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Based on observation and operational testing, the facility failed to maintain corridor doors that were capable of resisting the passage of smoke with positive latching devices. The deficient practice affected five smoke compartments, staff and 85 patients. The facility has a bed capacity of 187 beds. The facility had a census of 133 on the day of the exit.

Findings include:

#1. During the facility tour on November 3, 2014 observation revealed that the Dutch doors located on the 5th floor in the Psychiatric area were not on self closures and did not conform to the characteristics of a corridor door. as outlined in NFPA 101 Chapter 18.3.6.3

#2. During the facility tour on November 4, 2014 at approximately 10:00 am observation and operational testing revealed that the corridor door to room #509 would not close and latch properly. The door was not capable of resisting the passage of smoke as required for corridor doors in smoke compartments that are fully sprinkled.

#3. During the facility tour on November 4, 2014 at approximately 10:30 am observation and operational testing revealed that the corridor door to room #404 would not close and latch properly. The door was not capable of resisting the passage of smoke as required for corridor doors in smoke compartments that are fully sprinkled.

#4. During the facility tour on November 4, 2014 at approximately 11:30 am observation and operational testing revealed that the corridor door to room #333 would not close and latch properly. The door was not capable of resisting the passage of smoke as required for corridor doors in smoke compartments that are fully sprinkled.

#5. During the Rocky Mountain Surgery Clinic tour tour November 5, 2014 at approximately 1:00 pm observation revealed that the rated wall between the Pharmacy Dutch doors located in the Surgery Clinic and the Patient Recovery room doors needs to be on self-closures equipped with an astragal.


Actual NFPA standard:
18.3.6.3* Corridor Doors.
18.3.6.3.1*
Doors protecting corridor openings shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
18.3.6.3.2
Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.
18.3.6.3.6
Dutch doors shall be permitted where they conform to 18.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.
Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

Based on observation and interview, the facility failed to ensure that all smoke barriers would provide protection against the passage of smoke between smoke compartments. Openings in smoke barriers can allow smoke and fire gasses to enter other smoke compartments in the event of a fire. The facility has a capacity for 187 beds with a census of 133 on the day of the exit.

Findings include:

During the facility tour on November 4, 2014 at approximately 1:00 pm observation revealed that a false ceiling tile was missing in the CVOR storage room and CVOR UPS room. The deficient practice affected 29 patients. Interview with the chief engineer revealed that the facility was unaware of the ceiling tiles missing.

Actual NFPA Standards:
8.2.4.2
Smoke partitions shall extend from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces.
Exception*: Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspended ceiling system where the following conditions are met:
(a) The ceiling system forms a continuous membrane.
(b) A smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling.
(c) The space above the ceiling is not used as a plenum.

Based on observation and operational testing, the facility failed to ensure that all doors in smoke barriers were self-closing and resisted against the passage of smoke. The deficient practice affected patients throughout facility as well as staff and visitors. The facility has a capacity for 187 beds with a census of 133 on the day of the exit.

Findings include:

#1. During the facility tour on November 4, 2014 it was observed that the corridor smoke door leading to the stairwell next to room #536 on the 5th. floor Behavioral Health Unit did not close and latch.

#2. During the facility tour on November 5, 2014 at approximately 8:00 am it was observed that the corridor smoke door on 3rd floor between rooms #323 and #324 failed to seal when closed. An opening of approximately one inch was observed.

#3. During the facility tour on November 5, 2014 at approximately 11:00 am it was observed that the cross-corridor smoke door between 2nd floor northwest side of facility failed to close completely. An opening of approximately one inch was observed due to one leaf not completely closing.

#4. During the facility tour on November 5, 2014 at approximately 1:00 pm it was observed that the cross-corridor smoke door between OR storage failed to seal when closed. An opening of approximately one inch was observed.

Actual NFPA Standard:
18.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.
18.3.7.8
Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited.

Based on observation and operational testing the facility failed to provide separation of hazardous areas from other areas in the facility. Failing to provide separation can result in products of combustion to pass through a smoke barrier. The deficient practice affected residents and staff. The facility is licensed for 187 beds with a census of 133 the day of the exit.

Findings include:

#1. Observation on November 4, 2014 at approximately 1:30 pm revealed that the family waiting room had been converted to a storage room and the door now needs to be on a self-closure. This room was in excess of 50 square feet and contained combustible materials. The condition was also observed by the chief engineer.

