HospitalInspections.org

Based on observations and staff confirmation the facility failed to ensure that fire barriers were maintained. This had the potential to affect all patients, staff and visitors, with a capacity of 225 with a census of 216.

Findings include:

1. Observations were made on 05/06/14 at 1:58 PM on the fifth floor of an area of steel floor decking that did not have sprayed foam protection beyond the I beam. The area was above the clean supply room. The findings were confirmed at the time of observation with staff A and B.
2. Observations were made on 05/06/14 at 2:04 PM on the fifth floor of an area of steel floor decking approximately 6' x 4' without spray foam protection and a one foot section of I beam. The area was above the soiled utility room. The findings were confirmed at the time of the observation with staff A and B.

Based on observations and staff confirmation the facility failed to ensure that fire barriers were maintained. This had the potential to affect all patients, staff and visitors, with a capacity of 225 and a census of 216.

Findings include:

1. Observations were made on 05/06/14 on the fourth floor of a door from the corridor into the physical therapy gym that did not have positive latching to close. This finding was confirmed through demonstration with staff A and B at the time of the observation.





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2. On 05/06/14 at 1:40 P.M. a tour was conducted of the fifth floor with Staff A and B. Observation of the door to the janitor closet door, 5631, revealed it being equipped with a self closing device that failed to close the door.

On 05/06/14 at 1:40 P.M. in an interview, Staff A confirmed the finding.

3. On 05/06/14 at 2:22 P.M. a tour was conducted of the fourth floor with Staff A and B. At 3:15 P.M. observation of rehabilitation group room, TY010, revealed a door which failed to completely close.

On 05/06/14 at 3:15 P.M. in an interview, Staff A confirmed the observation.

Based on observation and interview, the facility failed to ensure each door that protected a corridor opening closed. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D. At 3:17 P.M. observation of the door to the janitor closet (room 2413) revealed it had a self closer and opened onto to a corridor, but failed to completely close when tested.

On 05/07/14 at 3:17 P.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to ensure each door on each stairway had a fire resistance rating of at least two hours. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/08/14 at 9:26 A.M. the tour of the second floor with Staff C and D resumed. At 9:26 A.M. the door to stairway C also identified as number 2 was observed not to be fire rated and was located in a two hour fire rated barrier.

On 05/08/14 at 9:26 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to ensure stairways were completely enclosed with construction having at least two hours fire resistive rating. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.
Findings include:
On 05/06/14 at 12:59 P.M. a tour was taken of the penthouse with Staff A and Staff C. During the tour, two hour rated doors in two hour fire rated construction wrapped around the elevator room was observed to be propped open with a metal wedge. No maintenance person was observed present at 1:07 P.M.
On 05/16/14 at 1:07 P.M. in an interview, Staff A confirmed the door had been held open an undeterminable amount of time.

Based on observations and staff confirmation the facility failed to ensure that smoke/fire barriers were maintained. This had the potential to affect all patients, staff and visitors, with a capacity of 225 and a census of 216.

Findings include:

1. Observations were made on 05/07/14 at 10:37 AM on the first floor of an approximately 4" by 4" cut out area of drywall and two metal conduits passing through the wall in a data closet that was a one hour fire wall designation. This observation was confirmed with staff A and staff B at 10:37 AM during the tour in that area.




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On 05/06/14 at 2:22 P.M. a tour of the fourth floor was conducted with Staff A and C.

2. Observation at 3:55 P.M. of the equipment room opposite the elevator revealed a one hour rated construction which had a half inch penetration in the wall dividing the room from the corridor.
On 05/06/14 at 3:55 P.M. in an interview, Staff A confirmed the observation.

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D.

3. At 8:53 A.M. observation above the drop down ceiling over the double doors leading to the cardiovascular unit revealed a two hour rated wall with a half-inch conduit with a blue wire running through it open to air.

On 05/07/14 at 8:53 A.M. in an interview, Staff D confirmed the observation.

4. At 9:12 A.M. observation above the drop down ceiling over the single door in the one hour barrier in the 180 degree corridor bisecting the cardiovascular unit revealed a half inch conduit open to air with a blue wire running through it.

