HospitalInspections.org

This deficiency applies to the Legacy Building (Bldg A-1).

Based on observation during the course of the survey, it was determined that the facility failed to maintain the two-hour fire-rated separation to the existing hospital building. This was evidenced by the following:

Ninety minute fire-rated separation doors did not close and positively latch into the door frame, as required. One of two 90-minute rated building separation doors (third floor-adjacent to the elevators) did not positively latch when tested.

Life Safety Code Section 8.2.3.2.1 requires fire doors be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies, and that doors be installed in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. Rated fire doors must positively latch into the door frame in accordance with NFPA 80.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation and staff interview, it was determined the facility failed to maintain the fire protection rating of the building structure in accordance with Life Safety Code Section 19.1.6.2. This was evidenced by the following:

Building structure protective assemblies were not maintained, as follows:
A) Sections of unprotected steel beams and steel columns were observed in the second floor respiratory equipment room and third floor soiled linen room. Each area was observed to have structural steel beams that had the original spray-on fire-proofing removed and a section of newer steel beam without any spray-on fire-proofing. Both areas were also observed to have sections of unprotected steel columns where the original protective assembly (3-layers of 5/8 inch gypsum board) had been removed. The newer unprotected steel beam was believed to be part of a 2005 construction project.

B) Sections of unprotected steel beams were observed in the shelled space storage room near nuclear medicine. One beam had the original spray-on fireproofing removed. A second beam did not have full thickness spray-on fireproofing applied.

C) The area described in item B above was observed to have unprotected combustible construction at the original building/ addition roof intersection. Unprotected wood was observed at the roof deck level which voids the fire-resistive construction rating of the building. The construction date of the addition observed in this room could not be determined.

Facility Plant Services and Safety Staff acknowledged the above conditions during a tour of the facility.

Life Safety Code Section 19.1.6.2 outlines allowed construction types. The original building is classified as Type I (332) which must be maintained and not diminished.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation and staff interview during the course of the survey, it was determined that corridor ceilings were not maintained to limit the transfer of smoke in accordance with Life Safety Code Section 19.3.6. This was evidenced by the following:

Corridor suspended ceilings (second and third floors) were not maintained to limit the transfer of smoke, as required.

A) Third floor, C wing: two suspended ceiling smoke dampers failed to close during a test of the fire alarm system.

B) Second floor, B wing: one unprotected air transfer opening in the suspended ceiling was not protected by an automatic smoke damper.

Plant Services Staff acknowledged the unprotected corridor ceiling openings during a tour of the facility and a test of the fire alarm system.

Section 19.3.6.2.1 requires corridor walls to be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through any interstitial structural and mechanical spaces. The walls shall have a fire resistance rating of not less than ? hour. Exception No. 1: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation during the survey, it was determined that the facility failed to install and maintain corridor doors in accordance with Life Safety Code Section 19.3.6.3. This was evidenced by the following:

A) Corridor doors were not arranged to positively latch into the door frame, as required.
The nuclear medicine suite double doors were not equipped with positive latching hardware.

B) Corridor doors were not arranged to automatically latch into the door frame, as required.

1. The office adjacent to the microbiology lab was equipped with double doors. One of two leafs was not equipped with automatic latching hardware. The leaf equipped with the latchset was arranged to latch into the "fixed" door leaf that was equipped with manual latching hardware. If the manual latching hardware was not engaged, neither leaf would be positively latched.

2. The shelled space area, adjacent to nuclear medicine, was not equipped with automatic latching hardware. The door was equipped with a deadbolt style lock only.

C) Corridor doors were not arranged to be closed with a push or pull, as required. One of two door leafs, cited in item B above, was equipped with a kick-stand hold-open device.

The Life Safety Code Section 19.3.6.3.3 permits hold-open devices that release when the door is pushed or pulled. The Life Safety Code Section 19.3.6.3.2 requires corridor doors be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation during the survey, it was determined the facility failed to maintain the fire protection rating of the vertical opening enclosures in accordance with Life Safety Code Section 19.3.1.1 and 8.2.5. This was evidenced by the following:

A) Second floor, B wing stair "C", the 90-minute rated fire door would not positively latch into the door frame, as required.

