/18/15 at 2:25 PM in an interview, Staff Q confirmed there weren't doors there.

Based on observation and interview, the facility failed to ensure the closing of its doors complied with 8.4 of life safety code 101, 2000 edition.

Findings include:

On 05/13/15 a tour was conducted of the building with Staff Q.

1. On 05/13/15 at 5:32 PM observation of the door in the one hour fire barrier surrounding an electric/boiler/mechanical space revealed it had a self closer with latching hardware that did not completely close and latch the door.

On 05/13/15 at 5:32 PM in an interview, Staff Q confirmed the observation.

2. On 05/13/15 at 6:00 PM observation of the door to the soiled linen room revealed it did not have a self closer.

On 05/13/15 at 6:00 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain the stated rating of the fire barriers protecting its hazardous areas, and failed to ensure each door protecting a hazardous area self closed completely. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

1. On 05/11/15 at 1:56 PM observation above the drop down ceiling of the one hour fire barrier surrounding the clean supply room revealed a one foot by one foot square opening and four one inch circles near the door/room entrance.

On 05/11/15 at 1:56 PM in an interview, Staff Q confirmed the observation.

2. On 05/11/15 at 2:37 PM, observation above the drop down ceiling of the one hour fire barrier in the back of the soiled utility room in the southern smoke compartment revealed a one inch open conduit with two grey wires traveling out of it.

On 05/11/15 at 2:37 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

3. On 05/12/15 at 1:46 PM observation of the door to the biohazard room in the fast track area was revealed it did not completely close.

On 05/12/15 at 1:46 PM in an interview, Staff R confirmed the observation, explaining the latch strike plate was broke.

4. On 05/12/15 at 3:20 PM the door to biohazard room 3027 was observed in a one hour barrier and equipped with a self closing device that did not completely close the door.

On 05/12/15 at 3:20 PM in an interview, Staff Q confirmed the observation.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

5. On 05/13/15 at 9:06 AM observation above the drop down ceiling of the one hour fire barrier protecting a storage room in the post partum area (compartment 2.3) revealed at the west wall a six inch by one foot square with conduits traveling through it, and a half inch conduit open to air.

On 05/13/15 at 9:06 AM in an interview, Staff Q confirmed the observation.

6. On 05/13/15 at 10:20 AM observation above the drop down ceiling of the one hour fire barrier protecting a soiled utility room, in the perimeter of suite S2 (a pediatric area), as seen from within, revealed a half inch conduit traveling to a junction box with an open half inch knock out hole.

On 05/13/15 at 10:20 AM in an interview, Staff Q confirmed the observation.

7. On 05/13/15 at 11:02 AM observation above the drop down ceiling of the one hour fire rated barrier protecting a clean utility room, as seen from within, revealed in the southwest corner near the door two one inch holes in the barrier.

On 05/13/15 at 11:02 AM in an interview, Staff Q confirmed the observation.

8. On 05/13/15 at 11:58 AM review of the floor plan for the clean and soiled utility room in compartment 2.1 revealed there is a one hour fire rated barrier between the rooms. Observation above the drop down ceiling between the two rooms revealed the barrier was not there.

On 05/13/15 at 11:58 AM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of the fire barriers protecting each of its exit components. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:


29377

On 05/14/15 beginning at 2:08 PM a tour of the Wellness Center/Cardiac Rehabilitation area was conducted with Staff Q.

1. At 2:08 PM observation of the two hour rated wall in the drop down ceiling of the exit corridor outside of the Wellness Center/Cardiac Rehabilitation area, near stair D3, revealed a one inch circular penetration in the barrier.

Staff Q confirmed the finding at that time by interview and observation.

2. At 2:13 PM observation of the two hour rated wall above the drop down ceiling of the east wall within the Wellness Center/Cardiac Rehabilitation area revealed an open one inch conduit with wire running through it.

Staff Q confirmed the finding at that time by interview and observation.

3. At 2:16 PM observation of the two hour rated wall above the drop down ceiling of the Wellness Center/Cardiac Rehabilitation area revealed a one inch circular penetration in the barrier.

Staff Q confirmed the finding at that time by interview and observation.

Based on interview and record review, the facility failed to ensure emergency illumination was provided in accordance with 7.9 and be tested annually for not less than 90 minutes. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

On 05/18/15 a review of the building's fire safety documentation was completed. The review revealed the building had battery operated emergency lighting. The review did not reveal where these emergency lights were tested annually for not less than 90 minutes.

On 05/18/15 at 12:40 PM in an interview, Staff Q confirmed the emergency lighting has not been tested annually for not less than 90 minutes.

Based on interview and record review, the facility failed to ensure emergency illumination was provided in accordance with 7.9 and be tested annually for not less than 90 minutes. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/18/15 a review of the facility's fire safety documentation was completed. The review did not reveal where emergency lighting was tested yearly for 90 minutes.

On 05/15/15 at 2:30 PM in an interview, Staff Q confirmed the finding stating rather than test the lighting, the batteries are changed.

Based on interview and record review, the facility failed to ensure emergency illumination was provided in accordance with 7.9 and tested annually for not less than 90 minutes. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

On 05/18/15 a review of the building's fire safety documentation was completed. The review revealed the building had battery operated emergency lighting. The review did not reveal these emergency lights were tested annually for not less than 90 minutes.

On 05/18/15 at 12:38 PM in an interview, Staff Q confirmed the emergency lighting has not been tested annually for not less than 90 minutes.

Based on record review and interview, the facility failed to ensure all personnel are familiar with the signals and emergency actions to take in a simulation of emergency fire conditions, i.e., a drill. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/18/15 a review of the building's fire safety documentation was completed, including its fire drills for the past 12 months. The surveyor was unable to discern whether any physicians participated in the drills.