On 05/07/14 at 9:12 A.M. in an interview, Staff D confirmed the observation.

5. At 9:45 A.M. observation of a non-fire rated door, 2H555A located in a one hour fire rated wall.

On 05/07/14 at 9:45 A.M. in an interview, Staff D confirmed the observation.

6. At 10:34 A.M. observation of the one hour rated wall above the double doors (2H533) leading to surgery revealed an open junction box with an open one inch conduit leading through the barrier.

On 05/07/14 at 10:34 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to maintain the stated fire resistive rating on its smoke and fire barriers. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D.

1. At 11:48 A.M. observation above the drop down ceiling of the one hour rated wall over the door to the outpatient pharmacy revealed a one by four inch open square.

On 05/07/14 at 11:48 A.M. in an interview, Staff D confirmed the observation.

2. At 11:56 A.M. observation above the drop down ceiling of the one hour wall inside 2A129 and outside the human resources coordinator's office revealed a one inch penetration.

On 05/07/14 at 11:56 A.M. in an interview, Staff D confirmed the observation.

3. At 2:48 P.M. observation above the drop down ceiling of the 30 minute rated barrier above the double doors to the laboratory revealed a one inch conduit open to air within an open one foot by one foot box.

On 05/07/14 at 2:48 P.M. in an interview, Staff D confirmed the observation.

4. At 4:24 P.M. observation above the drop down ceiling of the one hour rated barrier in the clean utility room in the operating room suite revealed a one inch penetration in the western most wall.

On 05/07/14 at 4:24 P.M. in an interview, Staff D confirmed the observation.

On 05/08/14 at 9:26 A.M. the tour of the second floor with Staff C and D resumed.

5. At 10:34 A.M. observation above the drop down ceiling over the door leading to zone four of the emergency department revealed going through a one rated wall two one inch conduits open to air with blue wires running through them.

On 05/08/14 at 10:34 A.M. in an interview, Staff D confirmed the observation.

6. At 10:52 A.M. observation in the emergency department above the drop down ceiling over the double doors leading to the parking lot revealed a one hour barrier, with the words " one hour wall " painted on it, with one layer of dry wall about one foot high and two feet long missing.

On 05/08/14 at 10:52 A.M. in an interview, Staff D confirmed the observation.

7. At 11:15 A.M. in the corner of room M2021 a two inch pipe was observed going into the one hour rated wall and to have an annular space around it.

On 05/08/14 at 11:15 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to ensure each door in a smoke barrier closed. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

1. On 05/07/14 at 2:00 P.M. the drop down door to the gift shop located within a one hour rated wall was tested through the alarm system's smoke detector. The door was not observed to drop.

On 05/07/14 at 2:00 P.M. in an interview, Staff A confirmed the observation saying the system was showing it to be disabled.

2. On 05/07/14 at 2:27 P.M. the horizontal door in a one hour rated wall to the east of the main entrance was tested through the alarm system's smoke detector. The door was not observed to extend across the corridor.

On 05/07/14 at 2:27 P.M. in an interview, Staff A confirmed the observation.

On 05/08/14 at 9:26 A.M. the tour of the second floor with Staff C and D resumed.

3. At 10:24 A.M. door 2028 was observed to be uncrated in a one hour rated barrier.

On 05/08/14 at 10:24 A.M. in an interview, Staff D confirmed the observation.

On 05/08/14 at 2:52 P.M. a tour was conducted of the first floor with Staff C and D.

4. At 2:52 P.M. double doors in one hour protective construction around room 21 and labeled IP404 were observed that if the right leaf of the door closed before left leaf (as entering the room), it prevented the left leaf from closing and latching.

On 05/08/14 at 2:52 P.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to have each exit access so arranged that exits were readily accessible. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D. At 11:36 A.M. a tour of the gift shop on the floor was undertaken. At a door within the gift shop and with an exit sign above it, hanging clothes and a cart was observed placed in front of it, blocking the path of egress.

