HospitalInspections.org

Based on observation, building plan review, and interview, the facility failed to meet the requirements of 42 CFR 485.623 - Life Safety Code from Fire and the applicable provisions of the 2000 (new) Life Safety Code of the National Fire Protection Association (NFPA) to provide a safe environment for all patients, staff and visitors.

Due to the widespread and cumulative effect of these deficient practices, which presented multiple hazards that directly affect the safety and well-being all patients, staff and visitors, it was determined that 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was out of compliance. The facility census was 16.

Based on observation, staff interview, record review, policy review, review of the consulting engineer letter and building plan review, the facility failed to determine compliance with the 2000 new edition of the Life Safety Code of the National Fire Protection Association (NFPA) in accordance with 42 CFR 485.623(d). The facility was found non-compliant. These deficiencies puts all patients, staff and visitors at a higher risk of injury or death from a fire. The facility census was 16.

Findings included:

1. All sections of the hospital meets the building construction type to be a hospital which is a Type II (111) for a two story hospital. The section of the building which is built as a Type II (000),(which is not allowed to be used as a two story hospital) provides no protection of the structure in the event of a fire. The Type II (000) construction type must have a complete two hour fire resistance rated wall separation from the first floor concrete slab to the second floor roof deck between the Type II (000) and the Type II (111). Without the separation of construction types puts the entire building as a Type II (000) and puts all patients, staff and visitors at a higher risk of injury or death from a fire.

-National Fire Protection Association (NFPA) 220, "Standard on Types of Building Construction", 1999 Edition, Chapter 2 Definitions states: 'Fire Resistance Rating.* The time, in minutes or hours, that materials or assemblies have withstood a fire exposure as established in accordance with the test procedures of NFPA 251, Standard Methods of Test of Fire Endurance of Building Construction and Materials."

-NFPA 220 table 3-1
Type II (000) construction standard does not require a protective foam coating or Class A interior protection to the vertical and horizontal steel beams that serve as main structural elements including connecting plates, bolts and cross-members (part of steel beam connecting other structural steel beams together) are vulnerable to heat and could fail and result in a catastrophic collapse of the entire structure due to having no protection provided between the building types.

Type II (111) construction standard requires application of protective foam coatings or Class A interior protection to the vertical and horizontal steel beams that serve as main structural elements including connecting plates, bolts and cross-members (part of steel beam connecting other structural steel beams together) are protected from heat.
The one hour (111) protection must be provided for the exterior bearing walls, interior bearing walls, columns, beams, girders, trusses and arches, floor-ceiling assemblies, roof-ceiling assemblies which provides a one hour protection of the building structure for fire.

NFPA 101, 2000 Edition, Section 18.1.2.3 states: " Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18.1.1.4."

Chapter 18.1.1.4.6 to 18.1.2 Mixed Occupancies (See also 6.1.14)

NFPA 101, 2000 edition, Section 6.1.14.2 states: " Applicable Requirements. Where a mixed occupancy classification occurs, the means of egress facilities, construction, protection, and other safeguards shall comply with the most restrictive life safety requirements of the occupancies involved.

Exception:* Where incidental to another occupancy, buildings used as follows shall be permitted to be considered part of the predominant occupancy and subject to the provisions of the Code that apply to the predominant occupancy:

(a) Mercantile, business, industrial, or storage use
(b)Nonresidential use with an occupant load fewer than that established by Section 6.1 for the occupancy threshold "

-Observation on 12/15/2015, during the facility tour, the first floor staff use corridor (smoke zone #5) between the Litton Conference room door and the 1 1/2 hour rated corridor doors showed a 1 hour fire resistance rated wall separating Type II (111) and the Type II (000) construction. This section did not have a two hour wall which ran from the first floor concrete slab to the second floor roof deck separating the Type II (000) building from the two story building. Without the two hour fire rated wall makes the entire section a Type II (000).

