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Based on observation and interview the facility failed to ensure all rated fire doors completely close when released from the electro-magnetic hold open devices when tested. The facility had a census of 345.

Findings included:

Observation and testing of the three hour rated fire door separating the facility from the medical office building on the ground floor of the Women's and Children's facility showed the doors were not closing completely when tested at 3:30 PM on 01/25/11.

Staff PPPP Safety Coordinator confirmed at that time the doors were not closing completely in order to maintain a separation between the two buildings.

National Fire Protection Association (NFPA) Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a two-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 19.1.1.4.1 and 19.1.1.4.2

Based on observation the facility (Ellis Fischel campus) failed to ensure that all fire doors in a required separation fully closed to provide protection to the building separations. The facility had a census of 345.

Findings included:

1. Observation on 01/19/11 in the Ellis Fischel building (outpatients only) revealed a fire separation between the 1930's and 1970's (year of construction) buildings that lead to the laboratory section of the 1970's building. The Class B fire door upon being released from the electromagnetic hold open device did not close completely and the coordinator (allows one half of door to close first) impeded the door from closing.

National Fire Protection Association (NFPA) Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a two-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 19.1.1.4.1 and 19.1.1.4.2

Based on observation, interview and record review the facility failed to ensure that all suites of the critical care addition at the Main campus each had two exit access doors for five areas with suites. The facility failed to ensure for the campus at Women's and Children's hospital that the surgical suite had two exits. The facility had a census of 345.

Findings included:
1. During tour of the facility on 01/20/11 of the seventh floor it was observed that two intensive care suites adjoined each other. Review of the floor plan for the area revealed that the suite on the left had one of two exits from the suite which would lead to the open area of the other suite and would not enter into a corridor system. The suite on the right also would exit into the adjoining suite. The square footage for Suite A was 4,399 square feet.
2. Observation on 01/20/11, of the fifth floor of the critical care addition for the facility, revealed that the intensive care suite on the left (as identified by the floor plan) had one exit into a corridor system and a second exit that lead directly to the neighboring suite. The suite on the left only had one exit that did not exit directly into another suite. The total square footage for suite A was listed a 4,385 square feet.
3. Based on observation on 01/20/11 the fourth floor of the critical care addition has one suite (left side per floor plan) which has one exit into a corridor and one exit that discharges directly into an adjoining suite. The suite does not have two direct exits. The floor plan indicates the suite is 4,895 square feet.
4. Observation on 01/25/11 of the third floor of the critical care addition revealed two suites that were adjoining each other. The floor plan and observation indicated that the suite on the left had one exit into a corridor and a second exit into the adjoining suite. The two suites were 4700 square feet for the suite on the left (per floor plan) and 5000 square feet for the suite on the right.
5. Observation during tour on 01/21/11 revealed that the suites for the sleep laboratory and endoscopy suite share a second exit. The sleep laboratory is approximately 4,031 square feet and the endoscopy suite is 7,639 square feet. During an interview on 01/21/11 at 11:00 AM Staff OOOO stated that the square footage of the two suites is over 11,000 square feet. The two suite type areas need two exits and the second exit for the sleep laboratory exits into the endoscopy suite at the rear of the suite.
Chapter 19.2.5.2 of the 2000 Life Safety code states that any patient sleeping room, or any suite that includes patient sleeping rooms of more than 1000 square feet shall have not less than two exit access doors remotely located from each other.
6. Based on observation of the campus at Women's and Children's hospital the surgical suites shared one exit and had one direct exit. The surgical suite had been previously divided from one suite that was approximately 13,488 square feet into two suites. In the middle of the suites was one exit which when utilized lead directly to the other suite and not to an exit corridor. This was the second exit for one suite of which both exceeded 2500 square feet in area.

Chapter 19.2.5.3 of the 2000 Life Safety Code (existing) states that any room or an suite of rooms, other than patient sleeping rooms, of more than 2500 square feet shall have not less than two exit access doors remotely located from each other.

Based on observation and interview the facility failed to ensure all units of the fire alarm system were being maintained. The facility had a census of 345.

Findings included:

Observation showed a smoke detector not firmly attached to the ceiling in room 3349 at 2:27 PM on 01/25/11 during a tour of the Women's and Children's facility.

Staff PPPP Safety Coordinator confirmed at that time the smoke detector was not firmly attached to the ceiling.

National Fire Protection Association (NFPA) 2000 Edition, section 9.6.1.4: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70 and NFPA 72.

Based on record review and interview the facility failed to inspect, test and maintain the sprinkler system in accordance with National Fire Protection Association 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. The facility had a census of 345.

Findings included:

Review of the facility sprinkler system inspection reports for the Women's and Children's facility, conducted on the morning of 01/25/11, showed the sprinkler system had been inspected on a semi-annual basis during the previous year, 2010.

Staff QQQQ Supervisor, when questioned at 9:40 AM on 01/25/11, stated that the sprinkler system was not inspected on at least a quarterly basis during the previous year 2010.