On 05/07/14 at 11:36 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to ensure smoke detectors were no closer than three feet to an air handling vent. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/06/14 at 2:22 P.M. a tour was conducted of the fourth floor with Staff A and C. At 2:25 P.M. patient rooms 4909, 4910, 4911, 4912, and 4913 were observed to have smoke detectors closer than three feet to an air handling vent.

On 05/06/14 at 2:25 P.M. in an interview, Staff A confirmed the observation.

Based on observation and interview, the facility failed to maintain evidence of smoke detector sensitivity testing. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the facility's smoke detector testing documentation failed to reveal documentation of its sensitivity testing.

On 05/08/14 at 3:00 P.M. in an interview, Staff A explained the smoke detector system was self monitoring and there wasn't a way to create a printout that shows the sensitivities of the smoke detectors.

Based on observation and interview, the facility failed to maintain an automatic sprinkler system in accordance with NFPA 25. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/06/14 at 2:22 P.M. a tour was conducted of the fourth floor with Staff A and C.

1. Observation at 2:25 P.M. of the sprinkler head in the nourishment room and transitional living apartment revealed sprinkler heads with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 2:25 P.M. in an interview, Staff A confirmed the observation.

2. Observation at 2:36 P.M. of the sprinkler head near the door to the rehabilitation waiting area revealed a sprinkler head with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 2:36 P.M. in an interview, Staff A confirmed the observation.

3. Observation at 2:58 P.M. of the program supply office revealed a sprinkler head with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 2:58 P.M. in an interview, Staff A confirmed the observation.

4. At 3:18 P.M. observation of room 4484 revealed a sprinkler head with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 3:18 P.M. in an interview, Staff A confirmed the observation.

5. On 05/06/14 at 4:05 P.M. a tour was conducted of the third floor with Staff A and C. At 4:08 P.M. observation of the sprinkler head by the tube station at the nursing station revealed a sprinkler head with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 4:08 P.M. in an interview, Staff A confirmed the observation.

6. At 4:11 P.M. observation of the sprinkler head in patient room seven revealed it with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 4:11 P.M. in an interview, Staff A confirmed the observation.

7. At 4:15 P.M. observation of the sprinkler head in the staff break room revealed it covered with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 4:15 P.M. in an interview, Staff A confirmed the observation.

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D.

8. On 05/07/13 at 9:30 A.M. observation of the sprinkler head across from room 2916 at the nursing station revealed it covered with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/07/14 at 9:30 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to maintain an automatic sprinkler system in accordance with NFPA 25. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D.

1. At 11:58 A.M. a sprinkler head outside the senior human resources consultant was observed to be covered with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/07/14 at 11:58 A.M. in an interview, Staff D confirmed the observation.

2. At 3:00 P.M. observation of the sprinkler head in the storage/pump room near the operating rooms revealed it was missing an escutcheon.

On 05/07/14 at 3:00 P.M. in an interview, Staff D confirmed the observation.

On 05/08/14 at 9:26 A.M. the tour of the second floor with Staff C and D was resumed.

3. At 10:52 A.M. in the emergency department at the double doors leading to the corridor to the parking lot, a sprinkler was observed to have a missing escutcheon.

On 05/08/14 at 10:52 A.M. in an interview, Staff D confirmed the observation.

4. At 2:22 P.M. in the radiology film room a sprinkler head was observed to be covered with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/08/14 at 2:22 P.M. in an interview, Staff D confirmed the observation.

Based on observations and staff interview the facility failed to ensure that fire barriers were maintained. This had the potential to affect all patients staff and visitors, with five operating rooms, three endoscopy rooms, and a yearly case load of 3,184 patients.

Findings include:

1) Observations were made on 05/07/14 at 11:25 AM on the second floor of a penetration around a 1.5 " medical vacuum pipe that was not sealed on either side of a two hour rated fire wall. The area was above a double door entryway from the main hospital building to the ambulatory surgical building. The finding was confirmed with staff A and B at 11:25 AM during the tour of the area.

