HospitalInspections.org

Based on schematic review, observation, and staff confirmation the facility failed to maintain the 1 hour fire rating on vertical openings including stairwells, elevator shafts, and chases. This has the potential to affect all patients receiving services at the facility. The facility census was 50.

Findings include:

1. Tour of the 3rd floor completed on 05/17/16 with Staff AA, and Staff BB between the hours of 1:00 PM and 5:00 PM, revealed the following findings.

a. Observation of the North wall in the Atrium area (elevators 1 and 2) revealed a 3 1/2 inch sprinkler line penetrating the wall with open annular space.

b. Observation of the the East wall above Stairwell 5 entry door revealed 2 inch gray PVC pipe with large black cables penetrating the wall open on the end, with open annular space, and the wall was not sealed at deck above with fire rated material.

c. Observation of the East wall of elevator 5 shaft revealed the wall was not sealed at deck above with fire rated material.

d. Observation of the North wall of the large South chase beside room 3088 as seen from this room revealed open space behind the large steal beam in far right corner.

2. Tour of the 2nd floor completed on 05/18/16 with Staff AA and Staff CC between the hours of 10:30 AM and 2:00 PM, revealed the following findings.

a. Observation of the East wall above Stairwell 4 entry door revealed a quarter inch hole with a red data cable passing through, and not sealed at deck above with a fire rated material.

b. Observation of the South wall of Stairwell 4 as seen from room 2022 revealed 1/2 inch conduit open on the end, a 3 inch by 2 inch hole, and another 3 inch by 2 inch hole with a 3/8 inch flex conduit passing through.

c. Observation of the West wall of Stairwell 2 as seen from the corridor revealed a tan colored material used to seal the wall at the deck above. Requested the fire rating on the material and no information was provided before exit.

d. Observation of the South wall of the large chase beside room 2125 as seen from this room revealed the wall not sealed at deck above with a fire rated material.

e. Observation of the West wall of Elevators 3 and 4 and East wall of Stairwell 3 as seen from the corridor revealed the walls not sealed at deck with a fire rated material.

f. Observation of the North wall of Elevators 1 and 2 as seen from the atrium side revealed the wall not sealed at where it meets the steal beam above with a fire rated material.

g. Observation of the West wall of Stairwell 1 revealed the wall not sealed at deck above with a fire rated material.

h. Observation of the South wall of the Chase beside room 2056 as seen from this room revealed two 1/2 inch conduits running along side of steal beam penetrating the fire rated wall with open space.

i. Observation of the South wall of the Chase beside room 2056 as seen from room 2057 revealed a 3/8 inch flex conduit with 1/2 inch annular space.

j. Observation of the East wall of Stairwell 5 above the entry door revealed a 3/8 inch conduit open on the end and the wall not sealed at deck above with a fire rated material.

3. Tour of the 3rd floor completed on 05/18/16 with Staff AA and Staff CC between the hours of 2:00 PM and 5:00 PM, revealed the following findings.

a. Observation of the north stairwell 5 wall between the stairwell and electrical room 1010 revealed a large area with no gypsum board at the top of the wall.

b. Observation of the West wall of elevators 3 and 4 revealed the wall not sealed at deck above with a fire rated material.

c. Observation of the South wall of stairwell 4 revealed Multiple penetrations varying in size and shape.

d. Observation of the South wall of stairwell 2 as seen from within the stairwell revealed 1 1/2 inch penetrating the wall with open annular space.

During interview on tour staff verified all findings.

Based on schematic review, observation, and staff interview the facility failed to maintain the fire rated smoke walls. This has the potential to affect all patients receiving services at the facility. The facility census was 50.

Findings include:

1. Observation of all the 1 and 1/2 hour smoke walls revealed the walls not sealed at deck above with a fire rated material throughout all three floors. Interview with Staff CC completed on 05/19/16 at 9:50 AM revealed the fire rated smoke walls do not have a fire rated material sealing the wall at the deck above.

2. Tour of the 3rd floor (New construction) completed on 05/17/16 between the hours of 1:00 PM and 5:00 PM with Staff AA and Staff BB, revealed the following findings.

a. Observation of the wall above the double smoke doors located between corridor 3117 and 3097 as seen from corridor 3117 side revealed multiple penetrations varying in size and shape.

b. Observation of the wall above the double smoke doors located between corridor 3117 and 3097 as seen from corridor 3097 side revealed multiple penetrations varying in size and shape.

c. Observation of the North wall for Room 3101 as seen from the corridor (3107) revealed a 12 inch by 10 inch hole above a chill water pipe, the area is right above the medical gas shut off in the corridor. Multiple other penetrations varying in size and shape, and not sealed at deck above with a fire rated material.

d. Observation of the North wall for Room 3101 as seen from within the room revealed multiple penetrations varying in size and shape, and not sealed at deck above with a fire rated material.

e. Observation of the North walls for Rooms 3104 and 3103 as seen from the corridor (3107) revealed multiple penetrations varying in size and shape, and not sealed at deck with a fire rated material.

f. Observation of the East wall of room 3103 as seen from corridor (3138) revealed Multiple penetrations varying in size and shape.

g. Observation of the North and East walls of room 3103 revealed a 1/2 inch flex conduit open on the end penetrating the East wall and a 1/2 inch conduit penetrating the East wall with open annular space.

h. Observations above the double doors between the atrium and corridor 3138 as seen from corridor 3188 side revealed multiple penetrations varying in size and shape and not sealed at deck with a fire rated material.

i. Observation above the double doors between the atrium and corridor 3052 as seen from the atrium side revealed the wall not sealed at the deck above with a fire rated material.

j. Observation of the East, South, and West walls of room 3090 as seen from within the room revealed multiple penetrations varying in size and shape.

k. Observation above the double doors between corridor 3097 and corridor 3079 as seen from corridor 3097 side revealed a 3/8 inch open on the end, in the right corner just above the drop ceiling.

l. Observation above the double doors between corridor 3097 and corridor 3079 as seen from corridor 3079 side revealed a 3/8 inch with open annular space and a tan colored material sealing the West wall of room 3093. Request was made for the rating of the tan material and no information was provided before exit.

m. Observation of the South wall of room 3093 as seen from corridor 3084 revealed a tan unrated material used to seal the wall at the deck above.

n. Observation above the double doors between Corridor 3052 and atrium as seen from corridor 3052 revealed it was not sealed at deck above with a fire rated material.