#2. Observation and operational testing on November 6, 2014 at approximately 8:30 am revealed that the corridor door from the vending machine area leading to the dining room/kitchen area was not equipped with a self closing device. This condition was also observed by the chief engineer.

#3. Observation and operational testing on November 5, 2014 at approximately 1:30 pm revealed that the doors on OR room #9 and #10 needs adjusting to allow for self closure and positive latching. This condition was also observed by the chief engineer.


Actual NFPA Standard:
18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

Based on observation and interview it was determined that the facility failed to ensure an exit discharge was unobstructed to a public way. Failure to provide accessible exit discharge prevents egress to a safe area by wheelchairs, beds and mobility impaired persons. The deficient practice affected six patients, staff and visitors present on the day of the survey.

Findings include:

During the facility tour on November 4, 2014 at approximately 3:30 PM, observation revealed the exit discharge in the rear of the Oncology facility did not connect to a public way or parking area. There was approximately five feet of landscaped surface to cross before a hard surface area was available. This was observed by the surveyor and acknowledged as a potential problem during snow and wet weather by the chief engineer.

Actual NFPA Standard:
38.2.7 Discharge from Exits
Exit discharge shall comply with Section 7.7.
7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based on observation, the facility failed to ensure the installation of smoke detection for the fire alarm system in accordance with LSC section 9.6. The facility has a capacity for 187 beds with a census of 133 on the day of exit.

Findings include:

During the tour on November 5, 2016 at approximately 10:00 am, observation revealed that no smoke detection was installed in electrical room # B 7.183 which houses a fire alarm control unit. This deficient practice would allow fire damage to the fire alarm system prior to the system activating allowing the rapid spread of smoke and fire in the facility.

Actual NFPA reference:
NFPA 72 1-5.6* Protection of Fire Alarm Control Unit(s).
In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

Based on observation, the facility failed to maintain the automatic sprinkler system in a reliable operating condition. The deficient practice could result in the system not properly activating during an emergency. This practice affected patients and staff present on the day of the survey. The facility has the capacity of 187 beds with a census of 133 on the day of exit.

Findings include:

#1. During the facility tour on November 4, 2014 at approximately 1:00 pm, observation revealed that escutcheons were missing from a sprinkler head located in room B 2.205 Communication room. The chief engineer acknowledged the finding and was unaware of the missing escutcheon.

#2. During the facility tour on November 4, 2014 at approximately 1:30 pm, observation revealed that escutcheons were missing from a sprinkler head located in room B 2.2306 Soiled utility closet. The chief engineer acknowledged the finding and was unaware of the escutcheon missing.

#3. During the facility tour on November 6, 2014 at approximately 8:00 am, observation revealed that escutcheons were missing from a sprinkler head at the front entrance vestibule. The chief engineer acknowledged the finding and was unaware of the missing escutcheon.

Actual NFPA reference:
NFPA 101 Chapter 18 NEW HEALTH CARE OCCUPANCIES
18.7.6 Maintenance and Testing.
(See 4.6.12.)
4.6.12 Maintenance and Testing.
4.6.12.1
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 13, 3-2.7.2*
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on observation and interview it was determined that the facility did not ensure the use of un-authorized portable space heaters. Use of portable heating devices has the potential to cause a fire. The facility had a census of 133 patients on the exit day of survey. This deficiency affected approximately 12 staff members and visitors.

Findings include:

During the tour of the facility between November 4-6, 2014, observation revealed the use of un-authorized portable space heaters were being utilized throughout the facility in the following locations: Life Flight pilot quarters, ground floor reception area, the Imaging conference room, the Chapel office, the material management room, and the IT office. This was observed and noted by the survey staff and the chief engineer. The chief engineer stated he was not aware of the presence of the heaters.


Actual NFPA Standard:
19.7.8 Portable Space-Heating Devices.
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Based on observation and interview the facility failed to maintain flame resistive characteristics of draperies and curtains. Failure to maintain flame resistive characteristics of draperies and curtains can result in rapid combustion growth. The deficient practice affected all patients, staff, and visitors in the Oncology facility.

Findings include:

Based on record review and observation on November 4, 2014 at approximately 3:30 the facility revealed loosely hung fabrics and quilts located in the Oncology facility without NFPA 701 tags affixed. Also, there was not any evidence the items received flame resistant treatment by the facility. Interview with the chief engineer revealed he was not aware of the situation.