2) Observations were made on 05/07/14 at 11:40 AM on the second floor of a single door that was part of the two hour fire wall that did not latch when closed. The finding was confirmed with staff A and B at that time.

Based on observations and staff interview the facility failed to ensure that fire/smoke barriers were maintained. This had the potential to affect all patients staff and visitors, with five operating rooms, three endoscopy rooms, and a yearly case load of 3,184 patients.

Findings include:

1) Observations were made on 05/07/14 at 2:47 PM on the second floor of a penetration around a 1.5" medical vacuum pipe in a one hour rated fire wall protecting a mechanical shaft. This finding was confirmed with staff A and B at that time.

2) Observations were made on 05/07/14 at 2:56 PM on the second floor of a penetration of approximately 1.5 " square cut out in the drywall with two red wires passing through the opening in a one hour rated wall at the rear of the reception area. This finding was confirmed with staff A and B at that time.

3) Observations were made on 05/07/14 at 3:08 PM on the second floor of a penetration of approximately 1.5" square cut out of dry wall with two red wires passing through the opening near the double doors in the pre-op area. This finding was confirmed with staff A and B at that time.

4) Observations were made on 05/07/14 at 3:17 PM on the second floor of penetrations around a 2" steam pipe passing through the one hour rated fire and smoke barrier wall in the pre-op hallway. This finding was confirmed with staff A and B at that time.

5) Observations were made on 05/07/14 at 3:33 PM on the second floor of a penetration in the drywall with a green wire passing through in a one hour fire/ smoke barrier wall on the east side of the sterile supply room. This finding was confirmed with staff A and B at that time.

6) Observations were made on 05/07/14 at 3:36 PM on the second floor of a penetration approximately 1" diameter in drywall with a black wire passing through in a one hour fire/ smoke barrier wall near the sterile supply room. This finding was confirmed with staff A and B at that time.

7) Observations were made on 05/07/14 at 3:40 PM on the second floor of a door leading to the sterile supply room from the corridor that was part of a one hour rated fire/ smoke barrier enclosure that did not latch when closed. This finding was confirmed with staff A and B at that time.

NFPA 101, 2000 edition

18.2.5.6
Suites of sleeping rooms shall not exceed 5000 square feet.

Based on review of the schematic for the second floor and third floor, and interview, the facility failed to maintain suite footage to not more than 5000 square feet for patient-sleeping suites. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the schematic of the third floor revealed the intensive care unit was designated as a 12,576 square foot, patient sleeping, suite.

Review of the schematic of the second floor revealed the cardiovascular unit was designated as a 12,920 square foot, patient sleeping, suite.

On 05/08/14 at 3:00 P.M. in an interview Staff A confirmed the square footage of the intensive care and cardiovascular units.

NFPA 101, 2000 edition

19.2.5.7
Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 square feet.

Based on review of the schematic for the second floor and the operating room suite, and interview, the facility failed to maintain suite footage to not more than 10,000 square feet for non patient-sleeping suites. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the schematic of the second floor revealed the operating room to be designated a 17,228 square foot non patient sleeping suite.

On 05/08/14 at 3:00 P.M. in an interview Staff A confirmed the square footage of the operating room suite.

Based on interview and record review, the facility does not have a fire watch system for when the automatic sprinkler system is down for longer than four hours for a scheduled shut down. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the facility's fire watch policy, approved 9/10/13, revealed a fire watch would not be implemented during a scheduled shutdown of the sprinkler system, even if the shut down lasts longer than four hours.

On 05/08/14 at 3:00 P.M. in an interview Staff A confirmed the policy as written.

Based on interview and record review, the facility does not have a fire watch system for when the fire alarm system is down for longer than four hours for a scheduled shut down. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the facility's fire watch policy, approved 9/10/13, revealed a fire watch would not be implemented during a scheduled shutdown of the fire alarm system, even if the shut down lasts longer than four hours.

On 05/08/14 at 3:00 P.M. in an interview Staff A confirmed the policy as written.

Based on observations and staff confirmation the facility failed to ensure that fire barriers were maintained. This had the potential to affect all patients, staff and visitors, with a capacity of 225 with a census of 216.

