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Based observation during the survey walk-through, and document review, the surveyor finds that the facility is not in compliance with a the Life Safety and failed to implement adequate interim life safety measures

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

The provider failed to implement and maintained adequate interim life safety measures in accordance with 4.5.1 of NFPA 101-1999.

Examples include:

1. At 1045AM on June 3, 2015 with the Manager of Facilities present, the surveyor observed two 5th Floor construction projects where the floor were continuously covered with paper and the sprinkler system (and an detection devices) were compromised by missing ceiling throughout the project area. A review of the project documentation at 10:00PM, with the Manager of Facilities present, included interim measures which showed this project had been evaluated as fully sprinklered and the "sprinkler system was not obstructed." The fire watch implemented for this project was documented as once every eight hours. The risk assessment was not accurate, the sprinkler system was obstructed and the interim measures implemented were based on faulty information. The provider failed to perform an accurate risk assessment and failed to implement adequate interim life safety measures.

2. At 1145AM on June 3, 2015 with the Manager of Facilities present, the surveyor observed a 1st Floor construction projects where the ceiling had been completely removed (electrical project). Two of two sprinkler heads were secured to a wall and were not installed to protect the room. A room adjacent to this space had a missing ceiling tile. A review of the project documentation at 10:00PM, including any interim measures, showed that this project had been evaluated as fully sprinklered and the sprinkler system was not obstructed. The fire watch implemented for this project was documented as once every eight hours. The risk assessment was not accurate, the sprinkler system was obstructed and the interim measures implemented were based on faulty information. The provider failed to perform an accurate risk assessment and failed to implement adequate interim life safety measures.

3. The north side of the hospital has a crawl space and mechanical system tunnels which are underground. One of these tunnels is located under the sidewalk along the north side of the hospital and is supported by unprotected structural steel. This tunnel is also not sprinklered. As part pf the Plan of Correction, this north tunnel was previously separated from the rest of the hospital by two hour fire barriers. However, at 1:00PM, on June 3, 2015, with Manager of Facilities present, the surveyor observed that two or two fire rated access panels in the two hour fire barrier was propped open. The provider lacks adequate means to maintain this required fire barrier.


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