-Observation on 12/15/15, during the facility tour, showed the first floor (smoke zone #1), which included the Emergency Department, Diagnostic Imaging/X-Ray, Laboratory and facility staff offices section (Medical Office Building or MOB) of the first floor was constructed to a Type II (000) standard. This section did not have a two hour wall with 1 1/2 hour rated doors separating the building from the two story building which ran from the first floor concrete slab to the second floor roof deck. Without the two hour fire rated wall makes the entire section a Type II (000).

-Observation on 12/15/15, during the facility tour, showed on the second floor the hospital's surgery wing, obstetrics (OB) wing, and medical surgical/ ICU wing Type II (111) was located above the non-conforming Type II (000) building which did not have a two hour separation wall that ran from the first floor concrete slab to the second story roof deck. The unprotected separation wall makes these building sections a Type II (000) which is not allowed for a two story hospital.

-Review of the consulting engineer letter dated September 12, 2012 to the Architect for the working drawings, item #1 stated the hospital construction type will have to be at least a Type II (111) per the 2000 Life Safety Code.

2. The two story atrium was not constructed with a one hour fire barrier rated wall protecting the open enclosure area in the atrium. This deficient practice affects two smoke compartments in the building. This deficient practice has the potential to affect all patients, staff and visitors in the facility in the event of a fire. Failure to ensure a one hour fire barrier rated wall protects the open enclosure area in the atrium could delay evacuation to a safe area away from the building and puts all patients, staff and visitors at a higher risk of injury or death from a fire.

-Observation on 12/15/15, during the facility tour, showed the wall separating the smoke compartment number #4 (Business office area) on the first floor from compartment #3 (Atrium area) did not have a one hour fire rated wall to separate and protect the vertical opening of the two story atrium.

-Record review of the Life Safety 1st floor plan G1.11, dated 8/2012, showed a smoke partition wall separating compartment #4(Business office area) from compartment #3 (Atrium area) instead of the required 1-hour fire resistance rated barrier wall.


-NFPA 101, Life Safety Code 2000 Edition, section 18.3.1.1 states: "Any vertical opening shall be enclosed or protected in accordance with 8.2.5."

-NFPA 101, Life Safety Code 2000 Edition, section 8.2.5.8 (2)(4)
Where permitted by Chapters 12 through 42 unenclosed vertical openings not concealed within the building construction shall be permitted as follows.
(2) Such opening shall be separated from unprotected vertical openings serving other floors by a barrier complying with 8.2.5.4
(4) Such openings shall not serve as a required means of egress.

-NFPA 101, Life Safety Code 2000 Edition section 8.2.5.4 (2)The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits).
(2) Other enclosures in new construction - 1 hour fire barriers.

3. The two story atrium was constructed to have a one hour fire barrier rated wall protecting the open enclosure area in the atrium. This deficient practice affects two smoke compartments in the building. This deficient practice has the potential to affect all patients, staff and visitors in the facility in the event of a fire. Failure to ensure a one hour fire barrier rated wall protects the open enclosure area in the atrium could delay evacuation to a safe area away from the building and puts all patients, staff and visitors at a higher risk of injury or death from a fire.

-Observation on 12/15/15, during the facility tour, showed the wall separating compartment #4 (Business office area) from compartment #3 (Atrium area) did not have a one hour fire resistance rating.

-Record review of the Life Safety 1st floor plan G1.11, dated 8/2012, showed a smoke partition wall separating compartment #4(Business office area) from compartment #3 (Atrium area) instead of the required 1-hour fire resistance rated barrier wall.


-NFPA 101, Life Safety Code 2000 Edition, section 18.3.7.3 states: "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.

Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6.1(1). Not less than two separate smoke compartments shall be provided on each floor.

Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems."

-NFPA 101, Life Safety Code 2000 Edition, section 8.2.5.6 states: "Unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:

(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating with opening protectives for corridor walls. (See 8.2.3.2.3.1(2), Exception No. 1.)"

-NFPA 101, Life Safety Code 2000 Edition section 8.3.2* states: "Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier."

4. All exits were continuous and led to a public way such as a parking lot and designated exits that exited into two story vertical opening atrium was constructed to have a one hour fire barrier rated wall protecting the open enclosure area in the atrium. This deficient practice affects six of six exit discharges. This deficient practice has the potential to affect all patients, staff and visitors in the facility in the event of a fire. Failure to ensure exits comply with Life Safety Code requirements could delay evacuation to a safe area away from the building.

