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Based on observation and interview, the facility did not provide adequate separation from other hospital occupancies for its off-site medical file records. This deficiency occurred on the 4th Floor of this North Tower, within the same building of Columbia Center and CSM-Ozaukee, and had the potential to affect 1 medical record staff from Columbia Center and others from the other hospital that may be up on this floor in a fire emergency. It is not part of the Columbia Center two smoke compartments.

FINDINGS INCLUDE:

On 09/16/2014 at 11:45 am, observation revealed on the 4th Floor of North Tower building, used by both Columbia Center and CSM-Ozaukee hospital, the medical records storage area of Columbia Center was not separated from the other hospital to the required two hour separation requirement. The door did not have a closer and the door was not fire-rated to 90 minutes. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.1 and sections 4.6.7, 4.6.9.1(1, 2 & 3), 4.6.10 and 4.6.12. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).
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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings or horizontal penetrations with sealed floor penetrations. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 09/15/2014 at 11:40 am, observation revealed on the Garden Terrace floor of Main Smoke Compartment, in the Large Electrical Room, that penetrations were not sealed according to an approved method. The deficiency included the floor fire seal between this floor space and above was missing at several of the 3" and 4 " diameter pipes. The fire safing was missing above electrical panel #DEA 12 in the horizontal assembly, required to be 2-hour fire rated. This observed situation was not compliant with NFPA 101 (2000 edition), section 8.2.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 09/16/2014 at 9:20 am, observation revealed on the Garden Terrace floor of Inpatient Smoke Compartment, in the Smoke Barrier wall at Corridor, that a penetration was not sealed according to an approved method. The deficiency included a 12" x 1/8" opening below the cable tray above the ceiling. The fire caulk came off the wall because the fire caulk was not inserted into the wall cavity per the code for a 1-hour fire-rated smoke barrier & assembly penetration requirement. This observed situation was not compliant with NFPA 101 (2000 edition), sections 18.3.7.3 & 8.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).

2. On 09/16/2014 at 9:34 am, observation revealed on the Garden Terrace floor of Main Smoke Compartment, in the Office #G 102, that a penetration was not sealed according to an approved method. The deficiency included a continuous 1/4" x 1/2" opening present around a 4" diameter cast iron pipe located above the ceiling in the Northwest corner of the room. This observed situation was not compliant with NFPA 101 (2000 edition), sections 18.3.7.3 & 8.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).

3. On 09/16/2014 at 10:16 am, observation revealed on the Garden Terrace floor of Inpatient Smoke Compartment, in the Storage Room #G 1550, that a penetration was not sealed according to an approved method. The deficiency included a 4" x 6" opening that was observed where the fire caulk had fallen from the hole above the ceiling near the concrete beam. This observed situation was not compliant with NFPA 101 (2000 edition), sections 18.3.7.3 & 8.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).
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Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements within the evacuation plan with all required elements. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 09/16/2014 at 10:40 am, observation revealed that during a review of documents it was discovered that the facility policy 'Columbia Center - Fire Plan', dated October 2013, revealed that the facility written fire safety plan did not address all of the elements required by the NFPA 101 Life Safety Code, 2000 edition. Missing was one out of eight points required in the Fire & Evacuation Plan. The missing point was the 'transmission of alarm' to the fire department. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.7.2.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).
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Based on observation, interview and review of record documents, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills, documentation of the alarm transmission to a monitoring station during a fire drill, fire drills that fully test the staff's ability to respond to fire emergencies, and fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 09/16/2014 at 10:30 am, observation revealed that during a review of facility documents the fire drill reports showed that fire drills were not conducted quarterly on every shift. This is a separate hospital (Columbia Center) from the other hospital (CSM-Ozaukee) and the required fire drills were not being performed as per NFPA 101 (2000 edition) section 18.7.1.2. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions. Only one out of twelve drills were being performed in this hospital in a year's time. Only the 2nd quarter of the 3rd shift drill was performed within this hospital based on the paperwork. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.7.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).

2. On 09/16/2014 at 10:31 am, observation revealed that during a review of documents it was discovered that the fire drill reports for the prior 12 months revealed that there was no documentation that the fire drills included the transmission of the fire alarm signal to the fire department. This observed situation was not compliant with NFPA 101, 2000 (edition), Section 18.7.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).

3. On 09/16/2014 at 10:32 am, observation revealed that the facility fire drill record for the past 12 months revealed that fire drills were not conducted at varied locations. The drills were missing varied locations within the two smoke compartments by quarter. Only one of the twelve drills were performed within this hospital. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.7.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).

4. On 09/16/2014 at 10:33 am, observation revealed that the facility fire drill record for the past 12 months revealed that fire drills were not conducted at varied times. The drills were missing varied times within the two smoke compartments by quarter. Only one of the twelve drills were performed within this hospital. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.7.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinkler coverage throughout the building. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 09/15/2014 at 11:51 am, observation revealed on the Garden Terrace floor of Main Smoke Compartment, in the Storage Room across corridor from Delivery Room #G50, that the room was not sprinkled. All areas of new healthcare must be protected with automatic sprinklers. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.3.5.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).
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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat, all required sprinkler system inspections, annual tests of the fire pump, and monthly tests of the fire pump. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 09/15/2014 at 11:48 am, observation revealed on the Garden Terrace floor of Main Smoke Compartment, in the Washer/Sterilizer & Steris Equipment Alcove in Clean Corridor outside Delivery Rooms, that there was one unsealed hole near the ceiling. The hole included a 2 inch diameter penetration around a vertical pipe. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler certification test. This observed situation was not compliant with NFPA 25 (1998 edition), section 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).