B) Stair D, exit discharge level-stair enclosure did not appear to be two-hour fire-rated. The enclosure area was part of the 2005 construction and addition. The original two-hour rated exit stair enclosure was extended as a part of this project. The enclosure was modified in 2006 due to penetration deficiencies within the new construction portion of the enclosure. The ceiling of the enclosure addition did not appear to be two-hour rated construction. Wall construction rating could not be determined at the time of the survey.

The Life Safety Code Section 8-2.3.2.1 requires, in part, that doors and windows be installed in accordance with National Fire Protection Association (NFPA) Standard 80, Standard for Fire Doors and Windows. Fire doors shall be self-closing or automatic closing in accordance with 7.2.1.8, and shall positively latch into the door frame.

This deficiency applies to the Legacy Building (Bldg A-1).

Based on observation and staff interview during the survey, it was determined the facility failed to install door hold-open devices in accordance with Life Safety Code Section 18.2.2.2.6. This was evidenced by the following:

A) Exit passageway separation doors were not arranged to automatically become self-closing, as required. The first floor exit passageway, double 90 minute rated fire doors (1D55), were equipped with a power operator that was arranged to hold the doors open for approximately 15 seconds. The power operating mechanism did not release the doors to become self-closing upon activation of the building fire alarm system.

B) Hazardous area separation doors were not arranged to automatically become self-closing, as required. The Materials Management double doors were equipped with a power operator that was arranged to hold the doors open for approximately 15 seconds. The power operating mechanism did not release the doors to become self-closing upon activation of the building fire alarm system.

Plant Services Staff acknowledged the door arrangement during a test of the fire alarm system.

Life Safety Code Section 19.2.2.2.6 requires that doors be held open only by an automatic release device that complies with Section 7.2.1.8.2. The fire alarm system, automatic sprinkler system (if provided) and the systems required by Section 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. Section 7.2.1.8.2 requires, in part, that the automatic release mechanism be activated by the operation of an approved smoke detector installed in accordance with the requirements for smoke detectors for door release service in National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation during the survey, it was determined the facility failed to mark access to exits in areas where the way to reach the exit was not readily apparent to occupants. This was evidenced by the following:

Illuminated exit signs were not installed as the way to reach the exit was not readily apparent, as required. The Emergency Department X-ray corridor did not have an exit sign installed above the smoke barrier doors (adjacent to the cardiac cath lab). The sign must be visible when exiting the nuclear medicine suite double doors.

The Life Safety Code Section 7.10.1.4 requires access to exits be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. When cross-corridor doors are closed, exit signs beyond the doors are no longer readily visible.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation and staff interview, it was determined the facility failed to maintain smoke barrier walls in accordance with the Life Safety Code Section 19-3.7. This was evidenced by the following:

Smoke barrier penetrations were not sealed with materials capable of maintaining the fire resistance rating of the barrier, as required.

A) Second floor, C wing near room 244: duct penetration with 1"-3" unsealed gaps around the duct.

B) First floor, outside of flow cytometry (door 1D101): fire stop pillows were dislodged in the area of the cable tray which voided the fire resistance rating of the fire stop system.

C) First floor radiology corridor (door 1A30): 1/4 inch unsealed gaps around an air duct.

Facility Plant Services and Safety Staff acknowledged the unsealed penetrations during a tour of the facility.

The Life Safety Code Section 8.3.2 requires the barrier be continuous through concealed spaces. Section 8-3.6.1 requires, in part, that the space between penetrations and the smoke barrier wall be filled with a material capable of maintaining the fire resistance rating of the barrier.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation and staff interview during the survey, it was determined the facility failed to maintain hazardous area enclosures in accordance with the Life Safety Code Section 19.3.2.1 and Section 8.4. This was evidenced by the following:

A) Sprinkler protected hazardous area enclosures were not maintained to be smoke resistive, as required. The second floor soiled linen room (core area) had an unprotected air-transfer opening in the ceiling that voided the smoke resistive rating of the enclosure.

B) Hazardous area enclosure doors were not self-closing, as required. The 90-minute fire-rated corridor door (microbiology lab) did not have a self-closing device installed.