-Observation on 12/15/15, during the facility tour, showed the marked designated exit, exited to an exterior sidewalk located outside the facility main atrium area near the cafeteria led to a door entering the Medical Plaza building which was not part of the hospital. Observation showed the exit path required patients, staff, and visitors who may also be in wheelchairs or have limited mobility to enter an adjoining structure instead of a public way such as a parking lot. The way to get to the public way off of the sidewalk did not have a hard path to safety but would require exiting though a grass yard not usable by wheelchairs or limited mobility patients, staff or visitors.

-Record review of the facility layout evacuation plan posted next to the elevator in the atrium designated this as the exit discharge from the cafeteria area as an exit from the building.


-During an interview on 12/16/15 at 1:10 PM, Staff GG, Lead Maintenance Engineer, acknowledged the finding and stated that he did not know the exit pathways needed to connect to a public way.

-Observation on 12/15/15, during the facility tour, showed the wall separating the smoke compartment number #4 (business office area) on the first floor from the atrium did not have a one hour fire rated wall to separate and protect the designated exit area for the vertical opening of the two story atrium.


-NFPA 101, Life Safety Code 2000 Edition, section 18.2.1 states "General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7."

-NFPA 101, Life Safety Code 2000 Edition, section 7.5.4.3 states "Each required accessible means of egress shall be continuous from each accessible occupied area to a public way or area of refuge in accordance with 7.2.12.2.2."

-NFPA 101, Life Safety Code 2000 Edition section 18.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5

-NFPA 101, Life Safety Code 2000 Edition, section 8.2.5.8 (2)(4) Where permitted by Chapters 12 through 42 unenclosed vertical openings not concealed within the building construction shall be permitted as follows.
(2) Such opining shall be separated from unprotected vertical openings serving other floors by a barrier complying with 8.2.5.4
(4) Such openings shall not serve as a required means of egress.

-NFPA 101, Life Safety Code 2000 Edition section 8.2.5.4 (2) The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits).
(2) Other enclosures in new construction - 1 hour fire barriers.

5. The facility maintained the sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition when two areas in the dietary area had the sprinkler heads obstructed. This deficient practice has the potential to affect all patients, staff and visitors in the facility. This deficient practice could effect the sprinkler systems ability to operate reliably in the event of a fire. The facility census was 16.

-Observation on 12/15/15 at 9:47 AM, during the Life Safety Code tour, showed in the cafeteria above a drink dispenser
the ice maker was installed approximately ten inches from a sprinkler head deflector obstructing the water spray pattern coverage of the sprinkler head.

-Observation on 12/15/15 at 10:00 AM, during the Life Safety Code tour, showed in the walk-in refrigerator four boxes of food stored approximately ten inches below the sprinkler head deflector.

-Record review of facility policy titled, "General Safety Rules", dated 12/2015, showed the directive for staff that there must be at least 18 inch clearance from overhead sprinklers.

-During an interview on 12/16/15 at 2:48 PM, Staff M, Registered Dietician, acknowledged the findings and stated:
-She expects staff to follow the policy.
-A vendor installed the ice maker in 2014.

-NFPA 25 , Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 edition, section 2-2.1 "Sprinklers." Section 2-2.1.2* states: "Unacceptable obstructions to spray patterns shall be corrected".

-NFPA 25 , Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 edition, section A2-2.1.2 states: "Obstructions to spray patterns include horizontal obstructions near the ceiling, vertical obstructions, suspended or floor mounted obstructions, and clearances between sprinklers and storage below. The clearance requirement between sprinkler deflectors and the top of storage is typically 18 in. (457 mm). Specific guidance for clearance and obstructions is found in NFPA 13, Standard for the installation of Sprinkler systems; NFPA 231, Standard for General Storage; NFPA 231C, Standard for Rack Storage of Materials, and other standards and specific sprinkler listings."


6. The facility restricted the use of portable space heaters to non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees Fahrenheit. This deficient practice has the potential to affect all patients, staff and visitors in the facility by increasing the risk of causing a fire.