2. On 09/15/2014 at 11:54 am, observation revealed on the Garden Terrace floor of Main Smoke Compartment, in the Housekeeping Closet Room #D 1640, that there was one unsealed hole near the ceiling. The hole included a 2" x 2" opening around the 1-1/2 inch diameter copper pipe. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler certification test. This observed situation was not compliant with NFPA 25 (1998 edition), section 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).

3. On 09/15/2014 at 1:10 pm, observation revealed that during a review of facility documents the monthly wet sprinkler inspections were not performed as required by the code. During review of the 2013 & 2014 Maintenance Department Monthly Sprinkler System Inspections, the last 12 months were missing the checking of gauge conditions and normal pressure per requirements of NFPA 25 (1998 edition), section 2-2.4.1. This information was missing in the monthly charting. This observed situation was not compliant with NFPA 25 (1998 edition), s. 2-2 and Table 2-1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).

4. On 09/15/2014 at 4:08 pm, observation revealed that during a review of documents the facility could not verify that all elements of the fire pump system's annual test was performed. The Annual Fire Pump Testing Report by a 3rd Party company dated July 28, 2014, did not show that they were exercising the fire pump circuit breaker annually per NFPA 110 (1999 edition), section 6-4.6. This is a requirement of the Essential Power Supply System (EPSS) for a Level 1 system. This observed situation was not compliant with NFPA 25 (1998 edition), section 5-3 & NFPA 110 (1999), section 6-4.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).

5. On 09/15/2014 at 4:05 pm, observation revealed that during a review of documents the facility could not verify that all elements of the fire pump system's monthly tests were performed. The exercising of the auto transfer switches associated with the fire pump were not being performed because they were missing in the Maintenance Monthly Inspection of Fire Pump by the in-house Columbia St. Mary's - Ozaukee staff, who perform this task for Columbia Center. This observed situation was not compliant with NFPA 25 (1998 edition), section 5-3 & NFPA 110 (1999 edition), section 6-4.5 for Level 1 Systems. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).
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Based on observation, interview and document review, the facility did not provide and implement a policy on the use of portable space heating devices with space heaters that comply with code requirements. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 09/16/2014 at 10:55 am, observation revealed that the facility did not have a policy that prohibited the use of space heaters in patient areas and permitted them only in non-sleeping areas when elements do not exceed 212 degrees. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.7.8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).
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Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes, with weekly inspections of the emergency generators. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 09/15/2014 at 3:20 pm, observation revealed that during a review of facility documents on weekly visual inspections of the generators, the checks of all general conditions and housekeeping were not recorded as recommended by the manufacturer or NFPA 110 (1999 edition), Figure A-6.3.1. During the documentation review it was observed that the weekly visual review is not inspecting for radiator cleanliness, general housekeeping and battery electrolyte levels. These are required per NFPA 110 (1999 edition), sections 6-4.1 & A 6-3.1(a). This observed situation was not compliant with NFPA 110 (1999 edition), section 6-4.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code, with non-compliance of closed electrical raceways and electrical panels with complete directories. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 09/15/2014 at 10:10 am, observation revealed on the Garden Terrace floor of Main Smoke Compartment, in the Main Waiting Room, that the electrical code was not followed. The emergency outlet located above the countertop was not correctly identified by the electrical code NFPA 70, Article 517. Electrical Code states that a emergency outlet served by the Essential Electrical System will be identified as to its power source. The outlet was uniquely identified per code by its red cover plate, but did not identify where it received its power. This observed situation was not compliant with NFPA 70 (1999 edition) National Electrical Code. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).

2. On 09/15/2014 at 10:20 am, observation revealed on the Garden Terrace floor of Main Smoke Compartment, in the Electrical Room #G 1653, that a 4" x 4" open electrical box did not have a cover so the race-way system was not enclosed. This outlet was located 12 feet above the finished floor. This observed situation was not compliant with NFPA 70 (1999 edition), article 517-12. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).

3. On 09/15/2014 at 10:00 am, observation revealed on the Garden Terrace floor of Main Smoke Compartment, in the Electrical Room #G 1551, that electrical panel breakers were not labeled to identify the loads they fed. Panel #ECGM (section 3) was observed to have breakers 109, 111, 113 through 126 in an 'ON' position and the breakers were marked as spares. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).
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Based on observation and interview, the facility did not provide and use a program to respond to outages of the sprinkler system with complete procedures for responding to outages. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 09/16/2014 at 10:45 am, observation revealed that during a review of documents it was discovered that the facility did not have an appropriate response to outages of the sprinkler system of more than 4 hours in a 24 hour period. The facility policy 'CSM - Fire Protection System Impairment Checklist,' did not include notification of the Wisconsin Department of Health Services, plus there was no documentation of an approved FIRE WATCH system in the affected portions of the Columbia Center building, and did not prescribe if the outage were in a 24 hour period. This observed situation was not compliant with NFPA 101 (2000 edition), section 9.7.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide and use a program to respond to outages of the fire alarm system with complete procedures for responding to outages. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 09/16/2014 at 10:50 am, observation revealed that during a review of documents it was discovered that the facility did not have an appropriate response to outages of the fire alarm system of more than 4 hours in a 24 hour period. The facility policy 'CSM - Fire Protection System Impairment Checklist,' did not include notification of the Wisconsin Department of Health Services, plus there was no documentation of an approved FIRE WATCH system in the affected portions of this Columbia Center building, and did not prescribe if the outage were in a 24 hour period. This observed situation was not compliant with NFPA 101 (2000 edition), section 9.6.1.8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities) and staff J (Maintenance Mechanic).
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