Actual NFPA reference: LSC 101
20.7.5 Furnishings, Bedding, and Decorations.
20.7.5.1*
Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in ambulatory health care occupancies shall be in accordance with the provisions of 10.3.1.
Exception: Curtains at showers.
10.3.1*
Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Based on observation and interview the facility failed to ensure smoke barrier penetrations were effectively sealed to prevent or impede the transfer of smoke between compartments. Failure to limit the products of combustion could affect patient safety. The facility has a licensed capacity of 187 beds with a census of 133 on the day of exit.

Findings include:

#1. During the facility tour on November 6, 2014 observation of the smoke barrier above the cross corridor doors separating the existing construction and the new construction on the ground floor at location #3 revealed 2-4 inch electrical conduits, not filled to prevent the passage of smoke. This deficient practice effected two smoke compartments on the ground floor.

#2. During the Rocky Mountain Surgery Clinic tour on November 5, 2014 at approximately 2:00 pm observation of the #2 OR oxygen storage room revealed a penetration through the ceiling.

#3. During the facility tour on November 5, 2014 at approximately 11:30 am, observation of the doors on the first floor south end in Same Day Surgery revealed penetrations through the fire doors. This deficient practice effected two of the three smoke compartments.

Actual NFPA Standard:
LSC 101
8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation the facility did not ensure that electrical wiring and equipment usage was in accordance with NFPA 70, UL listings or CMS categorical waivers. Utilizing relocatable power taps and extension cords improperly can lead to overload wiring and start a fire. The deficient practice affected all patients, staff, and visitors present on the dates of the survey. The facility has a capacity of 187 beds with a census of 133 on day of exit.

Findings include:

During the tour of the facility from November 3-6, 2014, observation revealed:

#1. Non special purpose Relocatable Power Taps (RPT) being used to power patient care equipment in Endoscopy.

#2. Use of standard RPT was being used as extension cords and in place of permanent wiring in breakrooms, offices, work areas, Nursery, Oncology, and Imaging staff lounge.

#3. RPT's daisy chained in PACS admin office.

#4. Use of extension cords in place of permanent wiring in the main lobby powering the piano and also located in C-Section #2.

Actual NFPA Standard:

NFPA 70 National Electrical Code 1999 Edition
400-3. Suitability
Flexible cords and cables and their associated fittings shall be suitable for the conditions of use and location.

110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
See UL listings:
XBYS Guide information
XBZN2 Guide information

Based on observation and operational testing, the facility failed to maintain corridor doors that were capable of resisting the passage of smoke with positive latching devices. The deficient practice affected five smoke compartments, staff and 85 patients. The facility has a bed capacity of 187 beds. The facility had a census of 133 on the day of the exit.

Findings include:

#1. During the facility tour on November 3, 2014 observation revealed that the Dutch doors located on the 5th floor in the Psychiatric area were not on self closures and did not conform to the characteristics of a corridor door. as outlined in NFPA 101 Chapter 18.3.6.3

#2. During the facility tour on November 4, 2014 at approximately 10:00 am observation and operational testing revealed that the corridor door to room #509 would not close and latch properly. The door was not capable of resisting the passage of smoke as required for corridor doors in smoke compartments that are fully sprinkled.

#3. During the facility tour on November 4, 2014 at approximately 10:30 am observation and operational testing revealed that the corridor door to room #404 would not close and latch properly. The door was not capable of resisting the passage of smoke as required for corridor doors in smoke compartments that are fully sprinkled.

#4. During the facility tour on November 4, 2014 at approximately 11:30 am observation and operational testing revealed that the corridor door to room #333 would not close and latch properly. The door was not capable of resisting the passage of smoke as required for corridor doors in smoke compartments that are fully sprinkled.

#5. During the Rocky Mountain Surgery Clinic tour tour November 5, 2014 at approximately 1:00 pm observation revealed that the rated wall between the Pharmacy Dutch doors located in the Surgery Clinic and the Patient Recovery room doors needs to be on self-closures equipped with an astragal.


Actual NFPA standard:
18.3.6.3* Corridor Doors.
18.3.6.3.1*
Doors protecting corridor openings shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
18.3.6.3.2
Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.
18.3.6.3.6
Dutch doors shall be permitted where they conform to 18.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.
Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

Based on observation and interview, the facility failed to ensure that all smoke barriers would provide protection against the passage of smoke between smoke compartments. Openings in smoke barriers can allow smoke and fire gasses to enter other smoke compartments in the event of a fire. The facility has a capacity for 187 beds with a census of 133 on the day of the exit.