On 05/18/15 at 3:00 PM in an interview, Staff W reviewed the fire drill documentation for the past 12 months and was able to find where two physicians participated in the drills. He/she said the facility had a staff of 320 physicians.

Based on interview and record review, the facility failed to ensure the sensitivity of the smoke detectors in its smoke detection system was tested in accordance with National Fire Protection Association 72 (1999 ed.) referenced in 9.6 and 21.3.4.1 in Life Safety Code 101 (2000 edition). This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

Review of the building's fire safety documentation was completed on 05/18/15. The review revealed the facility had 15 smoke detectors. The review did not reveal where the sensitivities of the smoke detectors were assessed.

On 05/18/15 at 12:40 PM in an interview, Staff Q confirmed they did not have evidence of a test of the smoke detectors sensitivities.

Based on observation and interview, the facility failed to maintain an automatic sprinkler system in accordance with NFPA 25 and 13. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

1. On 05/11/15 at 2:00 PM observation of the sprinkler head in room 638 revealed it had a missing escutcheon plate.

On 05/11/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 8:38 AM a tour of the fourth floor was conducted with Staff Q and R.

2. On 05/12/15 at 9:34 AM a sprinkler head in the hallway near room 422 was observed to be occluded with dust such that the fluid was difficult to see.

On 05/12/15 at 9:34 AM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

3. On 05/12/15 at 10:48 AM observation of patient room 316 revealed its sprinkler head was occluded with dust such that the fluid was difficult to see.

On 05/12/15 at 10:48 AM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

4. On 05/12/15 at 2:29 PM in the staff lounge in suite s2 a sprinkler head was observed to be occluded with dust such that the fluid was difficult to see.

On 05/12/15 at 2:29 PM in an interview, Staff Q confirmed the observation.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

5. On 05/13/15 at 11:50 AM observation of the sprinkler head in the clean utility room of compartment 2.1 revealed it to be occluded with dust such that the fluid was difficult to see.

On 05/13/15 at 11:50 AM in an interview, Staff Q confirmed the observation.

On 05/14/15 at 4:53 PM a tour was taken of the emergency department with Staff Q and R.

6. On 05/14/15 at 5:14 PM in the emergency department locker room a sprinkler head was observed to be occluded with dust such that the fluid was difficult to see.

On 05/14/15 at 5:14 PM in an interview, Staff Q confirmed the observation.


On 05/15/15 at 9:52 AM a tour was taken of the first floor of the facility with Staff Q and R.

7. On 05/15/15 at 9:59 AM in the nuclear medicine staff locker room a sprinkler head was observed to be occluded with dust such that the fluid was difficult to see.

On 05/15/15 at 9:59 AM in an interview, Staff R confirmed the observation.

8. On 05/15/15 at 12:02 PM observation in the pharmacy revealed shelving near the southern pillar in the center of the room that was within 18 inches of the sprinkler heads.

On 05/15/15 at 12:02 PM in an interview, Staff Q confirmed the observation.

9. On 05/15/15 at 1:13 PM observation in the kitchen area, near the server, a sprinkler head was observed to be occluded with dust such that the fluid was difficult to see.

On 05/15/15 at 1:13 PM in an interview, Staff Q confirmed the observation.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/18/15 a review of the building's fire safety documentation was completed. The review revealed the facility's fire dampers had been tested within the past four years; however, 89, mostly of the fusible link type, had a "visual pass", and were never tested.

On 05/15/15 at 3:20 PM in an interview, Staff Z confirmed the dampers had not been tested to assess how well they close.

Based on observation and interview, the facility failed to have its smoke damper in the heating, ventilation and cooling system comply with 9.2 of National Fire Protection Association 101, 2000 edition, and National Fire Protection Association 90A, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

On 05/13/15 a tour was conducted of the building with Staff Q. On 05/13/15 at 5:50 PM observation above the drop down ceiling in the one hour fire barrier between the ambulatory surgery center and the building's other tenant revealed a damper in the heating, ventilation and cooling system.

On 05/18/15 a review of the building's fire safety documentation was completed. The review did not reveal where the damper had last been tested.

On 05/15/15 at 3:30 PM in an interview, Staff Q confirmed he/she did not have documentation to show when the damper(s) had last been tested.

Based on observation and interview, the facility failed to ensure the medical gas room in the building had one hour fire resistive construction in accordance with National Fire Protection Association 99, 1999 edition, 4-3.1.1.2. This has the potential to affect all patient, staff, and visitors.

Findings include:

1. On 05/13/15 at 4:20 PM a tour was conducted of the building with Staff Q. On 05/13/15 at 4:45 PM observation of the medical gas room revealed it held more than 3000 cubic feet of oxygen. Observation of the door to the medical gas room had an illegible rating tag attached to it.

On 05/13/15 at 4:45 PM in an interview, Staff Q was unable to provide a rating to the door.

2. On 05/13/15 at 4:53 PM observation revealed to the left of the door of the barrier surrounding the medical gas room, three half inch holes and a three inch gap along an I-beam passing through the barrier near the door.

On 05/13/15 at 4:53 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to have a remote annunciator for its generator in a location readily observed by operating personnel in accordance with National Fire Protection Association 99 Chapter 3-4. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/15/15 at 11:33 AM a tour was taken of the site of the facility's two main generators as well as its emergency electrical system. A remote annunciator panel readily observed by operating personnel was not observed, and, consequently, neither was there a properly labeled audible or visual derangement signal.

On 05/18/15 at 10:10 PM in an interview, Staff Q confirmed the facility did not have a remote annunciator to its two main generators, relying instead on a cellular system wherein a wireless signal will be sent to certain individuals' phones alerting them to the fact the generator is running.

Based on observation and interview, the facility failed to maintain a one hour rating for the wall separating it from the other tenant in the building. This has the potential to affect all patients, staff, and visitors.

