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Based on observation and staff interview, the facility did not provide and maintain the required building construction type in accordance with NFPA 101 (2012 edition), 19.1.6.1. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Findings Include:
1. On 1/9/2017 at 10:00 AM observation revealed on the Terrace Level in Room 1550 that the steel beam fire protection was missing at the steel member lower flange for 24 lineal inches above the ceiling. This does not meet NFPA 101 (2012 edition), section 19.1.6.1. This deficient practice was visually confirmed by staff C (PO Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).

Based on observation and staff interview, the facility did not provide and maintain the required enclosure for hazardous materials in the Sterile Supplies Room, across the corridor from the Operating Rooms, in accordance with NFPA 101 (2012 edition), section 19.3.2.1. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Findings Include:
1. On 1/9/2017 at 11:41 AM observation revealed on the Terrace Level in Room 1638 the storage room doors were not self-closing or automatic-closing. This deficiency does not meet NFPA 101 (2012 edition), section 19.3.2.1. This deficient practice was visually confirmed by staff C (PO Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).

Based on record document review of the automatic sprinkler quarterly reports and staff interview, the facility did not provide the times of the required Supervisory Alarm Testing in the reports. This is not in accordance with NFPA 101 (2012 edition), sections 9.7.5, 9.7.7 & 9.7.8 Documentation & Record Keeping, and NFPA 25 (2011 edition), section 2-3.3. These deficient practices occurred in 3 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Findings Included:
1. On 1/10/2017 at 1:30 PM record review and interview revealed time of alarm not available, due to not being recorded by the outside sprinkler testing company. These deficiencies do not meet NFPA 101 (2012 edition), sections 9.7.5, 9.7.7 & 9.7.8. These deficient practices were confirmed during the record review by staff C (PO Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).

Based on observation and staff interview, the facility did not provide and maintain the closing seal on the double door set to the corridor, exceeding the limit to stop smoke from passing between the Post Anesthesia Recovery Room to the corridor or visa-versa, as required per NFPA 101 (2012 edition), section 19.3.6.3. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.


Findings Include:
1. On 1/9/2017 at 12:04 PM in Room G1642, Post Anesthesia Care Unit (PACU), the meeting edges of the double doors were greater than 1/4 inch, exceeding the limit to stop smoke from entering the room. The double door set did not have an astragal at the meeting edges. This deficiency does not meet NFPA 101 (2012 edition), section 19.3.6.3. This condition was visually confirmed by staff C (PO Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).

Based on observation and staff interview, the facility did not provide and maintain the supply and exhaust air system in its proper relationship to each other (positive pressure to negative pressure) including spaces Sterile Processing & Storage Room to Decontamination Room. This is not in accordance with NFPA 101 (2012 edition), sections 19.5.2.1 & 9.2, NFPA 99 (2012 edition), section 9.3.1.1 and ASHRAE 170, section 6.7.1 Air Distribution Systems and including maintaining pressure relationships required in Table 7-1. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Findings Include:
1. On 1/9/2017 at 12:06 PM in Room G1612 Sterile Processing & Storage Room, using the 'tissue test' against the glass double window edges between these rooms, it was observed that the air-flow between Rooms G1687 Decontamination and G1612 Sterile Processing showed the air movement was going from decontamination space to clean space, which is not allowed.

This condition was visually confirmed by staff C (PO Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).

Based on record review and staff interview, the facility did not provide, train and maintain the required fire drill record documents conducted quarterly on each shift. This is not in accordance with NFPA 101 (2012 edition), sections 19.7.1.4, 19.7.1.6 and 19.7.1.8. These deficient practices occurred in 3 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this facility.

Findings Include:
1. On 1/10/2017 at 10:01 AM, surveyor discovered through record review the fire alarm documents were missing 7 out of 12 quarterly fire drills, by shift. The quarterly drills missing by shift included; 1st Quarter/1st Shift, 1st Quarter/3rd Shift, 2nd Quarter/1st Shift, 2nd Quarter/2nd Shift, 2nd Quarter/3rd shift, 3rd Quarter/1st Shift and 3rd Quarter/2nd shift.

2. On 1/10/2017 at 10:02 AM, surveyor discovered through record review the fire alarm documents were missing transmission confirmation of the fire alarm signal to the fire department, in Mequon, during those quarterly drills by shift.