Findings include:

1. Observations were made on 05/06/14 at 1:58 PM on the fifth floor of an area of steel floor decking that did not have sprayed foam protection beyond the I beam. The area was above the clean supply room. The findings were confirmed at the time of observation with staff A and B.
2. Observations were made on 05/06/14 at 2:04 PM on the fifth floor of an area of steel floor decking approximately 6' x 4' without spray foam protection and a one foot section of I beam. The area was above the soiled utility room. The findings were confirmed at the time of the observation with staff A and B.

Based on observations and staff confirmation the facility failed to ensure that fire barriers were maintained. This had the potential to affect all patients, staff and visitors, with a capacity of 225 and a census of 216.

Findings include:

1. Observations were made on 05/06/14 on the fourth floor of a door from the corridor into the physical therapy gym that did not have positive latching to close. This finding was confirmed through demonstration with staff A and B at the time of the observation.





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2. On 05/06/14 at 1:40 P.M. a tour was conducted of the fifth floor with Staff A and B. Observation of the door to the janitor closet door, 5631, revealed it being equipped with a self closing device that failed to close the door.

On 05/06/14 at 1:40 P.M. in an interview, Staff A confirmed the finding.

3. On 05/06/14 at 2:22 P.M. a tour was conducted of the fourth floor with Staff A and B. At 3:15 P.M. observation of rehabilitation group room, TY010, revealed a door which failed to completely close.

On 05/06/14 at 3:15 P.M. in an interview, Staff A confirmed the observation.

Based on observation and interview, the facility failed to ensure each door that protected a corridor opening closed. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D. At 3:17 P.M. observation of the door to the janitor closet (room 2413) revealed it had a self closer and opened onto to a corridor, but failed to completely close when tested.

On 05/07/14 at 3:17 P.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to ensure each door on each stairway had a fire resistance rating of at least two hours. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/08/14 at 9:26 A.M. the tour of the second floor with Staff C and D resumed. At 9:26 A.M. the door to stairway C also identified as number 2 was observed not to be fire rated and was located in a two hour fire rated barrier.

On 05/08/14 at 9:26 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to ensure stairways were completely enclosed with construction having at least two hours fire resistive rating. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.
Findings include:
On 05/06/14 at 12:59 P.M. a tour was taken of the penthouse with Staff A and Staff C. During the tour, two hour rated doors in two hour fire rated construction wrapped around the elevator room was observed to be propped open with a metal wedge. No maintenance person was observed present at 1:07 P.M.
On 05/16/14 at 1:07 P.M. in an interview, Staff A confirmed the door had been held open an undeterminable amount of time.

Based on observations and staff confirmation the facility failed to ensure that smoke/fire barriers were maintained. This had the potential to affect all patients, staff and visitors, with a capacity of 225 and a census of 216.

Findings include:

1. Observations were made on 05/07/14 at 10:37 AM on the first floor of an approximately 4" by 4" cut out area of drywall and two metal conduits passing through the wall in a data closet that was a one hour fire wall designation. This observation was confirmed with staff A and staff B at 10:37 AM during the tour in that area.




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On 05/06/14 at 2:22 P.M. a tour of the fourth floor was conducted with Staff A and C.

2. Observation at 3:55 P.M. of the equipment room opposite the elevator revealed a one hour rated construction which had a half inch penetration in the wall dividing the room from the corridor.
On 05/06/14 at 3:55 P.M. in an interview, Staff A confirmed the observation.

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D.

3. At 8:53 A.M. observation above the drop down ceiling over the double doors leading to the cardiovascular unit revealed a two hour rated wall with a half-inch conduit with a blue wire running through it open to air.

On 05/07/14 at 8:53 A.M. in an interview, Staff D confirmed the observation.

4. At 9:12 A.M. observation above the drop down ceiling over the single door in the one hour barrier in the 180 degree corridor bisecting the cardiovascular unit revealed a half inch conduit open to air with a blue wire running through it.

On 05/07/14 at 9:12 A.M. in an interview, Staff D confirmed the observation.