Facility Plant Services and Safety Staff acknowledged the hazardous area arrangements during a tour of the facility.

Life Safety Code Section 19.3.2.1: Any hazardous areas shall be safeguarded by a fire barrier having a one-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

This deficiency applies to the Existing Hospital Building (Bldg. A-2)

Based on observation and staff interview, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This was evidenced by the following:

A) Egress doors equipped with Access-Controlled Egress special locking devices were not arranged in accordance with Life Safety Code Section 7.2.1.6.2, as required.

1. Push to Exit release buttons, installed throughout the facility, were not arranged to insure the doors would remain unlocked for not less than 30 seconds. The manual release buttons were a latching style, arranged to mechanically latch to interrupt power to the locking magnet. If an occupant attempting to egress pushed the button (after a prior exiting occupant activated the release button) the door would re-lock and prevent egress by the second occupant.

2. Two locked exit access doors (first floor, B wing-cross corridor and foyer doors) failed to unlock upon activation of the building fire protective signaling system.

3. The foyer door (identified in item A2 above) was not equipped with a functioning Push to Exit manual release button. Facility security staff reported the wiring for the button had not been completed.

B) Locked doors in the means of egress were not equipped with Special Locking Arrangements, as required. Second floor, C wing smoke barrier doors would lock upon activation of the HUGS abduction alarm. The doors were not equipped with access-controlled or delayed-egress special locking arrangements.

C) Doors equipped with delayed-egress special locking hardware were not arranged in accordance with Life Safety Code Section 7.1.6.1, as required. Second floor, Stair D door signage stated: Push until alarm sounds-door can be opened in 15 seconds. When tested the door released in 30 seconds.

D) Egress stair enclosures were not arranged in accordance with Life Safety Code Section 7.2.2.4.5. Stair D enclosure at the exit discharge level was constructed in 2005. One of two handrails was not installed at a height of 38 inches or less above the stair. One of two ends was not returned to the wall or floor, as required.

The Life Safety Code Section 19.2.1 requires means of egress components be in accordance with Chapter 7. Section 7.1.9 requires any device or alarm installed to restrict the improper use of a means of egress be designed and installed so it cannot, even in the case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 (Special Locking Arrangements).

Facility Plant Services and Safety Staff acknowledged the door locking and stair enclosure arrangements during a tour of the facility.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on record review during the survey, it was determined that the facility failed to maintain battery powered emergency lighting systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code. This was evidenced by the following:

Battery-powered emergency lighting units were not tested for duration of 90 minutes annually, as required. Records on premises documented a 90-minute test of the battery units in June 2009.

The Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment, states: "A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1? hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

This portion applies to Building AA, known as Skyline Imaging.

It was determined by observation and through record review during the course of the survey that the facility failed to perform fire drills in accordance with Life Safety Code section 21.7.1.2. This was evidenced by the following:

At the time of the survey, the building failed to provide documentation for having completed any fire drills in a one year period.

The fire drill deficiency item was discussed during the survey and again during the exit conference.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation and staff interview during the survey, it was determined the facility failed to install and maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A) Audible/Visual notification appliances were not installed to alert occupants in all building areas, as required. The Number 1 emergency generator room was not equipped with an audible/visual notification appliance. Life Safety Code Section 9.6.3.8: Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

B) Manual pull stations were not kept unobstructed and visible, as required. Pull stations in the following locations were obstructed by furnishing:

1. Third floor core area: pull station obstructed by a floor plant and easel.
2. Emergency Dept. waiting room: pull station and push to exit release button obstructed by a plant on a table.

Plant Services Staff removed the obstructions during a tour of the facility.

The Life Safety Code Section 9.6.2.6 requires each manual fire alarm box be accessible, unobstructed and visible.

C) Fire alarm wiring was not adequately supported from the building structure, as required. The main boiler room pull station wiring was observed to be wire-tied to the electrical raceway (220 volt conduit) adjacent to the station.

The National Electric Code, Section 760-54(c): Power-limited fire alarm circuit conductors shall not be strapped, taped or attached by any means to the exterior of any conduit or other raceway as a means of support.

This portion applies to Building AB, known as Physical Therapy at Berthoud Family Physicians.