3. On 1/10/2017 at 10:03 AM, surveyor discovered through record review the fire alarm documents were missing employees participating or being trained throughout the fire drill process, during those quarterly drills by shift.

These conditions were confirmed by staff C (PO Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).

Based on observation and staff interview, the facility did not provide and maintain the required gas cylinders per NFPA 99 (2012 edition), section 4.1.2 for Category 2 including section 5.2.3.1. Reference NFPA 99 (2012 edition), Section 5.1.3.1.8 Locations containing positive pressure gases other than oxygen and medical air shall have there doors labeled as follows: Positive Pressure Gases - NO Smoking or Open Flame - Room May Have Insufficient Oxygen - Open Door and Allow Room to Ventilate Before Entering. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Finding Includes:
On 1/9/2017 at 1:43 PM Reproductive Specialty Center Room G1664 was observed with signage missing on the door upon entering the room. This deficiency does not meet NFPA 99 (2012 edition), Section 5.1.3.1.8. This condition was confirmed by staff C (Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).
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This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility did not provide and maintain the required gas cylinders per NFPA 99 (2012 edition), section 4.1.2 for Category 2 including section 5.2.3.2. Reference NFPA 99 (2012 edition), Section 5.1.3.2.4 No flammable materials shall be stored in rooms with gas cylinders. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Finding Includes:
On 1/9/2017 at 1:44 PM Reproductive Specialty Center Room G1664 was observed with flammable materials (paper and booklets) on the desk and on shelving units within the room. This deficiency does not meet NFPA 99 (2012 edition), Section 5.1.3.2.4. This condition was confirmed by staff C (Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).
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This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility did not provide and maintain the required gas cylinders per NFPA 99 (2012 edition), section 4.1.2 for Category 2 including section 5.2.3.2. Reference NFPA 99 (2012 edition), Section 5.1.3.2.10 When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Finding Includes:
On 1/9/2017 at 1:45 PM Reproductive Specialty Center Room G1664 was observed with five A-Type cylinders, with 4 being connected to a valve control and used, and 1 cylinder not being used and stored. All cylinders were ganged together and should have been separated from those being used to those in storage mode. The one cylinder in storage was missing its safety cap. This deficiency does not meet NFPA 99 (2012 edition), Section 5.1.3.2.10. This condition was confirmed by staff C (Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).
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This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility did not provide and maintain the required gas cylinders per NFPA 99 (2012 edition), section 4.1.2 for Category 2 including section 5.2.3.2. Reference NFPA 99 (2012 edition), Section 5.1.3.2.3 Only gas cylinders, reusable shipping containers, and their accessories shall be permitted to be stored in rooms containing gas cylinders. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Finding Includes:
On 1/9/2017 at 1:46 PM Reproductive Specialty Center Room G1664 was observed with other items besides gas cylinders, reusable shipping containers, and their accessories. This deficiency does not meet NFPA 99 (2012 edition), Section 5.1.3.2.3. This condition was confirmed by staff C (Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).
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This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility did not provide and maintain the required gas cylinders per NFPA 99 (2012 edition), section 4.1.2 for Category 2 including section 5.2.3.3. Reference NFPA 99 (2012 edition), Section 5.1.3.3.2 (4) Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: If Indoors, they shall be constructed and use interior finishes of non-combustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Finding Includes:
On 1/9/2017 at 1:47 PM Reproductive Specialty Center Room G1664 was observed with room construction of combustible materials such that all walls, ceilings and doors are not a minimum 1-hour fire resistance rating. This deficiency does not meet NFPA 99 (2012 edition), Section 5.1.3.3.2 (4). This condition was confirmed by staff C (Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).
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This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility did not provide and maintain the required gas cylinders per NFPA 99 (2012 edition), section 4.1.2 for Category 2 including sections 5.2.3.1, 5.2.3.2 and 5.2.3.3. Reference NFPA 99 (2012 edition), Section 5.1.3.3.2 (7) Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty. This deficient practice occurred in 1 of the 3 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

Finding Includes:
On 1/9/2017 at 1:48 PM Reproductive Specialty Center Room G1664 was observed with cylinders not properly ganged together by type (Carbon Dioxide / Nitrogen) and usage (Full / Empty). This deficiency does not meet NFPA 99 (2012 edition), Section 5.1.3.3.2 (7). This condition was confirmed by staff C (Manager - Facilities & Maintenance Services), the facilities arm of Columbia Center (Birth Hospital).
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