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Based on observation, building plan review, and interview, the facility failed to meet the requirements of 482.41 (b)(1)(2)(3) - Life Safety Code from Fire and the applicable provisions of the 2000 (existing) Life Safety Code of the National Fire Protection Association (NFPA) to provide a safe environment for all patients, staff and visitors. (Refer to A710)

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 482.41 Condition of Participation: Physical Environment was out of compliance. The facility census was 131.

Based on observation, interview, policy review, and review of 482.41 (b)(1)(2)(3) - Life Safety Code from Fire and the applicable provisions of the 2000 (new) Life Safety Code of the National Fire Protection Association (NFPA) the facility failed to provide a safe environment. The facility must be in compliance with all applicable codes referenced in the Life Safety Code. Building #1 is the main hospital building and Building #2 is the in-patient acute care psychiatric unit located approximately six miles from the main hospital building.

The facility failed to ensure:

Building #2

- The one of one two hour separation wall between the hospital and the medical office building was maintained and intact when the wall had penetrations through the two hour wall that were not fire caulked and sealed. The fire rated doors that separate the two different occupancies (hospital patients and medical office patients) did not have an over lapping astragal (architectural element commonly used to seal the clearance gap of a pair of doors to prevent fire from passing through the openings between the doors) to seal the edges of the swinging doors. The walls and doors not being sealed puts all patients, staff and visitors at risk of injury or death from a fire in an adjoining building.
NFPA 18.1.1.4.1,18.1.1.4.2, 18.2.3.2

- The building meets the building construction type to be a hospital. The psychiatric unit is in a type V (000) unprotected construction (unprotected wood construction), which is not allowed to be used as a hospital. This type of construction puts all patients, staff and visitors at a higher risk of injury or death from a fire.
NFPA 101, 18.1.6.2,18.1.3.3,18.3.5.1

-There were two intact smoke compartments between the women's and men's unit in the patient care wing. This failure puts all patients, staff and visitors at risk of injury or death from a fire by not keeping the smoke contained to one side of the smoke wall.
NFPA 101, 18.3.7.1, 18.3.7.2

-One of one smoke barrier in the patient wing was constructed to provide a one hour fire resistance rating. The wall had multiple holes which compromised the one hour rating to resist the passage of smoke. Windows in the smoke barrier wall were missing and were not protected with fire-rated glazing or by wired glass panels. This failure exposes all patients, staff and visitors at risk of injury or death from a fire by not keeping fire and smoke from passing through the smoke barrier wall.
NFPA 101, 8.3, 18.3.7.3, 18.3.7.5

-Two of two smoke barrier walls had doors that resisted the passage of smoke and failed to ensure one door had a twenty minute fire rating or was 1 3/4 inch thick. This failure could potentially allow smoke to pass through the barrier wall and allow fire to come through the door, endangering all patients, staff and visitors.
NFPA 101, 18.3.7.5, 18.3.7.6, 18.3.7.8

-Three of three hazardous areas (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) walls were intact. The walls had multiple holes and penetrations in the one hour fire rated barrier. One of the three hazardous doors did not have 3/4 hour fire rating. Failure to maintain the one hour rated walls and provide a fire rated door puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area.
NFPA 101, 9.7, 18.3.2.1, 18.3.5.1

-One of three exits in the psychiatric unit was accessible at all times when the door exited into a court yard that did not have a hard path to a public way. The facility admits patients in wheel chairs and patients who have limited mobility. Failure to have a hard path to safety puts all patients, staff and visitors attempting to exit a building in case of an emergency at risk of injury or death by getting trapped in the court yard.
NFPA 101, 7.1, 18.2.1

-All magnetic locks on all exits were able to be unlocked in case of an emergency by all staff working in the unit. The failure to rapidly remove patients and staff in a fire puts them at risk from death or being injured when attempting to exit the building.
NFPA 101, 7.1, 18.2.1

-All staff was able to unlock the gate of the court yard where all patients exited from the building. Only security guards had access to unlock the gate to allow patients and staff to get to a public way to safety. Failure to leave the court yard puts all patients, staff and visitors at risk from fire by being trapped in a locked court yard.
NFPA 101, 7.1, 18.2.1

-Five of five patient exit corridors in the buildings in-patient care unit, serving as exit access, were eight feet in width. This reduction in the size of the corridors has the potential to place all patients, staff and visitors at risk of injury or death when attempting to exit the building in the case of a fire.
NFPA 101, 18.2.3.3, 18.2.3.4

-Four of six patient exit doors had an opening of at least 41.5 inches in clear width. Failure to provide 41.5 inch doors puts all patients, staff and visitors at risk of injury or death from a fire by restricting the access to the doors to exit the building.
NFPA 101, 18.2.3.5

Building #1

-They maintained the protective foam coatings of the vertical and horizontal steel beams in three of three shell space areas and two of two floors used for mechanical space. The vertical and horizontal steel beams serve as the main structural elements that support the nine floor building. Without the protective foam coating or Class A (high level of fire resistance) interior protection, the steel beams, 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, affecting all patients, staff and visitors.
NFPA 101, 18.1.6.2, 18.3.5.1

-Fire and smoke doors on four of seven occupied patient floors closed, to separate extended corridors and prevent the spread of smoke or fire to unaffected patient rooms. Failure to maintain separate fire spaces prevents staff from being able to isolate a fire to a limited area and prevent the spread of smoke, which potentially affects all staff, visitors and all patients in the nine story structure.
NFPA 101, 18.3.7.5, 18.3.7.6, 18.3.7.8

The facility census was 131.

