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Based on observation and interview with staff, the facility failed to provide a common wall with a nonconforming building that is a fire barrier having at least a two-hour fire resistance rating. Findings:

Deaconess at Bethany

1) The two-hour rated wall separating the hospital from the nonconforming south wing (vacant space) is not intact.

Based on observation , the facility failed to provide construction type in portions of the building that meets Table 19.1.6.2. Findings include:

Main Campus

The Basement, 1st, & 2nd floors of the north tower do not have a 1 hour UL Rated ceiling to achieve a 2-hour floor to floor separation. The 1-hour ceiling must have a UL approved cover over the light fixtures. Inspection from random areas above ceiling found that the tile used to case over the lights were often either missing or not in place. Some areas had ceilings replaced with materials that failed to provide a 1-hour rating.

The existing 3 story area west of the hospital elevators has unprotected steel for the roof structure. Buildings three stories in height with a complete automatic fire suppression system require Type II (111) construction.

Based on observation and interview with staff, the facility failed to provide vertical openings between floor enclosed with construction having a fire resistance rating. Findings:

Deaconess at Bethany

1) The two-hour rated separation between the high volume space and the second floor has unrated penetrations through the wall and has unrated expanding foam around other penetrations.

Based on observation and interview with staff, the facility failed to provide doors in a hazardous area that are held open only by devices arranged to automatically close upon activation of the fire alarm system: Findings:

Main campus

The rated doors in the boiler room separating the chiller from the boiler room and the emergency generator were held open by a wood door scotch.

Based on observation and interview with staff, the facility failed to provide smoke barriers having at least one-half hour fire resistance rating. Findings:

Main campus

1) The smoke barrier located between Smoke Compartments 13 and 14 (first floor) is missing above the double doors at the Elevator Lobby, adjacent to the Severer entrance.

2) The smoke barrier located between Smoke Compartments 9 and 10 (first floor) has multiple penetrations and is not intact along the corridor leading to the loading dock.

3) The smoke barrier located between Smoke Compartment 12 and the MOB-South (first floor) has multiple penetrations and is not intact; one corner above the ceiling is in need of repair; a portion of the block wall at the stairs is missing.

4) The smoke barrier located between Smoke Compartments 10 and 14 (first floor) along the back corridor to Dining has many penetrations and places where the wall is missing.

5) The smoke barrier located between Smoke Compartments 8 and 12 at the Nurse Station is not intact; there is unrated glazing in unrated HM frames in this wall, and part of the wall is not intact.

6) All other smoke barriers were found to have unrated penetrations of conduit, piping, ducts, and small open holes in the gypsum board.


Deaconess at Bethany

1) Smoke barriers have un-rated penetrations, holes in gypsum board, and missing gypsum board. The following are examples: There are penetrations in the smoke barrier (smoke compartment wall) in the north and east walls of the Chapel and in the north wall of Admissions. There are penetrations and an open joint between the top of the gypsum board and the bottom of the deck over the corridor double doors between Smoke Compartments 3 and 4.

Based on observation and interview with staff, the facility failed to provide exit and directional signs displayed in accordance with Section 7.10. Findings:

Main Campus

1) Exit doors from the Pharmacy, and at the east door from the Dining Room are not marked by approved signs readily visible from any direction of exit access.

Based on observation and review of the Fire Drill/Incident Critique Form, the facility failed to provide complete records for fire drills. Findings,:

The Fire Drill/Incident Critique Form used to evaluate drills were not complete for 1-7-10 at 1700 hours, 3-31-10 at 1000 hours; 3-30-10 at 0130 hours and 1-1-10 at 1703 hours.

Based on observation and interview with the Director of Engineering, the facility failed to provide a fire alarm system with devices and equipment that is installed in accordance with NFPA 72 and records maintained in accordance with NFPA 72 . Findings:

Main Campus

(1) The Fire Alarm Panel depicted a Trouble Light indicating an earth to ground deficiency on October 21, 11:00 am.

(2) The Combination Fire and Smoke dampers connected to the Fire Alarm System were not tested during the past two annual fire alarm tests

(3) There is no documentation of test for the past two years of the Smoke Evacuation Systems in the OR's.