A) It was determined by review of documentation during the course of the survey that the smoke detection system maintenance records did not indicate each smoke detector within the facility has had a sensitivity test completed as referenced in NFPA 72, National Fire Alarm Code or in accordance with the manufacturer's specifications. This was evidenced by the following:

There were no current records provided by an independent fire alarm system contractor and available on premises that documented the required sensitivity test for each smoke detector installed within the facility.

Sensitivity testing is required, per NFPA 72 section 7.3.2.1, which states in part "Sensitivity of smoke detectors and single and multiple-station smoke alarms, in other than one and two-family dwellings, shall be tested every alternate year after installation."

B) It was determined by review of documentation during the course of the survey that the smoke detection system was not maintained as required by NFPA 72, National Fire Alarm Code or in accordance with the manufacturers specifications. This was evidenced by the following:

There were no current records provided by an independent fire alarm system contractor and available on premises that documented the required annual testing and inspection for the smoke detection system .

The Smoke Detection System deficiency items were discussed during the survey and again during the exit conference.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation and staff interview, it was determined the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This was evidenced by the following:

A) The following rooms were not protected by the automatic sprinkler system, as required.
1. Third floor, C wing (Hospice wing): family room bathroom.
2. First floor (infusion suite area): Electric room with transformer.

B) Third floor core area electric room had an oversprayed pendant sprinkler head. The head was also missing the required escutcheon plate.

C) Ceilings were not smooth and continuous at the level of the sprinkler heads, due to missing ceiling tiles, in the following locations:
1. Microbiology Lab, back room.
2. Second floor telecom room.

D) Pendant style sidewall sprinkler heads were not installed with standard spacing in the A wing supply room. The existing arrangement resulted in an unprotected area approximately two feet deep behind one head. Horizontal spacing for one sidewall head was approximately 11 feet to the end wall and 7 ft 6 inches for a second head. NFPA 13 Section 5-7.2.2 allows a maximum of 7 ft distance to an end wall for a standard sidewall sprinkler head. Plant Services Staff acknowledged the sprinkler system deficiencies during a tour of the facility.

This portion applies to Building AB, known as Physical Therapy at Berthoud Family Physicians.

It was determined by observation during the survey that the facility failed to provide portable fire extinguishers in accordance with NFPA 10. This was evidenced by the following:

The portable fire extinguishers located within the facility were not being visually inspected after initially being placed in service at approximately 30-day intervals. Each fire extinguisher located throughout the building was not documented as receiving a "visual check" on the reverse side of the inspection tag in the space provided, the extinguisher is available, fully charged and operable according to the dial indicator.

The portable fire extinguisher deficiency item was discussed during the survey and again during the exit conference.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation and staff interview, it was determined the facility failed to install the fixed kitchen fire extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 96. This was evidenced by the following:

A) The fixed extinguishing system manual release was obstructed and not readily accessible, as required. The manual release station was obstructed by a trash can.

NFPA 96 Section 7-5.1 requires that a readily accessible means for manual activation be located between 42 inches and 60 inches above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so failure of one will not impair the operation of the other.

B) The wet chemical portable fire extinguisher, installed in the main kitchen was not visible and unobstructed, as required. Access to the extinguisher was obstructed by a trash can.

NFPA 96 Section 7-10.1: Portable fire extinguishers shall be installed in kitchen cooking areas in accordance with NFPA 10. NFPA 10 Section 4.3.2 requires, in part, that periodic inspections of fire extinguishers include a check of obstructions to access or visibility.

Plant Services Staff removed the obstruction during a tour of the facility.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation and staff interview during the survey, it was determined the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10. This was evidenced by the following:

Exit access corridors were not maintained free of obstructions and impediments to egress, as required. The south Emergency Department exit access corridor (near the trauma bays) was obstructed by three stretchers stored in the corridor. The facility Safety Officer acknowledged the storage during a tour of the facility.

The Life Safety Code Section 7.1.10.1 requires the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof. Carts that are actively in use and attended, such as housekeeping carts, are allowed to be in the corridor areas while rooms are in the process of being cleaned. Corridors are intended for means of egress and internal traffic.

This deficiency applies to the Legacy Building (Bldg A-1).

