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Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction to comply with 19.1.1.4, and 8.2.1. This deficiency could affect all patients, as well as staff and visitors due to required fire resistive construction requirements that are not completely protected to prevent the spread of fire from this area.

The finding is:

A. Afternoon of 12/5/12 the surveyor finds that portions of a building's separation between different construction types does not contain a 2-hour or greater vertically-aligned fire barrier wall to comply with NFPA 221, Standard for Fire Walls and Fire Barrier Walls.

1. Location observed, Second floor Roof/Patio garden wood trellis that extends North/South and connects to the North end addition. The combustible materials are incompatible with the building's construction type to comply with 19.1.6.2, 19.1.6.3 and NFPA 220. This condition could contribute fuel load in a fire and cause earlier failure of the structure adjacent to the two remote exits from this area.

Based on random observation, the surveyor finds that corridor doors are not always positive latching in accordance with 19.3.6.3.2 and/or that corridor doors are not installed to maintain a smoke tight condition. Failure to maintain corridor doors in accordance with NFPA 101 could allow smoke to spread from room to room in a fire emergency

Findings include:

A. Afternoon of 12/5/12, First floor O.R's. contain pairs of entry doors with an inactive leaf having a manual flush bolt. These doors do not maintain a closed and latched position due to the integrity of the doors Doors were observed which are warped out of plane approximately 1/2" vertical. Therefore the latching mechanisms do not engage. Due to this condition, pairs of doors are not provided with a means suitable for keeping them closed and latched. Locations observed:

1. O.R. # 10
2. O.R. # 6.
3. O.R. #7
4. O.R. # 4
5. Cysto

Based on random observation and staff interview during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

A. Afternoon of 12/05/12 Penthouse associated with Elevator machine room contains an abandoned pnuematic tube system. Two tubes were observed open to the machine room that progress vertically down through the building.

B. Afternoon of 12/05/12, Level B-2 shaft adjacent to Stair #4 (AB6A) contains abandoned pnuematic tubes observed to be open to the shaft. This same shaft is being used as storage.

C. Afternoon of 12/05/12 AB15A - Chute room contains an entry door which does not close to the latched position.

D. Afternoon of 12/05/12 Level B-2 shaft adjacent to Stair #4 (AB6A) was observed to lack a separtaion from the corridor and does not comply with 8.2.5.2 and 7.2.1.8 for a self closing access door that remains in the closed position.

Based on random observation and staff interview during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

A. Afternoon of 12/3/2012, Level B1, A room deemed as a hazardous area is being used for storage of boxes and files. The room which is located outside of the Radiology/Oncology suite (across the corridor from the Reading room) was observed to be open to the corridor by a door which was not self closing.

B. Afternoon of 12/3/2012, Level B1, A room deemed as a hazardous area is being used for storage of cardboard boxes containing x-ray films, medical records and files. The room is located within the Radiology/Oncology suite. The room is open to the corridor by a door which was not self closing.

C. Morning of 12/4/12 First floor Level, Clean Holding room within the O.R. area contains a pair of entry doors which do not close to a latching position to comply with 8.2.3.2.3.

D. Morning of 12/4/12, First floor Level, O.R. surveyor observed hazardous storage areas that are not separated from the egress corridors. Locations observed:
1. Clean Utility
2. Soiled Utility
3. Substeriles
These rooms contain entry doors having hold open devices which do not comply with 7.2.1.8.1.

E,. Afternoon of 12/5/12, Third floor Peds unit, corridor Linen Closet contains a pair of entry doors having a manual throw which was not engaged. Upon closing the doors, the surveyor was able to pull on one door which opened them both. Upon closing the doors again, they did not latch.

F. Afternoon of 12/05/12 Level B-2, vertical shaft adjacent to Stair # 4 is being used as storage. This does not comply with 8.2.5.3 for the function of a shaft.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies to comply with 7.1.3.2.1 (e) and 19.3.1.1. These deficiencies could affect all patients within the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection of an exit stair.

Findings include:

A. Afternoon of 12/04/12 a water pipe was observed within an exit stair enclosure which does not serve the stair. This construction does not maintain the 2-hour fire rated enclosure. Location observed:

1. First floor level, Stair # 3 this condition exists on several different floor levels within this stair.

B. Afternoon of 12/05/12 within Stair #4 between Level 1 and B1. A chase was observed within an exit stair enclosure which does not maintain the 2-hour fire rated stair enclosure due to the following:

1. An unrated access panel which does not self close to the latched position.

2. The chase walls contains one layer of gypsum board which does not constitute a 2- hour construction. A small motor and fan were observed within the chase. These items do not serve the stair.

Based on random observation and staff interview during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all timesto comply with 19.2.1 and Chapter 7. These deficiencies could affect all patients, staff and visitors in the facility, by preventing occupants from reaching an exit from the building.

Findings include:

A. Morning of 12/5/12 numerous controlled access egress doors did not release upon loss of power. Example locations observed:

1. Both Cath Labs
2. Emergency Department
3. Level B2 - entering B2 North

B. Afternoon of 12/04/12 pair of cross corridor glass doors located at Birth Center Nurses Station contain a remote wall hung activation device with a green button reading "emergency exit lift cover push button". The facility representative was unable to determine the function of this remote egress device.

C. Afternoon of 12/5/12 at the second floor patiowith a wooden trellis, there is a sign above the North addition door reads "Not an Exit". This does not comply with 39.2.5.3 for common path of travel.