Findings include

On 05/13/15 at 4:20 PM a tour was conducted of the building with Staff Q. Based on observation and interview with Staff Q, the occupancy separation barrier between the ambulatory surgery center and the other tenant was determined to be the southern most barrier which ran east/west to an outer wall.

1. On 05/13/15 at 4:35 PM observation above the drop down ceiling of the one hour rated occupancy separation barrier, just west of the pain clinic, revealed an annular space surrounding a ceiling joist.

On 05/13/15 at 4:35 PM in an interview, Staff Q confirmed the finding.

2. Further west of that, on 05/13/15 at 4:42 PM observation above the drop down ceiling of the one hour rated occupancy separation barrier, revealed an unsealed space between an I-beam and ceiling joist.

On 05/13/15 at 4:42 PM in an interview, Staff Q confirmed the finding.

21.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.


Based on observation and interview, the facility failed to maintain the integrity of its one hour rated smoke barrier. This has the potential to affect all patients, staff, and visitors.

Findings include:

On 05/13/15 a tour was conducted of the building with Staff Q.

1. On 05/13/15 at 5:22 PM observation above the drop down ceiling of the one hour rated smoke barrier as seen from the corridor opposite from the locker room and east of the electrical room revealed a half inch by 12 inch rectangular penetration with two one inch conduits traveling through it.

On 05/13/15 at 5:22 PM in an interview, Staff Q confirmed the observation.

2. On 05/13/15 at 5:23 PM observation above the drop down ceiling of the one hour rated smoke barrier as seen from the corridor, and to the immediate left of the door to the electric room, revealed a flex conduit with an annular space.

On 05/13/15 at 5:23 PM in an interview, Staff Q confirmed the observation.

3. On 05/13/15 at 5:52 PM observation of the office door next to the double doors leading to the operating rooms revealed the door had a self closer and latching hardware that did not completely close and latch the door.

On 05/13/15 at 5:52 PM in an interview, Staff Q confirmed the observation.


21.2.9.2
Where general anesthesia or life-support equipment is used, each ambulatory health care facility shall be provided with an essential electrical system in accordance with NFPA 99, standard for Health Care Facilities.

Based on interview and record review, the facility failed to ensure the ambulatory surgery center's generator is maintained to a reasonable degree to supply service when needed as referenced in National Fire Protection Association 110, 6-3.1 and 99, 3-4.4. (1999 editions.)

Findings include:

The ambulatory surgery center performs surgeries that utilize general anesthesia and life support. On 05/18/15 a review of the maintenance and testing records to the building's emergency power supply system (a diesel generator) was completed. The review revealed a repair order dated 02/13/15 that stated:

"Travel to location got to unit checked fuel then fuel filters they had frozen water in them replaced them. Tried (sic) to run unit it would not (sic) found pick up tube was froze up. Will return to location on Sunday."

The review revealed a repair order dated 02/15/15 that stated:

"Stopped by (local home improvement store) picked up some black pipe travel to unit made up a new pick up tube for fuel supply installed threw vent tube temporary till things warm up and we can filter water out of tank! Ran unit tested ok."

On 05/18/15 at 2:55 PM in an interview, Staff Z was asked whether the "temporary" tube had been replaced and all necessary repairs made. He/she explained the generator would be corrected before the next deep freeze.

Based on document review and interview, the facility failed to ensure the building's generator was inspected weekly and electrical transfer times documented in accordance with National Fire Protection Association 110, 1999 edition. This has the potential to affect all patients, staff, and visitors to the emergency department.

Findings include:

The building contains a detached emergency department that utilizes electrical equipment for life support when necessary. On 05/18/15 a review of the building's fire safety documentation was completed. The review revealed the generator had been tested monthly. However, it did not reveal where it had been inspected weekly for the months of February and March. The documentation also did not indicate the amount of time elapsed to transfer power from the electric company to the generator.

On 05/18/15 at 11:25 AM in an interview, Staff S confirmed the findings.

Based on observation and interview, the facility failed to maintain a two hour rated fire barrier between itself and adjacent business occupancies. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

On 05/11/15 at 3:08 PM a tour was taken of the fourth floor with Staff Q and R.

1. On 05/11/15 at 3:14 PM observation near the door and above the drop down ceiling of the two hour fire barrier between the building and an existing business occupancy revealed an open one inch conduit.

On 05/11/15 at 3:14 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

2. On 05/12/15 at 3:42 PM observation above the drop down ceiling in the room perpendicular to the nurse executive office, next to stair A3, of the two hour fire barrier separating the facility from an administrative area (existing business occupancy), revealed an open one inch by one inch square with two conduits running out of it.

On 05/12/15 at 3:42 PM in an interview, Staff Q confirmed the observation.

3. On 05/12/15 at 3:55 PM observation above the drop down ceiling in the conference lounge of the two hour fire barrier separating the facility from an administrative area (existing business occupancy), revealed a one inch square in the drywall with a conduit traveling through it.

On 05/12/15 at 3:55 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 4:00 PM a tour was conducted of the second floor with Staff Q and R.

4. On 05/12/15 at 4:19 PM observation above the drop down ceiling of the two hour fire rated barrier over double doors leading to an existing business occupancy (administrative space for respiratory therapy) revealed a four finger-width opening with a conduit traveling through it.

On 05/12/15 at 4:19 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure all doors protecting corridor openings were free of impediments to their closing. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

1. In the critical care area of compartment 2.1, on 05/13/15 at 11:50 AM Staff X was asked in an interview to close the door to room one and three (thereby protecting the rooms from the corridor). Staff X was unable to close either door completely. Having difficulty getting the latching hardware to work, he/she needed the help of management to close the doors such that it took two people to close each door.

The two individuals and Staff Q were then unable to reopen the door to patient room 3 and required a family member who happened to be visiting the patient, to open the door from within.