Findings include:

During the facility tour on November 4, 2014 at approximately 1:00 pm observation revealed that a false ceiling tile was missing in the CVOR storage room and CVOR UPS room. The deficient practice affected 29 patients. Interview with the chief engineer revealed that the facility was unaware of the ceiling tiles missing.

Actual NFPA Standards:
8.2.4.2
Smoke partitions shall extend from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces.
Exception*: Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspended ceiling system where the following conditions are met:
(a) The ceiling system forms a continuous membrane.
(b) A smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling.
(c) The space above the ceiling is not used as a plenum.

Based on observation and operational testing, the facility failed to ensure that all doors in smoke barriers were self-closing and resisted against the passage of smoke. The deficient practice affected patients throughout facility as well as staff and visitors. The facility has a capacity for 187 beds with a census of 133 on the day of the exit.

Findings include:

#1. During the facility tour on November 4, 2014 it was observed that the corridor smoke door leading to the stairwell next to room #536 on the 5th. floor Behavioral Health Unit did not close and latch.

#2. During the facility tour on November 5, 2014 at approximately 8:00 am it was observed that the corridor smoke door on 3rd floor between rooms #323 and #324 failed to seal when closed. An opening of approximately one inch was observed.

#3. During the facility tour on November 5, 2014 at approximately 11:00 am it was observed that the cross-corridor smoke door between 2nd floor northwest side of facility failed to close completely. An opening of approximately one inch was observed due to one leaf not completely closing.

#4. During the facility tour on November 5, 2014 at approximately 1:00 pm it was observed that the cross-corridor smoke door between OR storage failed to seal when closed. An opening of approximately one inch was observed.

Actual NFPA Standard:
18.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.
18.3.7.8
Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited.

Based on observation and operational testing the facility failed to provide separation of hazardous areas from other areas in the facility. Failing to provide separation can result in products of combustion to pass through a smoke barrier. The deficient practice affected residents and staff. The facility is licensed for 187 beds with a census of 133 the day of the exit.

Findings include:

#1. Observation on November 4, 2014 at approximately 1:30 pm revealed that the family waiting room had been converted to a storage room and the door now needs to be on a self-closure. This room was in excess of 50 square feet and contained combustible materials. The condition was also observed by the chief engineer.

#2. Observation and operational testing on November 6, 2014 at approximately 8:30 am revealed that the corridor door from the vending machine area leading to the dining room/kitchen area was not equipped with a self closing device. This condition was also observed by the chief engineer.

#3. Observation and operational testing on November 5, 2014 at approximately 1:30 pm revealed that the doors on OR room #9 and #10 needs adjusting to allow for self closure and positive latching. This condition was also observed by the chief engineer.


Actual NFPA Standard:
18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

Based on observation and interview it was determined that the facility failed to ensure an exit discharge was unobstructed to a public way. Failure to provide accessible exit discharge prevents egress to a safe area by wheelchairs, beds and mobility impaired persons. The deficient practice affected six patients, staff and visitors present on the day of the survey.

Findings include:

During the facility tour on November 4, 2014 at approximately 3:30 PM, observation revealed the exit discharge in the rear of the Oncology facility did not connect to a public way or parking area. There was approximately five feet of landscaped surface to cross before a hard surface area was available. This was observed by the surveyor and acknowledged as a potential problem during snow and wet weather by the chief engineer.

Actual NFPA Standard:
38.2.7 Discharge from Exits
Exit discharge shall comply with Section 7.7.
7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based on observation, the facility failed to ensure the installation of smoke detection for the fire alarm system in accordance with LSC section 9.6. The facility has a capacity for 187 beds with a census of 133 on the day of exit.

Findings include:

During the tour on November 5, 2016 at approximately 10:00 am, observation revealed that no smoke detection was installed in electrical room # B 7.183 which houses a fire alarm control unit. This deficient practice would allow fire damage to the fire alarm system prior to the system activating allowing the rapid spread of smoke and fire in the facility.

Actual NFPA reference:
NFPA 72 1-5.6* Protection of Fire Alarm Control Unit(s).
In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

Based on observation, the facility failed to maintain the automatic sprinkler system in a reliable operating condition. The deficient practice could result in the system not properly activating during an emergency. This practice affected patients and staff present on the day of the survey. The facility has the capacity of 187 beds with a census of 133 on the day of exit.

Findings include:

#1. During the facility tour on November 4, 2014 at approximately 1:00 pm, observation revealed that escutcheons were missing from a sprinkler head located in room B 2.205 Communication room. The chief engineer acknowledged the finding and was unaware of the missing escutcheon.