5. At 9:45 A.M. observation of a non-fire rated door, 2H555A located in a one hour fire rated wall.

On 05/07/14 at 9:45 A.M. in an interview, Staff D confirmed the observation.

6. At 10:34 A.M. observation of the one hour rated wall above the double doors (2H533) leading to surgery revealed an open junction box with an open one inch conduit leading through the barrier.

On 05/07/14 at 10:34 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to maintain the stated fire resistive rating on its smoke and fire barriers. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D.

1. At 11:48 A.M. observation above the drop down ceiling of the one hour rated wall over the door to the outpatient pharmacy revealed a one by four inch open square.

On 05/07/14 at 11:48 A.M. in an interview, Staff D confirmed the observation.

2. At 11:56 A.M. observation above the drop down ceiling of the one hour wall inside 2A129 and outside the human resources coordinator's office revealed a one inch penetration.

On 05/07/14 at 11:56 A.M. in an interview, Staff D confirmed the observation.

3. At 2:48 P.M. observation above the drop down ceiling of the 30 minute rated barrier above the double doors to the laboratory revealed a one inch conduit open to air within an open one foot by one foot box.

On 05/07/14 at 2:48 P.M. in an interview, Staff D confirmed the observation.

4. At 4:24 P.M. observation above the drop down ceiling of the one hour rated barrier in the clean utility room in the operating room suite revealed a one inch penetration in the western most wall.

On 05/07/14 at 4:24 P.M. in an interview, Staff D confirmed the observation.

On 05/08/14 at 9:26 A.M. the tour of the second floor with Staff C and D resumed.

5. At 10:34 A.M. observation above the drop down ceiling over the door leading to zone four of the emergency department revealed going through a one rated wall two one inch conduits open to air with blue wires running through them.

On 05/08/14 at 10:34 A.M. in an interview, Staff D confirmed the observation.

6. At 10:52 A.M. observation in the emergency department above the drop down ceiling over the double doors leading to the parking lot revealed a one hour barrier, with the words " one hour wall " painted on it, with one layer of dry wall about one foot high and two feet long missing.

On 05/08/14 at 10:52 A.M. in an interview, Staff D confirmed the observation.

7. At 11:15 A.M. in the corner of room M2021 a two inch pipe was observed going into the one hour rated wall and to have an annular space around it.

On 05/08/14 at 11:15 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to ensure each door in a smoke barrier closed. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

1. On 05/07/14 at 2:00 P.M. the drop down door to the gift shop located within a one hour rated wall was tested through the alarm system's smoke detector. The door was not observed to drop.

On 05/07/14 at 2:00 P.M. in an interview, Staff A confirmed the observation saying the system was showing it to be disabled.

2. On 05/07/14 at 2:27 P.M. the horizontal door in a one hour rated wall to the east of the main entrance was tested through the alarm system's smoke detector. The door was not observed to extend across the corridor.

On 05/07/14 at 2:27 P.M. in an interview, Staff A confirmed the observation.

On 05/08/14 at 9:26 A.M. the tour of the second floor with Staff C and D resumed.

3. At 10:24 A.M. door 2028 was observed to be uncrated in a one hour rated barrier.

On 05/08/14 at 10:24 A.M. in an interview, Staff D confirmed the observation.

On 05/08/14 at 2:52 P.M. a tour was conducted of the first floor with Staff C and D.

4. At 2:52 P.M. double doors in one hour protective construction around room 21 and labeled IP404 were observed that if the right leaf of the door closed before left leaf (as entering the room), it prevented the left leaf from closing and latching.

On 05/08/14 at 2:52 P.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to have each exit access so arranged that exits were readily accessible. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D. At 11:36 A.M. a tour of the gift shop on the floor was undertaken. At a door within the gift shop and with an exit sign above it, hanging clothes and a cart was observed placed in front of it, blocking the path of egress.

On 05/07/14 at 11:36 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to ensure smoke detectors were no closer than three feet to an air handling vent. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/06/14 at 2:22 P.M. a tour was conducted of the fourth floor with Staff A and C. At 2:25 P.M. patient rooms 4909, 4910, 4911, 4912, and 4913 were observed to have smoke detectors closer than three feet to an air handling vent.