Based on observation and interview, the facility failed to maintain the stated rating of its fire barriers protecting its stairways and other vertical openings. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

1. On 05/11/15 at 11:40 AM observation above the drop down ceiling of the two hour rated wall at the northwest corner of the single elevator bank revealed a half inch open conduit.

On 05/11/15 at 11:40 AM in an interview, Staff Q confirmed the observation.

2. On 05/11/15 at 12:00 PM observation above the drop down ceiling in the nurse assistant manager office, of the two hour fire rated barrier surrounding a chaise, that traveled through at least five floors, revealed a half inch conduit and rebar with annular spaces

On 05/11/15 at 12:00 PM in an interview, Staff Q confirmed the observation.

On 05/11/15 at 3:08 PM a tour was taken of the fourth floor with Staff Q and R.

3. On 05/11/15 at 3:38 PM observation above the drop down ceiling of the two hour rated fire barrier surrounding a chase in the northeast corner of the locker room revealed two heating, ventilation and cooling ducts with a space between them creating a penetration in the barrier.

On 05/11/15 at 3:38 PM in an interview, Staff Q confirmed the observation.

4. On 05/11/15 at 3:56 PM observation above the drop down ceiling of the two hour fire barrier surrounding stair B4 revealed a two inch sprinkler line with an annular space.

On 05/11/15 at 3:56 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

5. On 05/12/15 at 9:51 AM observation above the drop down ceiling of the two hour fire barrier surrounding a chase next to the northern bank of elevators revealed, as seen from its middle, a half inch hole.

On 05/12/15 at 9:51 AM in an interview, Staff R confirmed the observation.

On 05/12/15 at 4:00 PM a tour was conducted of the second floor with Staff Q and R.

6. On 05/12/15 at 4:12 PM observation above the drop down ceiling of the two hour fire rated barrier surrounding stair 4b revealed a half inch conduit traveling to metal plate which had an annular space around it.

On 05/12/15 at 4:12 PM in an interview, Staff R confirmed the observation.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

7. On 05/13/15 at 8:39 AM observation above the drop down ceiling of the two hour fire barrier protecting stair B1 revealed a half inch penetration and a two inch by two inch opening above an old exit sign.

On 05/13/15 at 8:39 AM in an interview, Staff R confirmed the observation.

8. On 05/13/15 at 10:05 AM observation above the drop down ceiling of the two hour fire barrier protecting stairway B3 revealed grey wires traveling through a one foot by one foot square opening.

On 05/13/15 at 10:05 AM in an interview, Staff R confirmed the observation.

9. On 05/13/15 at 11:22 AM observation above the drop down ceiling of the two hour rated fire barrier protecting stair A4 revealed a half inch opening in the drywall.

On 05/13/15 at 11:22 AM in an interview, Staff Q confirmed the observation.

10. On 05/13/15 at 11:24 AM observation above the drop down ceiling, as seen from the corridor, of the two hour fire rated barrier protecting the chase in compartment 2.1 revealed a three inch by six inch rectangular penetration near an heating, ventilation and cooling damper, with heating, ventilation and cooling duct traveling to stair A4.

On 05/13/15 at 11:24 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure each door in stairway completely self closed. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

On 05/11/15 at 11:45 AM the door to exit stairway B4 was observed to not close and latch.

On 05/11/15 at 11:45 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain the ratings of its smoke barriers. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

1. On 05/11/15 at 2:52 PM observation above the drop down ceiling of the 30 minute smoke barrier separating the north compartment from the south compartment revealed to the right of the double doors and facing the nursing station, a one inch conduit open to air.

On 05/11/15 at 2:52 PM in an interview, Staff Q confirmed the observation.

2. On 05/11/15 at 2:58 PM observation above the drop down ceiling of the 30 minute smoke barrier separating the north compartment from the south compartment as seen from within the medication room revealed the word "DATA" written on the wall and three one inch circles with blue wires traveling into the word.

On 05/11/15 at 2:58 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was taken of the third floor with Staff Q and R.

3. On 05/12/15 at 10:34 AM observation above the drop down ceiling of the smoke barrier in the clean utility room and bordering compartments 3.2, 3.3, and 3.4, revealed a half inch conduit, running east/west, with an open joint that had been held together with duct tape. Coming out of the conduit was grey wiring.

On 05/12/15 at 10:34 AM in an interview, Staff Q confirmed the observation.

4. On 05/12/15 at 11:55 AM observation above the drop down ceiling of the two hour rated fire barrier toward the back of the bathroom revealed a conduit traveling to an open junction box.

On 05/12/15 at 11:55 AM in an interview, Staff R confirmed the observation.

5. On 05/12/15 at 1:48 PM observation above the drop down ceiling of the two hour rated fire barrier located to the left of the copier in the fast track area revealed a one foot by one foot square cut from the drywall.

On 05/12/15 at 1:48 PM in an interview, Staff Q confirmed the observation.

6. On 05/12/15 at 1:56 PM observation above the drop down ceiling of the two hour fire rated barrier around the corner from the previous finding in the fast track area revealed an open 0.75 inch conduit near where two I-beams meet.

On 05/12/15 at 1:56 PM in an interview, Staff Q confirmed the observation.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

7. On 05/13/15 at 9:45 AM observation above the drop down ceiling of the smoke barrier separating compartment 2.4 from 2.3, and perpendicular to audiology office, revealed a half inch open conduit with a blue wire traveling from it.

On 05/13/15 at 9:45 AM in an interview, Staff Q confirmed the observation.

8. On 05/13/15 at 10:38 AM observation above the drop down ceiling over double doors in a two hour fire rated barrier protecting an electric room in the southern part of compartment 2.1, as seen from within the compartment (called colloquially as new peds), revealed a half inch flex conduit leading to an open junction box with an opening within the box itself from where the conduit enters.