#2. During the facility tour on November 4, 2014 at approximately 1:30 pm, observation revealed that escutcheons were missing from a sprinkler head located in room B 2.2306 Soiled utility closet. The chief engineer acknowledged the finding and was unaware of the escutcheon missing.

#3. During the facility tour on November 6, 2014 at approximately 8:00 am, observation revealed that escutcheons were missing from a sprinkler head at the front entrance vestibule. The chief engineer acknowledged the finding and was unaware of the missing escutcheon.

Actual NFPA reference:
NFPA 101 Chapter 18 NEW HEALTH CARE OCCUPANCIES
18.7.6 Maintenance and Testing.
(See 4.6.12.)
4.6.12 Maintenance and Testing.
4.6.12.1
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 13, 3-2.7.2*
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on observation and interview it was determined that the facility did not ensure the use of un-authorized portable space heaters. Use of portable heating devices has the potential to cause a fire. The facility had a census of 133 patients on the exit day of survey. This deficiency affected approximately 12 staff members and visitors.

Findings include:

During the tour of the facility between November 4-6, 2014, observation revealed the use of un-authorized portable space heaters were being utilized throughout the facility in the following locations: Life Flight pilot quarters, ground floor reception area, the Imaging conference room, the Chapel office, the material management room, and the IT office. This was observed and noted by the survey staff and the chief engineer. The chief engineer stated he was not aware of the presence of the heaters.


Actual NFPA Standard:
19.7.8 Portable Space-Heating Devices.
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Based on observation and interview the facility failed to maintain flame resistive characteristics of draperies and curtains. Failure to maintain flame resistive characteristics of draperies and curtains can result in rapid combustion growth. The deficient practice affected all patients, staff, and visitors in the Oncology facility.

Findings include:

Based on record review and observation on November 4, 2014 at approximately 3:30 the facility revealed loosely hung fabrics and quilts located in the Oncology facility without NFPA 701 tags affixed. Also, there was not any evidence the items received flame resistant treatment by the facility. Interview with the chief engineer revealed he was not aware of the situation.

Actual NFPA reference: LSC 101
20.7.5 Furnishings, Bedding, and Decorations.
20.7.5.1*
Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in ambulatory health care occupancies shall be in accordance with the provisions of 10.3.1.
Exception: Curtains at showers.
10.3.1*
Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Based on observation and interview the facility failed to ensure smoke barrier penetrations were effectively sealed to prevent or impede the transfer of smoke between compartments. Failure to limit the products of combustion could affect patient safety. The facility has a licensed capacity of 187 beds with a census of 133 on the day of exit.

Findings include:

#1. During the facility tour on November 6, 2014 observation of the smoke barrier above the cross corridor doors separating the existing construction and the new construction on the ground floor at location #3 revealed 2-4 inch electrical conduits, not filled to prevent the passage of smoke. This deficient practice effected two smoke compartments on the ground floor.

#2. During the Rocky Mountain Surgery Clinic tour on November 5, 2014 at approximately 2:00 pm observation of the #2 OR oxygen storage room revealed a penetration through the ceiling.

#3. During the facility tour on November 5, 2014 at approximately 11:30 am, observation of the doors on the first floor south end in Same Day Surgery revealed penetrations through the fire doors. This deficient practice effected two of the three smoke compartments.

Actual NFPA Standard:
LSC 101
8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation the facility did not ensure that electrical wiring and equipment usage was in accordance with NFPA 70, UL listings or CMS categorical waivers. Utilizing relocatable power taps and extension cords improperly can lead to overload wiring and start a fire. The deficient practice affected all patients, staff, and visitors present on the dates of the survey. The facility has a capacity of 187 beds with a census of 133 on day of exit.

Findings include:

During the tour of the facility from November 3-6, 2014, observation revealed:

#1. Non special purpose Relocatable Power Taps (RPT) being used to power patient care equipment in Endoscopy.

#2. Use of standard RPT was being used as extension cords and in place of permanent wiring in breakrooms, offices, work areas, Nursery, Oncology, and Imaging staff lounge.

#3. RPT's daisy chained in PACS admin office.

#4. Use of extension cords in place of permanent wiring in the main lobby powering the piano and also located in C-Section #2.

Actual NFPA Standard:

NFPA 70 National Electrical Code 1999 Edition
400-3. Suitability
Flexible cords and cables and their associated fittings shall be suitable for the conditions of use and location.

110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
See UL listings:
XBYS Guide information
XBZN2 Guide information