(4) The annunciating device (horn) located in the connecting corridor of 3 rd floor ICU is hanging above the ceiling and not installed as required by NFPA 72.

(5) There is no documentation of re-acceptance testing after modification, repair, adjustment to the system or components circuits, system operations.

(6) Work tracking numbers on Simplex Grinned work orders 4315, 5574 and work order forms dated 8-12-10 and 8-10-10 did not meet the documentation process required by NFPA 72 7-5.2.2.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system installed in accordance with NFPA 13. Findings:

Deaconess at Bethany

1) There are missing escutcheons on the sprinkler heads in the Chapel.

Based on interview with the Anesthesiologist; in the presence of the Director of Facilities and the CFO, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Health Care Facilities, 1999 Edition, Findings:

Main Campus

(a) There are not shutoff valves located outside each anesthetizing location arranged so that shutting off one room or location will not affect others.
(1) There is not a wall intervening between the valves and the outlets to PACU and the pre-op doors (first floor) because the doors to these spaces do not provide a suitable means for keeping the doors closed. These doors do not have latching hardware.
(2) The Zone Valves for the Third Floor ICU are located within the ICU suite, without intervening walls.

(b) Relative humidity is not maintained equal to or greater than 35%.
(1) In January 2010, the facility failed to take action when the humidity fell below 30% in the C-Section rooms on 10 days. The dates are January 1, 2, 4, 5, 6, 7, 8, 11, 12, 25, 26, 29. In February, 2010, the facility failed to take action when the humidity in the C-Section rooms fell below 30% on 9 days for rooms. The dates are February 4, 5, 6, 7, 8, 11, 12, 25, 26 and 29
(c) Windowless Anesthetizing locations are not provided with a method to automatically evacuate smoke from the room.
(1) The facility is conducting anesthetizing procedures in OB, MRI and in the Cath LAB without meeting the requirements of NFPA 99.

Based upon observation and interview with staff, other LSC Deficiencies were as follows, Findings:

Main Campus

1. The facility failed to extend an egress means to a public way from the North Stair Tower, adjacent to the Dinning Room, in accordance with 19.2.1, 7.7.1.

2. Where the Fume Hood. is used as a fixed part of the exhaust system, the room shall have the air supply and exhaust system balanced to provide a negative pressure with respect to the surrounding hospital occupancy as required by NFPA 99 Chapter 5-4.2.1. The Lab Director could only provide testing of the fume hood and not for negative pressure of the room with respect to the surrounding hospital occupancies. The facility failed to provide other air balance testing records of the Lab.

3. Patient Care Related Electrical Appliances are to be tested in accordance with NFPA 99, 1999 Edition, 7-5.1. The facility failed to provide records of testing of approximately 10 Low Air Loss, Hill Rohm Compressors found in the soiled utility rooms on Floors 5 and 6. This was verified by the Director of Engineering and the 6 th Floor Nurse Manager on 10-27-10, at approximately 1:00 PM.

Based on observation and interview with the Lead Electrician, the facility failed to properly divide the Type I EES into Critical, Life Safety and Equipment Branch in accordance with NFPA 99, 3.4.2.2.2, Findings:

Main Campus

The Single Line Diagrams of the Distribution of Emergency Power posted adjacent to the Emergency Generators were not correct. The Critical and Life Safety branch panels were labeled incorrectly. Life Safety lighting is on the same panel as Critical Care Equipment. Panel Schedules through out the facility were miss-labeled and panels not in use were not removed or labeled as Out of Service. All deficiencies found were verified by the electrician on staff, on 10-27-10 at approximately 10:30 am.

Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code, and NFPA 99, Section 3-3.3.4.2. Findings:

Main Campus

1) There is no documentation for the Line Isolation Monitors (LIM). The facility failed to test and maintain the Line Isolation Monitors in accordance with Section 3-3.3.4.2. This was verified by the Director of Facilities at 2:30 PM on 10-26-10.

2) Junction boxes without cover plates were found above the ceiling in several locations throughout the facility.

Deaconess at Bethany

1) Junction boxes without cover plates were found above the ceiling in the west office in Suite 1 B and the corridor between the Chapel and Women Restroom.