Based on observation and staff interview, it was determined that the facility failed to install loosely hanging fabrics that were flame resistant in accordance with the provisions of the Life Safety Code Section 18.7.5 and 10.3.1. This was evidenced by the following:

Records were not available to document that loosely hanging fabrics, installed on corridor walls, were flame resistant, as required. A 4 ft x 5 ft decorative quilt was installed on the second floor corridor wall. Facility staff were not aware of any records to document the material was flame resistant.

The Life Safety Code Section 18.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on record review, staff interview and observation during the course of the survey it was determined the facility failed to install and maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities (1999). This was evidenced by the following:

A) Deficiencies noted during the annual medical gas system inspection were not corrected, as required. The following deficiencies, noted during the August 2009 inspection, had not been corrected. Plant Services Staff verified the outstanding deficiencies and stated they were scheduled for repair in October 2010.

1. Main oxygen piping in the boiler room did not have supports with a copper finish.
2. Medical Air source valve was not a three piece ball valve with brazing extensions.
3. Medical Air intake pipe on the roof was not separated from any opening by a minimum distance of 10 feet.
4. Three zone valve boxes were located inside the area served and were not separated from the outlets served by a wall. The zone valve boxes were installed in ENDO Room 4, the Emergency Department intake area and the Infusion Area nurse's station.
5. ENDO zone valve box controls other zone valve boxes which is not authorized.
6. Medical gas area alarm panel, outside the first floor CT/MRI area needs to be relocated to the CT control desk and re-labeled for the correct rooms/area served.

B) The following piped medical gas deficiencies were observed during the survey.

1. Access to the outside emergency oxygen connection was obstructed by equipment storage (numerous snow plows). NFPA 99 Section 4-3.1.1.8(h)3 requires that the emergency oxygen supply connection be located on the main building where it is accessible by the emergency supply vehicle at all times in all weather conditions.
2. The oxygen system source valve (located at the bulk site) was incorrectly labeled as "Main Shut Off". NFPA 99 Section 4-3.1.2.3(a): Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source of supply, including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled "SOURCE VALVE FOR THE (SOURCE NAME)."
3. Two argon gas cylinders, stored in the manifold room, were not in a rack or chained, as required.
4. The zone valve box (nuclear medicine suite) was not accurately labeled for the rooms served in the suite.

C) NFPA 99 Section 4-3.1.1.2(b)1 requires oxygen supply and storage locations having a total capacity of more than 20,000 cubic feet be in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. The following deficiencies were noted at the bulk oxygen storage site:

1. The bulk oxygen site was not located at least 50 feet from buildings of wood frame construction, as required.
a) The grounds/maintenance building was constructed with exterior metal panels supported by wood framing and was located approximately 20 feet from the bulk oxygen equipment.
b) A wood storage shed was located approximately 18 feet from the bulk site enclosure fence.
2. Liquid oxygen system pressure regulators and piping were located less than 10 feet from openings in an adjacent structure. The adjacent structure, approximately 12 ft x 20 ft was a wood framed canopy with steel columns and chain-link fence enclosure walls. The enclosure fence wall was approximately 6 feet from the oxygen regulators and piping.
3. The fenced storage enclosure, described in item C2 above, was used for the storage of combustible materials that could burn rapidly (plastic bins with combustible bio-hazard waste). The storage was not located at least 50 feet from the bulk site.

NFPA 50 Section 2-2.1: 50 ft (15 m) from buildings of wood frame construction. Section 2-2.3:
At least 10 ft (3 m) from any opening in walls of adjacent structures. This provision shall apply to all elements of a bulk oxygen system where the oxygen storage is high pressure gas. Where the storage is as a liquid, this provision shall apply to only pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping. Section 2-2.7: 50 ft (15 m) from solid materials that burn rapidly, such as excelsior or paper.

This deficiency applies to the Legacy Building (Bldg A-1).

Based on staff interview during the course of the survey, it was determined the facility failed to protect anesthetizing locations in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This was evidenced by the following:

A) Anesthetizing locations (second floor-C Section Rooms) were not arranged to automatically vent smoke and products of combustion in accordance with NFPA 99 Section 5-4.1.2. The Facility Safety Officer confirmed inhalation anesthetics may be used in the rooms. Plant Services Staff confirmed the HVAC unit serving the area was not programmed for venting smoke and a consulting engineering firm had evaluated the rooms and presented the facility with options for automatically venting smoke from the rooms.