-Observation on 12/2015 at 10:18 AM showed in the Information Technology room a small running portable space heater under a desk.

-Record review of the facility's policy "Electrical Equipment Safety," dated 03/01/2012 showed portable space heaters restricted to non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees Fahrenheit.

-During an interview on 12/16/2015 at 10:18 AM, Staff GG acknowledged the finding and stated that he did not know the highest temperature the heating element reached.

-NFPA 101section 18.7.8 of states : "Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 F (100 C)."


7. The hospital installed a break glass type remote manual stop switch for the facility emergency generator according to NFPA standards. This deficient practice has the potential to effect all patients, staff and visitors in the facility. Failure to install the generator in accordance with NFPA standards increases the probability the generator will not function as designed in the event of a power outage.

-Observation on 12/15/2015 showed, during the facility tour, a break glass type remote manual stop switch for the facility emergency generator was not installed remotely from the location of the emergency generator.

-During an interview on 12/16/2015 at 1:15 PM, Staff GG acknowledged the finding and stated that he did not know the generator required a manual stop switch.

-NFPA 110 "Emergency and Standby Power Systems", 1999 edition, section 3-5.5.6 states: "All level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building."


8. The facility developed a procedure to implement anytime the facility sprinkler system is non-operational for more than four hours. This deficient practice has the potential to effect all patients, staff and visitors in the facility. Lack of these complete written policies and procedures could result in staff failing to implement interim measures in the event the automatic sprinkler system is not functioning to extinguish a fire in the building exposing occupants to the fire in the building, possibly resulting in patients, staff and visitors to injury or death in a fire.

-Record review of facility policies did not show a fire watch procedure to implement any time the facility sprinkler system is non-operational for more than four hours.


-During an interview on 12/16/2015 at 3:23 PM, Staff GG acknowledged the finding and stated that:

-The facility did not have a procedure to implement if the facility sprinkler system were non-operational for more than 4 hours in a 24 hour time frame.


-NFPA 101 chapter 9.7.6.1 states: "Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service."

-NFPA 101 Annex A Chapter 9.6.1.8, revealed: "A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes."

-NFPA 101, Section 9.7.6.2 states: "Sprinkler impairment procedures shall comply with NFPA 25, Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems".

9. The facility developed a procedure to implement any time the facility fire alarm system is non-operational for more than four hours. This deficient practice has the potential to effect all patients, staff and visitors in the facility. Lack of these complete written policies and procedures could result in staff failing to implement interim measures in the event the fire alarm system is not functioning to alert building occupants of a fire in the building, possibly exposing patients, staff and visitor to injury or death in a fire.

-Record review of facility policies did not show a fire watch procedure to implement any time the facility fire alarm system is non-operational for more than four hours.


-During an interview on 12/16/2015 at 3:23 PM, Staff GG acknowledged the finding and stated that:

-The facility did not have a procedure to implement if the facility fire alarm system were non-operational for more than 4 hours in a 24 hour time frame.

-NFPA 101 chapter 9.6.1.8 states: "Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service."

NFPA 101 Annex A Chapter 9.6.1.8, revealed: "A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes."

Based on interview and record review, the Governing Body failed to ensure the facility was operated to provide health care in a safe physical environment and administered using policies to establish, maintain, implement and monitor adherence to necessary life safety code requirements. (Refer to C 0241).

The cumulative effect of these systemic failures resulted in the facility's failure to meet the requirements under 42 CFR 485.627 the Condition of Participation: Organizational Structure. The facility census was 16.

Based on interview and record review, the Board of Directors (BOD) failed to ensure the facility was operated in a manner to provide all patients health care in a safe physical environment that was free of applicable life safety code violations. The BOD also, failed to ensure appropriate life safety code policies and procedures were developed, maintained, fully implemented and that implementation was monitored to ensure a safe physical environment was kept for all patients, staff and visitors. The facility census was 16.

Findings included:

1. Record review of the facility's document titled, "Fourth Amended and Restated Bylaws of the Hospital, Article 3, Board of Directors," dated 10/15/14 showed the facility was managed by or under the direction of the Board of Directors.