On 05/06/14 at 2:25 P.M. in an interview, Staff A confirmed the observation.

Based on observation and interview, the facility failed to maintain evidence of smoke detector sensitivity testing. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the facility's smoke detector testing documentation failed to reveal documentation of its sensitivity testing.

On 05/08/14 at 3:00 P.M. in an interview, Staff A explained the smoke detector system was self monitoring and there wasn't a way to create a printout that shows the sensitivities of the smoke detectors.

Based on observation and interview, the facility failed to maintain an automatic sprinkler system in accordance with NFPA 25. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/06/14 at 2:22 P.M. a tour was conducted of the fourth floor with Staff A and C.

1. Observation at 2:25 P.M. of the sprinkler head in the nourishment room and transitional living apartment revealed sprinkler heads with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 2:25 P.M. in an interview, Staff A confirmed the observation.

2. Observation at 2:36 P.M. of the sprinkler head near the door to the rehabilitation waiting area revealed a sprinkler head with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 2:36 P.M. in an interview, Staff A confirmed the observation.

3. Observation at 2:58 P.M. of the program supply office revealed a sprinkler head with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 2:58 P.M. in an interview, Staff A confirmed the observation.

4. At 3:18 P.M. observation of room 4484 revealed a sprinkler head with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 3:18 P.M. in an interview, Staff A confirmed the observation.

5. On 05/06/14 at 4:05 P.M. a tour was conducted of the third floor with Staff A and C. At 4:08 P.M. observation of the sprinkler head by the tube station at the nursing station revealed a sprinkler head with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 4:08 P.M. in an interview, Staff A confirmed the observation.

6. At 4:11 P.M. observation of the sprinkler head in patient room seven revealed it with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 4:11 P.M. in an interview, Staff A confirmed the observation.

7. At 4:15 P.M. observation of the sprinkler head in the staff break room revealed it covered with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/06/14 at 4:15 P.M. in an interview, Staff A confirmed the observation.

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D.

8. On 05/07/13 at 9:30 A.M. observation of the sprinkler head across from room 2916 at the nursing station revealed it covered with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/07/14 at 9:30 A.M. in an interview, Staff D confirmed the observation.

Based on observation and interview, the facility failed to maintain an automatic sprinkler system in accordance with NFPA 25. This has the potential to affect all patients, staff and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

On 05/07/14 at 8:53 A.M. a tour was conducted of the second floor of the tower building with Staff C and D.

1. At 11:58 A.M. a sprinkler head outside the senior human resources consultant was observed to be covered with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/07/14 at 11:58 A.M. in an interview, Staff D confirmed the observation.

2. At 3:00 P.M. observation of the sprinkler head in the storage/pump room near the operating rooms revealed it was missing an escutcheon.

On 05/07/14 at 3:00 P.M. in an interview, Staff D confirmed the observation.

On 05/08/14 at 9:26 A.M. the tour of the second floor with Staff C and D was resumed.

3. At 10:52 A.M. in the emergency department at the double doors leading to the corridor to the parking lot, a sprinkler was observed to have a missing escutcheon.

On 05/08/14 at 10:52 A.M. in an interview, Staff D confirmed the observation.

4. At 2:22 P.M. in the radiology film room a sprinkler head was observed to be covered with enough dust to partially obscure the view of the color of the fluid bulb inside the sprinkler head.

On 05/08/14 at 2:22 P.M. in an interview, Staff D confirmed the observation.

Based on observations and staff interview the facility failed to ensure that fire barriers were maintained. This had the potential to affect all patients staff and visitors, with five operating rooms, three endoscopy rooms, and a yearly case load of 3,184 patients.

Findings include:

1) Observations were made on 05/07/14 at 11:25 AM on the second floor of a penetration around a 1.5 " medical vacuum pipe that was not sealed on either side of a two hour rated fire wall. The area was above a double door entryway from the main hospital building to the ambulatory surgical building. The finding was confirmed with staff A and B at 11:25 AM during the tour of the area.