Record review of the following National Fire Protection Association (NFPA) Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and inspected and tested in accordance with NFPA 25 5.2

Based on observation and interview the facility failed to ensure all rated fire doors completely close when released from the electro-magnetic hold open devices when tested. The facility had a census of 345.

Findings included:

Observation and testing of the three hour rated fire door separating the facility from the medical office building on the ground floor of the Women's and Children's facility showed the doors were not closing completely when tested at 3:30 PM on 01/25/11.

Staff PPPP Safety Coordinator confirmed at that time the doors were not closing completely in order to maintain a separation between the two buildings.

National Fire Protection Association (NFPA) Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a two-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 19.1.1.4.1 and 19.1.1.4.2

Based on observation the facility (Ellis Fischel campus) failed to ensure that all fire doors in a required separation fully closed to provide protection to the building separations. The facility had a census of 345.

Findings included:

1. Observation on 01/19/11 in the Ellis Fischel building (outpatients only) revealed a fire separation between the 1930's and 1970's (year of construction) buildings that lead to the laboratory section of the 1970's building. The Class B fire door upon being released from the electromagnetic hold open device did not close completely and the coordinator (allows one half of door to close first) impeded the door from closing.

National Fire Protection Association (NFPA) Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a two-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 19.1.1.4.1 and 19.1.1.4.2

Based on observation, interview and record review the facility failed to ensure that all suites of the critical care addition at the Main campus each had two exit access doors for five areas with suites. The facility failed to ensure for the campus at Women's and Children's hospital that the surgical suite had two exits. The facility had a census of 345.

Findings included:
1. During tour of the facility on 01/20/11 of the seventh floor it was observed that two intensive care suites adjoined each other. Review of the floor plan for the area revealed that the suite on the left had one of two exits from the suite which would lead to the open area of the other suite and would not enter into a corridor system. The suite on the right also would exit into the adjoining suite. The square footage for Suite A was 4,399 square feet.
2. Observation on 01/20/11, of the fifth floor of the critical care addition for the facility, revealed that the intensive care suite on the left (as identified by the floor plan) had one exit into a corridor system and a second exit that lead directly to the neighboring suite. The suite on the left only had one exit that did not exit directly into another suite. The total square footage for suite A was listed a 4,385 square feet.
3. Based on observation on 01/20/11 the fourth floor of the critical care addition has one suite (left side per floor plan) which has one exit into a corridor and one exit that discharges directly into an adjoining suite. The suite does not have two direct exits. The floor plan indicates the suite is 4,895 square feet.
4. Observation on 01/25/11 of the third floor of the critical care addition revealed two suites that were adjoining each other. The floor plan and observation indicated that the suite on the left had one exit into a corridor and a second exit into the adjoining suite. The two suites were 4700 square feet for the suite on the left (per floor plan) and 5000 square feet for the suite on the right.
5. Observation during tour on 01/21/11 revealed that the suites for the sleep laboratory and endoscopy suite share a second exit. The sleep laboratory is approximately 4,031 square feet and the endoscopy suite is 7,639 square feet. During an interview on 01/21/11 at 11:00 AM Staff OOOO stated that the square footage of the two suites is over 11,000 square feet. The two suite type areas need two exits and the second exit for the sleep laboratory exits into the endoscopy suite at the rear of the suite.
Chapter 19.2.5.2 of the 2000 Life Safety code states that any patient sleeping room, or any suite that includes patient sleeping rooms of more than 1000 square feet shall have not less than two exit access doors remotely located from each other.
6. Based on observation of the campus at Women's and Children's hospital the surgical suites shared one exit and had one direct exit. The surgical suite had been previously divided from one suite that was approximately 13,488 square feet into two suites. In the middle of the suites was one exit which when utilized lead directly to the other suite and not to an exit corridor. This was the second exit for one suite of which both exceeded 2500 square feet in area.

Chapter 19.2.5.3 of the 2000 Life Safety Code (existing) states that any room or an suite of rooms, other than patient sleeping rooms, of more than 2500 square feet shall have not less than two exit access doors remotely located from each other.

Based on observation and interview the facility failed to ensure all units of the fire alarm system were being maintained. The facility had a census of 345.

Findings included:

Observation showed a smoke detector not firmly attached to the ceiling in room 3349 at 2:27 PM on 01/25/11 during a tour of the Women's and Children's facility.

Staff PPPP Safety Coordinator confirmed at that time the smoke detector was not firmly attached to the ceiling.

National Fire Protection Association (NFPA) 2000 Edition, section 9.6.1.4: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70 and NFPA 72.

Based on record review and interview the facility failed to inspect, test and maintain the sprinkler system in accordance with National Fire Protection Association 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. The facility had a census of 345.

Findings included:

Review of the facility sprinkler system inspection reports for the Women's and Children's facility, conducted on the morning of 01/25/11, showed the sprinkler system had been inspected on a semi-annual basis during the previous year, 2010.

Staff QQQQ Supervisor, when questioned at 9:40 AM on 01/25/11, stated that the sprinkler system was not inspected on at least a quarterly basis during the previous year 2010.

Record review of the following National Fire Protection Association (NFPA) Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and inspected and tested in accordance with NFPA 25 5.2