On 05/13/15 at 10:38 AM in an interview, Staff Q confirmed the observation.

9. On 05/13/15 at 10:44 AM observation above the drop down ceiling of the two hour fire rated barrier as seen from the corridor just north of the electrical closet revealed at the right angle formed by a room into the corridor a one and a half plumbing pipe with an annular space around it.

On 05/13/15 at 10:44 AM in an interview, Staff Q confirmed the observation.

10. Continuing north along the same corridor, on 05/13/15 at 10:55 AM observation above the drop down ceiling of the two hour rated fire barrier protecting a nearby data closet revealed above the double doors a one inch open conduit with a blue wire traveling out of it, and a pale blue flex conduit with an annular space.

On 05/13/15 at 10:55 AM in an interview, Staff Q confirmed the observation.

On 05/15/15 at 9:52 AM a tour was taken of the first floor of the facility with Staff Q and R.

11. On 05/15/15 at 11:03 AM observation above the drop down ceiling of the two hour fire rated barrier over the double doors that protect the southeast north/south corridor from a east/west intersecting corridor (near an industrial storage area), revealed a junction box with the words "fire alarm" written on it that had a missing circular knock out. Traveling to the box was a conduit from the area of the doors.

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

12. On 05/15/15 at 1:29 PM observation above the drop down ceiling of the northwest part of the one hour rated fire barrier in dietary storage in compartment 1b.3 revealed a half inch open conduit.

On 05/15/15 at 1:29 PM in an interview, Staff Q confirmed the observation.





29377

On 05/14/15 at beginning at 8:45 AM a tour of the first floor was conducted with Staff Q and Staff R.

13. At 8:55 AM observation of the two hour rated wall above the drop down ceiling in the Family Lounge revealed a one inch conduit open to air.

Staff Q confirmed the finding at that time by interview and observation.

14. At 9:00 AM observation of the two hour rated wall above the drop down ceiling in Triage Room 26 revealed an open 2 inch black pipe with black cables running through it.

Staff Q confirmed the finding at that time by interview and observation.

15. At 9:03 AM observation of the two hour rated wall above the drop down ceiling in Triage Room 25 revealed a one inch circular penetration in the barrier.

Staff Q confirmed the finding at that time by interview and observation.

16. At 9:09 AM observation of the two hour rated wall above the drop down ceiling in Triage Room 24 revealed an open 2 inch drain pipe traveling through the barrier.

Staff Q confirmed the finding at that time by interview and observation.

17. At 9:14 AM observation of the two hour rated wall above the drop down ceiling in Triage Room 23 revealed annular spaces around blue wires, a one inch conduit and a metal junction box.

Staff Q confirmed the findings at that time by interview and observation.

18. At 9:20 AM observation of the two hour rated wall above the drop down ceiling as seen within the soiled utility room of the Triage area was conducted. Two three inch circular penetrations in the barrier were observed as well as an annular opening around the heating, ventilation and cooling duct work.

Staff Q confirmed the findings at that time by interview and observation.

19. At 9:24 AM observation facing the south two hour rated wall above the drop down ceiling as seen in the clean utility room of the Triage area revealed a one inch conduit open to air.

Staff Q confirmed the finding at that time by interview and observation.

20. At 9:30 AM observation facing the east two hour rated wall above the drop down ceiling as seen in the same clean utility room revealed one, one inch copper pipe open to air and a circular opening around a one inch conduit traveling through the barrier.

Staff Q confirmed the findings at that time by interview and observation.

21. At 9:50 AM observation of the two hour rated wall above the drop down ceiling outside of the mammography waiting area revealed circular openings around three, one inch conduits traveling through the barrier.

Staff Q confirmed the findings at that time by interview and observation.

22. At 10:23 AM observation of the two hour rated wall within the electrical closets located adjacent to the gift shop revealed the separation between the two spaces did not fully extend up to the ceiling above as indicated on the building schematics.

Staff Q confirmed the finding at that time by interview and observation.

23. At 11:07 AM observation of the two hour rated wall above the drop down ceiling in the corridor outside of the clinical dietician's office revealed one inch conduit open to air.

Staff Q confirmed the finding at that time by interview and observation.

24. At 1:19 PM observation of the two hour rated wall above the drop down ceiling in the northwest corner of the pharmacy revealed two circular penetrations in the barrier.

Staff Q confirmed the findings at that time by interview and observation.

25. At 1:26 PM observation of the two hour rated wall above the drop down ceiling in the pharmacy narcotic vault revealed one circular penetration in the barrier.

Staff Q confirmed the finding at that time by interview and observation.

26. At 2:34 PM observation of the two rated wall in the drop down ceiling outside of the data room revealed the barrier did not fully extend up to the floor above. The entire room was noted to be a two hour rated space as indicated on the plan.

Staff Q confirmed the finding at that time by interview and observation.

Based on observation and interview, the facility failed to ensure that the coordinator to double doors in smoke barriers coordinated the doors to close completely, that each door in a smoke barrier had a self closer, and that each door in a smoke barrier equipped with latching hardware latched shut. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

1. On 05/12/15 at 2:15 PM the double doors, in the smoke barrier, and leading to the endoscopy area were observed to have a coordinator that did not coordinate the doors' closing, leaving a gap between the two.

On 05/12/15 at 2:15 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 4:00 PM a tour was conducted of the second floor with Staff Q and R.

2. On 05/12/15 at 4:33 PM double doors with latching hardware in a smoke barrier leading to maternity, were observed to not completely close and latch.

On 05/12/15 at 4:33 PM in an interview, Staff R confirmed the observation explaining the latching hardware was broken.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

3. On 05/13/15 at 10:31 AM observation of the double doors in the smoke barrier leading to level two new pediatric area revealed they had latching hardware, but when closed, the latching hardware did not completely close and latch the doors.