B) Anesthetizing locations were not provided with battery powered emergency lighting, as required. Plant Services Staff confirmed the second floor C Section rooms were not equipped with battery powered emergency lighting in accordance with NFPA 99 Section 3-3.2.1.2(a) 5e.

NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation, it was determined the facility failed to construct interior mezzanine floors and stairs using materials that were non-combustible or limited-combustible in accordance with Life Safety Code Section 19.1.6.3. This was evidenced by the following:

Mezzanine floors were not constructed using framing materials that were non-combustible or limited combustible, as required. The back room of the Security Office (first floor adjacent to Plant Services) is constructed as a mezzanine, approximately 8 ft x 12 ft. The floor, stair and floor support joists are all combustible wood construction. The underside of the mezzanine is accessed via the main boiler room. The building is classified as Type I (332) fire-resistive construction.

Life Safety Code Section 19.1.6.3: All interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials. Exception: Listed, fire-retardant-treated wood studs shall be permitted within non-load bearing one-hour fire-rated partitions.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation and staff interview during the survey, it was determined the facility failed to install emergency eye wash equipment for laboratory areas in accordance with NFPA 99, Health Care Facilities. This was evidenced by the following:

The Microbiology Lab was not equipped with emergency eye wash equipment designed and installed to avoid injurious water pressure, as required. The laboratory was equipped with four retractable hose & nozzle emergency shower/eye wash stations. When tested, the nozzle produced a straight water stream with significant pressure. As arranged, the straight water stream would not be suitable for emergency quick drenching or flushing of the eyes. The facility Safety Officer confirmed the use of corrosive materials in the laboratory and acknowledged the straight stream nozzle arrangement during a tour of the facility.

NFPA 99 Section 10.6: Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths shall be designed and installed to avoid injurious water pressure.

If shutoff valves or stops are installed in the branch line leading to safety drenching equipment, the valves shall be OS and Y (outside stem and yoke), labeled for identification, and sealed in the open position. The installation of wall-mounted portable eye-wash stations shall not preclude the adherence to the provisions of this section.

This portion applies to Building A-3, known as the McKee Cancer Center.

It was determined by observation during the course of the survey the facility failed to properly maintain and test the emergency power source. This was evidenced by the following:

As required by NFPA 110, 6-4.1, the facility failed to provide documentation to reflect inspection of the generator at least weekly.

The emergency power supply system deficiency item was discussed during the exit conference.

This deficiency applies to the Existing Hospital Building (Bldg A-2)

Based on observation during the survey, it was determined that the facility failed to install and maintain electrical equipment in accordance with National Fire Protection Association Standard 70, National Electric Code. This was evidenced by the following:

A) Life Safety Branch panelboard 1E1B (electric room adjacent to main boiler room) was missing four of eight screws that attach the cover to the enclosure.

B) The main kitchen was observed to have a six-way outlet extender installed.

NFPA 70 Section 384-18 requires panelboards be within an enclosure designed for the purpose and shall be dead front. Dead front arrangement prohibits live parts exposing a person on the operating side of the panelboard. Adaptors that increase the number of devices supplied by a duplex receptacle can result in an overload of the receptacle beyond its rated capacity.

This deficiency applies to the Legacy Building (Bldg. A-1).

Based on observation and staff interview during the survey, it was determined that the facility failed to install alcohol based hand rub dispensers in accordance with Life Safety Code Section 19.3.2.7 (as amended by NFPA Technical Interim Amendment TIA 00-1 (101). This was evidenced by the following:

Alcohol Based Hand Rub dispensers were not installed with adequate separation from an ignition source, as required. The wall mounted dispenser (PACU-first floor) was installed directly above a duplex electric receptacle. Plant Services Staff acknowledged the dispenser installation during a tour of the facility.

Life Safety Code Section 19.3.2.7 states, in part, that alcohol based hand rub dispensers shall not be installed over or adjacent to an ignition source.