2. During a telephone interview on 12/21/15 from 2:31 PM through 2:50 PM, Staff JJ, Vice President for Health Systems and BOD member stated the following:
- The eight or nine member BOD met every other month.
- There were set agenda topics that were discussed at every BOD meeting such as safety.
- BOD members hired the architect, engineers and contractors and had verified their credentials.
- The BOD had received periodic progress reports during construction and had no reason to feel construction was not performed as required by life safety code regulations.
- The BOD was not made aware of and had not discussed any life safety code violations (not adhering to construction standards; lack of a hard path to safety from one of four exits; staff using unapproved electric space heaters; obstructed fire suppression sprinkler heads; lack of post indicator valve on the sprinkler supply line; lack of emergency generator cut off switch other than on the generator; lack of a fire watch policy when the sprinkler system was not working; and lack of a policy directing staff when the fire alarm system was out of service) prior to survey.

Based on interview, record review and policy review the facility staff failed to ensure the Pre Anesthesia (total or partial loss of sensation induced by medication) Evaluation forms were individually dated and timed for one current patient (#23) of one current anesthesia record reviewed and two discharged patients (#25 and #27) of three discharged records reviewed. This failure had the potential to adversely affect all patients that received anesthesia in the surgical department. The facility performed an average of 114 surgical/procedural cases per month that require anesthesia and 1,470 cases annually. The facility census was 16.

Findings included:

1. Record review of the facility policy titled, "Amended and Restated Rules and Regulations of the Medical Staff," dated 08/22/13, showed direction that all clinical entries in the patient's medical record must be individually authenticated (signed), dated and timed, promptly by the medical staff member or allied health professional who was responsible for the entry.

2. Record review of current Patient #23's History & Physical (H&P) dated 12/16/15 showed the patient was scheduled for an esophagogastroduodenoscopy (EGD, procedure that allows the physician to visualize the lining of the esophagus, stomach and first part of the small intestine) and a colonoscopy (procedure that allows the physician to visualize the lining of the large intestine).

Record review of the medical record for Patient #23 showed a form titled Pre Anesthesia Evaluation initialed by Staff EE, Certified Registered Nurse Anesthetist, (CRNA). No date or time was documented. The second page of this form was found towards the end of the medical record as it was separated from the first page.

During an interview on 12/16/15 at 11:50 AM, Staff EE, CRNA, stated that he signed, dated and timed the second page of the Pre Anesthesia Evaluation form. He stated that the two page form used to be a two sided form and that the signature was indicated on the second side. Staff EE stated that he didn't realize that he did not document a date or time on the first page.

3. Record review of discharged Patient #25's H&P dated 11/10/15 and updated on 12/07/15 showed the patient was scheduled for an excision (surgical removal or resection) of the left posterior (back of) neck mass on 12/07/15.

Record review of the medical record for Patient #25 showed the Pre Anesthesia Evaluation initialed by Staff CC, CRNA. No date or time was documented.

4. Record review of discharged Patient #27's H&P dated 01/24/15 showed the patient was scheduled for a right knee arthroscopy (surgical procedure on a joint) on 01/24/15.

Record review of the medical record showed the Pre Anesthesia Evaluation initialed by Staff FF, CRNA. No date or time was documented.

During an interview on 12/16/15 at 11:55 AM, Staff DD, Registered Nurse, (RN), Director of Surgical Services, stated that the Pre Anesthesia Evaluation form used to be a two sided form and that she had not realized the first page was not dated or timed by the CRNA's. She stated that the first page did not have a signature line for signature, date and time. Staff DD stated that there was only a box for the CRNA's to initial. She stated that there was the potential for these two pages to become separated and that if that occurred no one would know that the two pages belonged together.

During an interview on 12/16/15 at 1:26 PM, Staff A, RN, Chief Nursing Officer, (CNO), stated that the Pre Anesthesia Evaluation form was not a new form; that it had once been a two sided form but the facility had made it into two separate forms. She stated that it had the potential to be a problem if the two pages of the anesthesia evaluation ever became separated.