Findings included:

Building #2

1. Observation on 07/07/15 at 9:00 AM, during the building tour, showed the two hour common wall between the medical office building and the buildings women's locker room had a conduit running through the wall above the lay in ceiling that was not fire sealed around the pipe. The pair of fire rated doors between the medical office building did not have an over lapping astragal installed on the doors.

2. Observation on 07/07/15 at 9:00 AM and review of the building plans showed the building had unprotected wood stud construction which is a type V (000) type construction which provides no protection of the structure in a fire.

3. Observation on 07/07/15 at 10:00 AM showed a window in the smoke barrier wall at the nurses' station had been removed creating an opening in the wall approximately three feet by two feet in size. This would allow smoke to pass through into each unit in a fire.

4. Observation on 07/07/15 at 10:00 AM showed:
-In the attic the smoke barrier wall between the women's and men's unit had five holes.
-At the nurses' station a piece of glass was removed from the smoke barrier wall creating an opening approximately three feet by two feet. Another glass approximately three feet by three feet did not have fire glazing.
-The door to the nurses' station in the smoke wall had a piece of glass approximately two feet by two feet that did not have fire glazing.

5. Observation on 07/07/15 at 10:00 AM showed the door in the smoke barrier by exam room #7 and the door between the men's and women's unit did not have an astragal, rabbet or bevel (architectural element commonly used to seal the clearance gap of a pair of doors to prevent fire from passing through the openings between the doors). The door for the nurses' station was not a solid core 1 3/4 inch door and did not have a twenty minute fire rating.

6. Observation on 07/07/15 at 9:30 AM showed:
-In the soiled utility room above the lay in ceiling the wall had multiple holes in the sheet rock ranging from one inch to six inches in size.
-In the supply room (which is over 100 square feet in size) above the lay in ceiling open attic access showed a hole to the attic approximately two feet by two feet square exposing the wood studs.
-In the kitchen a wall by the dining room above the lay in ceiling had an open conduit running through the wall that was not sealed, and flexible conduit and water lines passing through the wall were not sealed. There was a hole 12 inches by 14 inches in the wall by the hallway entrance above the lay in ceiling.
-The wall above the mechanical room above the lay in ceiling had a hole eight inches in diameter and a hole three inches by three inches in the sheet rock.
-The door to the soiled utility room did not have a 45 minute fire rated door.

7. Observation on 07/07/15 at 10:30 AM showed the middle exit door in the women's side of the unit in between the men's and women's side exited into a locked court yard which did not have a hard path to a public way.

During an interview on 07/07/15 at 10:30 AM the Director of the unit confirmed that the unit does take limited mobility patients in wheel chairs.

8. Observation on 07/07/15 between 9:00 AM and 11:30 AM during the building tour showed every exit door out of the facility had a magnetic lock.

During an interview 07/07/15 at 10:30 AM the Director of the unit confirmed that all the exit doors have magnetic locks and they do not disengage with the fire alarm. All staff do not have access with the badge reader to release the locks. Two security guards are there to let patients and staff out of the building. The exit access is restricted to only direct care workers in the unit to have access with a badge reader to unlock the exit doors. None of the other staff working in the building have access to release the doors and are dependent on security guards to release the locks on the doors.

9. Observation on 07/07/15 at 10:45 AM showed the designated exit out of the patient unit exited into a court yard with padlocked gates.

During an interview on 07/07/15 at 10:45 AM the Director of the unit confirmed the gates are locked and only the two security officers had keys to unlock the gates. None of the other staff in the building had a key to the locked gate.

10. Observation on 07/07/15 between 9:00 AM and 11:30 AM showed the exit corridor to the patient hall, the three exits out of the men's and women's unit was seven feet six inches in width. The exit corridor where the patient therapy room was located was six feet wide.(The code is for the corridor to be eight feet wide.)

11. Observation on 07/07/15 between 9:00 AM and 11:30 AM showed the exit doors in the patient care unit had three exit doors that were 36 inches wide and the exit door out of the therapy room exit corridor was 32 inches wide.

Building #1

12. Observation on 07/06/15 at 3:00 PM showed holes and penetrations in the fire resistant foam covering structural steel beams, random corners, crevices, connecting plates and cross-members in the 9th floor Penthouse, 8th, 6th and 1st floor shell space (unfinished space) and in the Lower Level mechanical rooms. The heat-protective foam coatings in these areas was vulnerable and had been struck or gouged by other equipment such as forklifts, pallets and mechanical cabinets, or scraped off to provide secure mounting points for electrical conduits, water pipes and bracing.

During an interview on 07/06/15 at 4:30 PM, Staff A, Plant Manager, acknowledged the findings.

13. Observation on 07/06/15 at 3:30 PM showed one or both of the following pairs of doors failed to close together when released:
- A pair of doors in a 7 South corridor fire wall.
- A pair of doors in a 7 North corridor fire wall.
- A pair of doors in the 2nd floor Cancer Center fire wall.
- A pair of doors in the 2nd floor elevator (#11) lobby.
- A pair of doors in the lower level main corridor (outside of Central Sterile).
- A pair of doors in a 6 North corridor fire wall did not have an astragal to cover the gap between doors.

During an interview on 07/06/15 at 4:30 PM, Staff A, Plant Manager, acknowledged the findings and stated that the last Preventive Maintenance and Fire Evaluation rounds had been completed about two months ago.