On 05/13/15 at 10:31 AM in an interview, Staff Q confirmed the observation.

On 05/15/15 at 9:52 AM a tour was taken of the first floor of the facility with Staff Q and R.

4. On 05/15/15 at 10:48 AM observation of the main door to enter the pharmacy and in a one hour fire rated barrier revealed it did not have a self closer.

On 05/15/15 at 10:48 AM in an interview, Staff Q confirmed the observation.

5. On 05/15/15 at 1:25 PM double doors in a one hour fire rated barrier in the central sterile corridor leading to dietary storage were observed to have a coordinator that did not coordinate the doors to close completely.

On 05/15/15 at 1:25 PM in an interview, Staff Q confirmed the observation.

6. On 05/15/15 at 2:11 PM observation of the double doors in the two hour fire rated barrier, near the southeast exit, near an industrial storage area, and perpendicular to the quality assurance office, revealed when tested they failed to completely close.

On 05/15/15 at 2:11 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure doors to hazardous areas completely self closed. This has the potential to affect all patients, staff, and visitors to the sleep clinic.

Findings include:

On 05/15/15 at 2:50 PM a tour was conducted of the facility with Staff Q and another surveyor. Observation of the soiled utility room door revealed it to have a self closer with latching hardware. Observation of the complete self closing system revealed the door would close but not completely as the latching hardware did not latch.

On 05/15/15 at 2:50 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure the building's hazardous area, a laboratory, was separated from other parts of the building with one hour fire resistive rating construction. This has the potential to affect all patients, staff, and visitors.

Findings include:

On 05/13/15 at 2:25 PM a tour was taken of the building with Staff Q. During the tour a laboratory was observed in use for the emergency department. The laboratory had unprotected openings to an exit corridor and to the nursing station.

On 05/18/15 at 2:25 PM in an interview, Staff Q confirmed there weren't doors there.

Based on observation and interview, the facility failed to ensure the closing of its doors complied with 8.4 of life safety code 101, 2000 edition.

Findings include:

On 05/13/15 a tour was conducted of the building with Staff Q.

1. On 05/13/15 at 5:32 PM observation of the door in the one hour fire barrier surrounding an electric/boiler/mechanical space revealed it had a self closer with latching hardware that did not completely close and latch the door.

On 05/13/15 at 5:32 PM in an interview, Staff Q confirmed the observation.

2. On 05/13/15 at 6:00 PM observation of the door to the soiled linen room revealed it did not have a self closer.

On 05/13/15 at 6:00 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain the stated rating of the fire barriers protecting its hazardous areas, and failed to ensure each door protecting a hazardous area self closed completely. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

1. On 05/11/15 at 1:56 PM observation above the drop down ceiling of the one hour fire barrier surrounding the clean supply room revealed a one foot by one foot square opening and four one inch circles near the door/room entrance.

On 05/11/15 at 1:56 PM in an interview, Staff Q confirmed the observation.

2. On 05/11/15 at 2:37 PM, observation above the drop down ceiling of the one hour fire barrier in the back of the soiled utility room in the southern smoke compartment revealed a one inch open conduit with two grey wires traveling out of it.

On 05/11/15 at 2:37 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

3. On 05/12/15 at 1:46 PM observation of the door to the biohazard room in the fast track area was revealed it did not completely close.

On 05/12/15 at 1:46 PM in an interview, Staff R confirmed the observation, explaining the latch strike plate was broke.

4. On 05/12/15 at 3:20 PM the door to biohazard room 3027 was observed in a one hour barrier and equipped with a self closing device that did not completely close the door.

On 05/12/15 at 3:20 PM in an interview, Staff Q confirmed the observation.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

5. On 05/13/15 at 9:06 AM observation above the drop down ceiling of the one hour fire barrier protecting a storage room in the post partum area (compartment 2.3) revealed at the west wall a six inch by one foot square with conduits traveling through it, and a half inch conduit open to air.

On 05/13/15 at 9:06 AM in an interview, Staff Q confirmed the observation.

6. On 05/13/15 at 10:20 AM observation above the drop down ceiling of the one hour fire barrier protecting a soiled utility room, in the perimeter of suite S2 (a pediatric area), as seen from within, revealed a half inch conduit traveling to a junction box with an open half inch knock out hole.

On 05/13/15 at 10:20 AM in an interview, Staff Q confirmed the observation.

7. On 05/13/15 at 11:02 AM observation above the drop down ceiling of the one hour fire rated barrier protecting a clean utility room, as seen from within, revealed in the southwest corner near the door two one inch holes in the barrier.

On 05/13/15 at 11:02 AM in an interview, Staff Q confirmed the observation.

8. On 05/13/15 at 11:58 AM review of the floor plan for the clean and soiled utility room in compartment 2.1 revealed there is a one hour fire rated barrier between the rooms. Observation above the drop down ceiling between the two rooms revealed the barrier was not there.

On 05/13/15 at 11:58 AM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of the fire barriers protecting each of its exit components. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:


29377

On 05/14/15 beginning at 2:08 PM a tour of the Wellness Center/Cardiac Rehabilitation area was conducted with Staff Q.

1. At 2:08 PM observation of the two hour rated wall in the drop down ceiling of the exit corridor outside of the Wellness Center/Cardiac Rehabilitation area, near stair D3, revealed a one inch circular penetration in the barrier.

Staff Q confirmed the finding at that time by interview and observation.

2. At 2:13 PM observation of the two hour rated wall above the drop down ceiling of the east wall within the Wellness Center/Cardiac Rehabilitation area revealed an open one inch conduit with wire running through it.

Staff Q confirmed the finding at that time by interview and observation.

3. At 2:16 PM observation of the two hour rated wall above the drop down ceiling of the Wellness Center/Cardiac Rehabilitation area revealed a one inch circular penetration in the barrier.

