HospitalInspections.org

Based on Life Safety Code (LSC) survey, St. Catherine Hospital Inc. was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety From Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This seven story facility with a basement was determined to be of Type II (222) construction and was partially sprinklered. The hospital consists of four connected buildings: The patient Tower, the Block building, the "E" building and the Physician's office building. (POB)
The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors. The facility has a capacity of 168 beds.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure elevator shafts were enclosed with construction with a fire resistance rating of at least one hour in 2 of 4 buildings (see K 020), failed to ensure the travel distance from the most remote point to a smoke barrier does not exceed 200 feet in 2 of 4 buildings (see K 024), failed to ensure at least two exits with a least one exit providing a continuous path of travel to an exit discharge were provided in 2 of 4 buildings (see K 032), failed to ensure the travel distance to an exit does not exceed 150 feet in 2 of 4 buildings (see K 036), failed to ensure the width of aisles or corridors serving as exit access was at least four feet in 2 of 4 buildings (see K 039), failed to ensure 3 of 3 fire pumps were provided with an adequate and reliable water supply for the automatic sprinkler system (see K 063), failed to ensure all sources of fuel and electric power that produce heat to all equipment requiring protection by that system shall automatically shut off for 2 of 2 kitchen fire extinguishing systems and failed to install and maintain 2 of 2 kitchen hood exhaust systems (see K 069).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review, observation and interview, the facility failed to ensure elevator shafts were enclosed with construction with a fire resistance rating of at least one hour in 2 of 4 buildings, failed to ensure the travel distance from the most remote point to a smoke barrier does not exceed 200 feet in 2 of 4 buildings, failed to ensure at least two exits with a least one exit providing a continuous path of travel to an exit discharge were provided in 2 of 4 buildings, failed to ensure the travel distance to an exit does not exceed 150 feet in 2 of 4 buildings, failed to ensure the width of aisles or corridors serving as exit access was at least four feet in 2 of 4 buildings (see K 039), failed to provide exterior emergency lighting for 28 of 31 exits, failed to ensure sprinklers in areas where cubicle curtains were provided in 25 of 25 patient rooms on the 5th floor Acute Rehab Unit, failed to electronically supervise 2 of 10 sprinkler valves in the Physician's Office Building (POB), failed to ensure 3 of 3 fire pumps were provided with an adequate and reliable water supply for the automatic sprinkler system, failed to ensure all sources of fuel and electric power that produce heat to all equipment requiring protection by that system shall automatically shut off for 2 of 2 kitchen fire extinguishing systems and failed to install and maintain 2 of 2 kitchen hood exhaust systems, failed to enforce it's space heater policy in employee areas for the use of 1 of 1 portable space heaters in the facility, failed to ensure 2 of 2 emergency generators were provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurse station and failed to ensure 2 of 2 emergency generators with over 100 horsepower were equipped with a remote manual stop, failed to ensure ground fault circuit interrupter (GFCI) receptacles on 4 of 7 floors were provided and operated properly to protection against electric shock and failed to ensure high current draw electrical devices were not plugged into powerstrips or fused multiplug adapters as a substitute for fixed wiring on 1 of 7 floors, failed to provide a complete written policy indicating procedures to be followed in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period, failed to ensure its written fire watch policy addressed all procedures to be followed in this facility in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period and failed to ensure 10 of 10 alcohol based hand rub dispensers within the Intensive Care Unit (ICU) were not installed over an ignition source.

Findings:

1. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated the public and staff elevators in the "E" building and Block wing were equipped with standard steel doors that do not bear a label indicating the fire resistive rating.

2. Based on interview on 07-29-14 at 0945 hours, DE1 acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

3. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated the travel distance from the most remote point to a smoke barrier exceed 200 feet in Zones 2B, 4A, 5A and 1J.

4. Based on interview on 07-29-14 at 0945 hours, DE1 acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

5. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated exit stairs in the "E" building and Block wing do not discharge to the outside or through an approved exit passageway.

6. Based on interview on 07-29-14 at 0945 hours, DE1 acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

7. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated the travel distance to an exit exceeds 150 feet in Zones 1B and 1J.

8. Based on interview on 07-29-14 at 0945 hours, DE1 acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

9. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated the corridor width was reduced to less than four feet in Zones 1F and 1J.

10. Based on interview on 07-29-14 at 0945 hours, the Director of Engineering acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

11. Based on review of the fire sprinkler contractor annual "Fire Pump & Controller Test reports" for pumps # 1, # 2, and # 3 dated 09/23/13 on 03/05/14 from 9:30 a.m. to 2:30 p.m. with the Engineering Quality Coordinator, the reports indicated in the final remarks on the tests that the three fire pumps failed to reach 100% capacity and recommended contacting the city to verify the city valves were fully open.

12. Based on interview on 07/29/14 at 11:00 a.m. with the the Chief Executive Officer and the Director of Engineering, it was acknowledged and documented that the facility has been in contact with city officials, have met on several occasions and are working towards a solution to the aforementioned condition.