Based on random observation and staff interview during the survey walk-through, not all designated suites are provided with exits to comply with 19.2.5. Intervening rooms within a suite allow for a delay in becoming aware of a fire and to reach an exit access corridor. This condition could affect patients, visitors and staff within the O.R. and PACU areas.

Findings include:

A. Morning of 12/05/12 PACU deemed a suite by the facility, lacks the required arrangement of a means of egress and does not comply with 19.2.5.3 due to the following:

1. A designated means of egress through a staff dictation/work area (continuous counter, with chairs and storage) does not comply with 19.2.3.3 for obstructions within the means of egress and maintaining a clear minimum egress width.

2. The pair of egress doors from PACU lack access to a corridor to comply with 19.2.5.1. The PACU connects to a deadend elevator/stair lobby without direct access to a corridor.

3. Due to the conditions in A.1 and A.2. the PACU suite which is over 2,500 square feet does not comply with 19.2.5.3 for a minimum of two remote exits.

Based on random observation during the survey walk-through, not all designated or required fire barriers are constructed or maintained as fire resistive assemblies to comply with 8.2.2.2, 8.2.3.. This deficiency could affect all persons on the second floor level within the North and South buildings, by preventing the intended separation and protection provided by a barrier.

Finding includes:

A. Afternoon of 12/5/12 a Second floor level exterior patio with a structural wood trellis was observed. The wooden trellis is anchored to the North addition above a required exit door. This does not comply based on the following items:

1. A window on the third floor level above the aluminum door at the North addition does not maintain the two hour separation due to the lack of fire rated glazing.

2. The North addition door is glass and aluminum which does not comply with 8.2.3.2.1 for a fire door assembly required to maintain a fire barrier separation. Based on random observation the surveyors find that designated two hour fire barriers are not installed or maintained in accordance with Chapter 8 of NFPA 101:

Based on direct observation 12/3/12, the surveyor finds the facility failed to provide automatic sprinkler protection for the following areas. These deficiencies compromise the safety of all occupants and does not allow for fire suppression and alarm to the facility:

A. The facility failed to provide automatic sprinkler protection for Oak elevator machine room. (At the time of survey the elevators controllers are in the process being upgraded and the sprinkler protection was removed to provide clearance for the upgrade.)

B. The facility failed to provide automatic sprinkler protection for the patient room wardrobes on 3 South nursing unit.

Based on random observation and staff interview during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. and 7.1.10. These deficiencies could affect any patients, staff, or visitors attempting to utilize these corridors under emergency conditions by impeding egress.

The finding is:

A. Afternoon of 12/3/12 Third floor telemetry Post OP inpatient corridor contains remote nurse stations within two foot deep alcoves. Stools with rollers were observed within the exit access corridor which does not compy with 7.1.10.

Based on random observation during the survey walk through Medical gas systems are not maintained in accordance with NFPA 99 and NFPA 50.

Findings include:

A. Afternoon of 12/5/12 By direct observation the surveyor finds not all medical gas zone valves are labeled to reflect the outlets/inlets they serve (NFPA 99, 1999, 4-3.1.2.14 (b) 3). Location observed, the former Pain Clinic.

B. Afternoon of 12/5/12 By direct observation the surveyor finds that not all medical gas zone valves are separated from the outlets/inlets they serve. This does not comply with NFPA 99, 1999, 4-3.1.2.3. Locations observed:

1. First floor PACU
2. Former Pain Clinic.

Based on random observation during the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

A. The 400, 600, and 1000 KW emergency generators did not have a remote annunciators or a derangement signal at a 24 hour staffed location to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

A. Interim Life Safety Measures: 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.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

A. Life safety panels 5LS2, B2LS1and other life safety panels throughout the older portion of the main building are serving loads other than those specifically allowed by NFPA70, Section 517-32.

B. Critical panels F5CR5, 4CR7-A1, F3CR5, BB2CR1, B2CR1, and B2CR2 were serving loads other than those allowed on the critical power system. Critical panel F5CR5 had a circuit feeding the fire alarm system, 4CR7 and F3CR5 were serving med gas alarms (which should be on the life safety panel). This does not meet the requirements of NFPA70, Section 517-33.

C. The fire alarm circuit breaker in the panel F2LS1 as well as any othe breakers serving fire alarm panels or NAC are required to be marked red and have a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.

D. Panels PPENPH, EMBR1, EMBR2, CLP1, CLP2, EAG, EMBW1, E1, ESB2 and other emergency panels are not separated into life safety, critical and equipments branches in accordance with the 1999 Edition of NFPA-70, Section 30 through 35.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. Normal power receptacles were not provided in operating rooms, and rooms 1, 2, 17, and 19 in the ER as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power which could endanger any patient being treated at the time.

B. Electrical room A414A housed 4160 Volt, 2000 Amp switchgear and did not have access and exiting meeting the requirements of NFPA-70, Section 110-33, and Table 110-34(a). This sutuation could endanger the life of anyone working in the electrical room if a fault occured on the equipment.

C. The car lighting disconnects for the oaks elevators, and elevators 3, 4, and 5 did not meet the requirements of NFPA-70, Section 620-53.

D. The med gas piping was not bonded in accordance with NFPA-70, Section 250-104(c).

E. Several panel schedules in the older part of the hospital were hand written and not current and did not meet the requirements of NFPA-70, Section 110-22.