Staff Q confirmed the finding at that time by interview and observation.

Based on interview and record review, the facility failed to ensure emergency illumination was provided in accordance with 7.9 and be tested annually for not less than 90 minutes. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

On 05/18/15 a review of the building's fire safety documentation was completed. The review revealed the building had battery operated emergency lighting. The review did not reveal where these emergency lights were tested annually for not less than 90 minutes.

On 05/18/15 at 12:40 PM in an interview, Staff Q confirmed the emergency lighting has not been tested annually for not less than 90 minutes.

Based on interview and record review, the facility failed to ensure emergency illumination was provided in accordance with 7.9 and be tested annually for not less than 90 minutes. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/18/15 a review of the facility's fire safety documentation was completed. The review did not reveal where emergency lighting was tested yearly for 90 minutes.

On 05/15/15 at 2:30 PM in an interview, Staff Q confirmed the finding stating rather than test the lighting, the batteries are changed.

Based on interview and record review, the facility failed to ensure emergency illumination was provided in accordance with 7.9 and tested annually for not less than 90 minutes. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

On 05/18/15 a review of the building's fire safety documentation was completed. The review revealed the building had battery operated emergency lighting. The review did not reveal these emergency lights were tested annually for not less than 90 minutes.

On 05/18/15 at 12:38 PM in an interview, Staff Q confirmed the emergency lighting has not been tested annually for not less than 90 minutes.

Based on record review and interview, the facility failed to ensure all personnel are familiar with the signals and emergency actions to take in a simulation of emergency fire conditions, i.e., a drill. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/18/15 a review of the building's fire safety documentation was completed, including its fire drills for the past 12 months. The surveyor was unable to discern whether any physicians participated in the drills.

On 05/18/15 at 3:00 PM in an interview, Staff W reviewed the fire drill documentation for the past 12 months and was able to find where two physicians participated in the drills. He/she said the facility had a staff of 320 physicians.

Based on interview and record review, the facility failed to ensure the sensitivity of the smoke detectors in its smoke detection system was tested in accordance with National Fire Protection Association 72 (1999 ed.) referenced in 9.6 and 21.3.4.1 in Life Safety Code 101 (2000 edition). This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

Review of the building's fire safety documentation was completed on 05/18/15. The review revealed the facility had 15 smoke detectors. The review did not reveal where the sensitivities of the smoke detectors were assessed.

On 05/18/15 at 12:40 PM in an interview, Staff Q confirmed they did not have evidence of a test of the smoke detectors sensitivities.

Based on observation and interview, the facility failed to maintain an automatic sprinkler system in accordance with NFPA 25 and 13. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

1. On 05/11/15 at 2:00 PM observation of the sprinkler head in room 638 revealed it had a missing escutcheon plate.

On 05/11/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 8:38 AM a tour of the fourth floor was conducted with Staff Q and R.

2. On 05/12/15 at 9:34 AM a sprinkler head in the hallway near room 422 was observed to be occluded with dust such that the fluid was difficult to see.

On 05/12/15 at 9:34 AM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

3. On 05/12/15 at 10:48 AM observation of patient room 316 revealed its sprinkler head was occluded with dust such that the fluid was difficult to see.

On 05/12/15 at 10:48 AM in an interview, Staff Q confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

4. On 05/12/15 at 2:29 PM in the staff lounge in suite s2 a sprinkler head was observed to be occluded with dust such that the fluid was difficult to see.

On 05/12/15 at 2:29 PM in an interview, Staff Q confirmed the observation.

On 05/13/15 at 8:35 AM a tour was resumed of the second floor with Staff Q and R.

5. On 05/13/15 at 11:50 AM observation of the sprinkler head in the clean utility room of compartment 2.1 revealed it to be occluded with dust such that the fluid was difficult to see.

On 05/13/15 at 11:50 AM in an interview, Staff Q confirmed the observation.

On 05/14/15 at 4:53 PM a tour was taken of the emergency department with Staff Q and R.

6. On 05/14/15 at 5:14 PM in the emergency department locker room a sprinkler head was observed to be occluded with dust such that the fluid was difficult to see.

On 05/14/15 at 5:14 PM in an interview, Staff Q confirmed the observation.


On 05/15/15 at 9:52 AM a tour was taken of the first floor of the facility with Staff Q and R.

7. On 05/15/15 at 9:59 AM in the nuclear medicine staff locker room a sprinkler head was observed to be occluded with dust such that the fluid was difficult to see.

On 05/15/15 at 9:59 AM in an interview, Staff R confirmed the observation.

8. On 05/15/15 at 12:02 PM observation in the pharmacy revealed shelving near the southern pillar in the center of the room that was within 18 inches of the sprinkler heads.

On 05/15/15 at 12:02 PM in an interview, Staff Q confirmed the observation.

9. On 05/15/15 at 1:13 PM observation in the kitchen area, near the server, a sprinkler head was observed to be occluded with dust such that the fluid was difficult to see.

On 05/15/15 at 1:13 PM in an interview, Staff Q confirmed the observation.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/18/15 a review of the building's fire safety documentation was completed. The review revealed the facility's fire dampers had been tested within the past four years; however, 89, mostly of the fusible link type, had a "visual pass", and were never tested.

On 05/15/15 at 3:20 PM in an interview, Staff Z confirmed the dampers had not been tested to assess how well they close.

Based on observation and interview, the facility failed to have its smoke damper in the heating, ventilation and cooling system comply with 9.2 of National Fire Protection Association 101, 2000 edition, and National Fire Protection Association 90A, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility.

Findings include:

On 05/13/15 a tour was conducted of the building with Staff Q. On 05/13/15 at 5:50 PM observation above the drop down ceiling in the one hour fire barrier between the ambulatory surgery center and the building's other tenant revealed a damper in the heating, ventilation and cooling system.