2) Observations were made on 05/07/14 at 11:40 AM on the second floor of a single door that was part of the two hour fire wall that did not latch when closed. The finding was confirmed with staff A and B at that time.

Based on observations and staff interview the facility failed to ensure that fire/smoke barriers were maintained. This had the potential to affect all patients staff and visitors, with five operating rooms, three endoscopy rooms, and a yearly case load of 3,184 patients.

Findings include:

1) Observations were made on 05/07/14 at 2:47 PM on the second floor of a penetration around a 1.5" medical vacuum pipe in a one hour rated fire wall protecting a mechanical shaft. This finding was confirmed with staff A and B at that time.

2) Observations were made on 05/07/14 at 2:56 PM on the second floor of a penetration of approximately 1.5 " square cut out in the drywall with two red wires passing through the opening in a one hour rated wall at the rear of the reception area. This finding was confirmed with staff A and B at that time.

3) Observations were made on 05/07/14 at 3:08 PM on the second floor of a penetration of approximately 1.5" square cut out of dry wall with two red wires passing through the opening near the double doors in the pre-op area. This finding was confirmed with staff A and B at that time.

4) Observations were made on 05/07/14 at 3:17 PM on the second floor of penetrations around a 2" steam pipe passing through the one hour rated fire and smoke barrier wall in the pre-op hallway. This finding was confirmed with staff A and B at that time.

5) Observations were made on 05/07/14 at 3:33 PM on the second floor of a penetration in the drywall with a green wire passing through in a one hour fire/ smoke barrier wall on the east side of the sterile supply room. This finding was confirmed with staff A and B at that time.

6) Observations were made on 05/07/14 at 3:36 PM on the second floor of a penetration approximately 1" diameter in drywall with a black wire passing through in a one hour fire/ smoke barrier wall near the sterile supply room. This finding was confirmed with staff A and B at that time.

7) Observations were made on 05/07/14 at 3:40 PM on the second floor of a door leading to the sterile supply room from the corridor that was part of a one hour rated fire/ smoke barrier enclosure that did not latch when closed. This finding was confirmed with staff A and B at that time.

NFPA 101, 2000 edition

18.2.5.6
Suites of sleeping rooms shall not exceed 5000 square feet.

Based on review of the schematic for the second floor and third floor, and interview, the facility failed to maintain suite footage to not more than 5000 square feet for patient-sleeping suites. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the schematic of the third floor revealed the intensive care unit was designated as a 12,576 square foot, patient sleeping, suite.

Review of the schematic of the second floor revealed the cardiovascular unit was designated as a 12,920 square foot, patient sleeping, suite.

On 05/08/14 at 3:00 P.M. in an interview Staff A confirmed the square footage of the intensive care and cardiovascular units.

NFPA 101, 2000 edition

19.2.5.7
Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 square feet.

Based on review of the schematic for the second floor and the operating room suite, and interview, the facility failed to maintain suite footage to not more than 10,000 square feet for non patient-sleeping suites. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the schematic of the second floor revealed the operating room to be designated a 17,228 square foot non patient sleeping suite.

On 05/08/14 at 3:00 P.M. in an interview Staff A confirmed the square footage of the operating room suite.

Based on interview and record review, the facility does not have a fire watch system for when the automatic sprinkler system is down for longer than four hours for a scheduled shut down. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the facility's fire watch policy, approved 9/10/13, revealed a fire watch would not be implemented during a scheduled shutdown of the sprinkler system, even if the shut down lasts longer than four hours.

On 05/08/14 at 3:00 P.M. in an interview Staff A confirmed the policy as written.

Based on interview and record review, the facility does not have a fire watch system for when the fire alarm system is down for longer than four hours for a scheduled shut down. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings:

Review of the facility's fire watch policy, approved 9/10/13, revealed a fire watch would not be implemented during a scheduled shutdown of the fire alarm system, even if the shut down lasts longer than four hours.

On 05/08/14 at 3:00 P.M. in an interview Staff A confirmed the policy as written.