On 05/18/15 a review of the building's fire safety documentation was completed. The review did not reveal where the damper had last been tested.

On 05/15/15 at 3:30 PM in an interview, Staff Q confirmed he/she did not have documentation to show when the damper(s) had last been tested.

Based on observation and interview, the facility failed to ensure the medical gas room in the building had one hour fire resistive construction in accordance with National Fire Protection Association 99, 1999 edition, 4-3.1.1.2. This has the potential to affect all patient, staff, and visitors.

Findings include:

1. On 05/13/15 at 4:20 PM a tour was conducted of the building with Staff Q. On 05/13/15 at 4:45 PM observation of the medical gas room revealed it held more than 3000 cubic feet of oxygen. Observation of the door to the medical gas room had an illegible rating tag attached to it.

On 05/13/15 at 4:45 PM in an interview, Staff Q was unable to provide a rating to the door.

2. On 05/13/15 at 4:53 PM observation revealed to the left of the door of the barrier surrounding the medical gas room, three half inch holes and a three inch gap along an I-beam passing through the barrier near the door.

On 05/13/15 at 4:53 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to have a remote annunciator for its generator in a location readily observed by operating personnel in accordance with National Fire Protection Association 99 Chapter 3-4. This has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/15/15 at 11:33 AM a tour was taken of the site of the facility's two main generators as well as its emergency electrical system. A remote annunciator panel readily observed by operating personnel was not observed, and, consequently, neither was there a properly labeled audible or visual derangement signal.

On 05/18/15 at 10:10 PM in an interview, Staff Q confirmed the facility did not have a remote annunciator to its two main generators, relying instead on a cellular system wherein a wireless signal will be sent to certain individuals' phones alerting them to the fact the generator is running.

Based on observation and interview, the facility failed to maintain a one hour rating for the wall separating it from the other tenant in the building. This has the potential to affect all patients, staff, and visitors.

Findings include

On 05/13/15 at 4:20 PM a tour was conducted of the building with Staff Q. Based on observation and interview with Staff Q, the occupancy separation barrier between the ambulatory surgery center and the other tenant was determined to be the southern most barrier which ran east/west to an outer wall.

1. On 05/13/15 at 4:35 PM observation above the drop down ceiling of the one hour rated occupancy separation barrier, just west of the pain clinic, revealed an annular space surrounding a ceiling joist.

On 05/13/15 at 4:35 PM in an interview, Staff Q confirmed the finding.

2. Further west of that, on 05/13/15 at 4:42 PM observation above the drop down ceiling of the one hour rated occupancy separation barrier, revealed an unsealed space between an I-beam and ceiling joist.

On 05/13/15 at 4:42 PM in an interview, Staff Q confirmed the finding.

21.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.


Based on observation and interview, the facility failed to maintain the integrity of its one hour rated smoke barrier. This has the potential to affect all patients, staff, and visitors.

Findings include:

On 05/13/15 a tour was conducted of the building with Staff Q.

1. On 05/13/15 at 5:22 PM observation above the drop down ceiling of the one hour rated smoke barrier as seen from the corridor opposite from the locker room and east of the electrical room revealed a half inch by 12 inch rectangular penetration with two one inch conduits traveling through it.

On 05/13/15 at 5:22 PM in an interview, Staff Q confirmed the observation.

2. On 05/13/15 at 5:23 PM observation above the drop down ceiling of the one hour rated smoke barrier as seen from the corridor, and to the immediate left of the door to the electric room, revealed a flex conduit with an annular space.

On 05/13/15 at 5:23 PM in an interview, Staff Q confirmed the observation.

3. On 05/13/15 at 5:52 PM observation of the office door next to the double doors leading to the operating rooms revealed the door had a self closer and latching hardware that did not completely close and latch the door.

On 05/13/15 at 5:52 PM in an interview, Staff Q confirmed the observation.


21.2.9.2
Where general anesthesia or life-support equipment is used, each ambulatory health care facility shall be provided with an essential electrical system in accordance with NFPA 99, standard for Health Care Facilities.

Based on interview and record review, the facility failed to ensure the ambulatory surgery center's generator is maintained to a reasonable degree to supply service when needed as referenced in National Fire Protection Association 110, 6-3.1 and 99, 3-4.4. (1999 editions.)

Findings include:

The ambulatory surgery center performs surgeries that utilize general anesthesia and life support. On 05/18/15 a review of the maintenance and testing records to the building's emergency power supply system (a diesel generator) was completed. The review revealed a repair order dated 02/13/15 that stated:

"Travel to location got to unit checked fuel then fuel filters they had frozen water in them replaced them. Tried (sic) to run unit it would not (sic) found pick up tube was froze up. Will return to location on Sunday."

The review revealed a repair order dated 02/15/15 that stated:

"Stopped by (local home improvement store) picked up some black pipe travel to unit made up a new pick up tube for fuel supply installed threw vent tube temporary till things warm up and we can filter water out of tank! Ran unit tested ok."

On 05/18/15 at 2:55 PM in an interview, Staff Z was asked whether the "temporary" tube had been replaced and all necessary repairs made. He/she explained the generator would be corrected before the next deep freeze.

Based on document review and interview, the facility failed to ensure the building's generator was inspected weekly and electrical transfer times documented in accordance with National Fire Protection Association 110, 1999 edition. This has the potential to affect all patients, staff, and visitors to the emergency department.

Findings include:

The building contains a detached emergency department that utilizes electrical equipment for life support when necessary. On 05/18/15 a review of the building's fire safety documentation was completed. The review revealed the generator had been tested monthly. However, it did not reveal where it had been inspected weekly for the months of February and March. The documentation also did not indicate the amount of time elapsed to transfer power from the electric company to the generator.

On 05/18/15 at 11:25 AM in an interview, Staff S confirmed the findings.