3. Tour of the 2nd floor (existing construction) completed on 05/18/16 between the hours of 10:30 AM and 2:00 PM with Staff AA and Staff CC, revealed the following findings.

a. Observation above the double doors located between rooms 2122 and 2013 as seen from the West side revealed a 1 inch by 1/2 inch gap above and below a 6 inch by 6 inch wire chase.

b. Observation above the double doors between corridor 2123 and corridor 2088 revealed a 1/2 inch conduit with open annular space and not sealed at deck with a fire rated material.

c. Observation of the South wall of room 2124 as seen from corridor 2104 revealed a 2 inch gap between the wall and the deck above.

d. Observation above the double doors between corridor 2104 and nurses station 2144 as seen from nurses station side revealed a 3/8 inch gap beside a 6 inch by 6 inch wire chase.

e. Observation of the South wall of room 2133 as seen from within the room revealed a 1/2 inch hole with 1 data cable passing through above the entry door.

f. Observation above the double doors between rooms 2067 and 2112 as seen from the East side revealed 1/2 inch gap below 3 fire foam bricks just above the ceiling grid.

g. Observation above the double doors between corridor 2088 and 2059 as seen from corridor 2088 revealed multiple penetrations varying in size and shape.

h. Observation of the North wall of room 2072 as seen from corridor 2079 revealed a 3/4 inch conduit open on the end.

4. Tour of the 1st floor (existing construction) completed on 05/18/16 between the hours of 2:00 PM and 5:00 PM with Staff AA and Staff CC, revealed the following findings.

a. Observation of the South wall of material management room 1054 as seen from the corridor side revealed the wall not sealed at deck above with a fire rated material.

b. Observation of the South wall of 1047 as seen form corridor 1046 revealed it was not sealed at deck with a fire rated material.

c. Observation above the double doors from corridor 1046 to the main lobby revealed multiple penetrations varying in size.

d. Observation above the double door from corridor 1046, the north wall of 1143, and the West wall of room 1142 revealed the wall was not sealed at deck with a fire rated material.

e. Observation above the double doors between corridor 1056 and corridor 1100 as seen form corridor 1056 side revealed multiple penetrations.

Staff present during tour verified all findings.

Based on schematic review, observation, and staff verification the facility failed to maintain the fire rated walls of their hazardous areas. This has the potential to affect all patients receiving services at the facility. The facility census was 50.

Findings include:

1. Tour of the 3rd floor (new construction) completed on 05/17/16 between the hours of 1:00 PM and 5:00 PM with Staff AA and Staff BB, revealed the following findings.

a. Observation of the Northeast corner of room 3126 as seen from inside the room revealed the wall not sealed at the deck above.

b. Observation of the North wall for room 3130 as seen from corridor 3131 revealed a 1/2 inch blue conduit with 1 yellow conduit open on the end.

c. Observation of the North wall of room 3130 as seen from within the room revealed the wall not sealed at deck above with a fire rated material.

d. Observation of the north wall of room 3133 as seen from corridor 3131 revealed 3/8 inch hole with red data cable passing through in the alcove area (left small wall).

e. Observation of the walls in room 3133 as seen from within the room revealed a 1/2 inch conduit with a yellow data cable open on the end penetrating the east wall, a 1 1/2 inch sprinkler pipe with open annular space penetrating the west wall.

f. Observation of the East wall of room 3120 as seen from corridor 3117 revealed no fire rated material sealing the wall at the deck above.

g. Observation of the North wall of room 3120 as seen from inside the room revealed the wall not sealed at deck above with a fire rated material.

h. Observation of the West wall of room 3120 as seen from room 3121 revealed a 1/2 inch hole above the 1 inch sprinkler line.

i. Observation of the North wall of room 3096 as seen from within the room revealed 3 open spaces at the deck, above steel plates.

j. Observation of the North and South walls of room 3071 as seen from inside room revealed both walls not sealed at deck with a fire rated material, and a 1/2 inch conduit open on the end penetrating the North wall.

k. Observation of the East wall of room 3055 as seen from corridor 3052 revealed a 1/2 inch open on the end.

l. Observation of the walls in room 3065 revealed multiple penetrations varying in size and shape in the West wall, and no observable fire rated wall was noted in the East wall.

During interview staff present during tour verified all findings.

Based on documentation review and staff interview the facility failed to ensure annual battery backup lighting was completed. This has the potential to affect all patients receiving services at the facility. The facility census was 50.

Findings include:

Documentation review completed on 05/19/16 revealed no documentation of annual battery backup light testing.

Interview with Staff AA completed on 05/19/16 at 11:05 AM revealed the annual testing on battery backup lighting testing has not been completed.

Based on documentation review, and staff interview the facility failed to ensure bi-annual smoke detector sensitivity testing was completed and all fire system devices were tested annually. This has the potential to affect all patients receiving services at the facility. The facility census was 50.

Findings include:

Review of the Fire Alarm and Life Safety System inspections completed in 2014 and 2015 completed on 05/19/16 revealed no documentation of smoke sensitivity testing. The 2015 inspection revealed 33 fire system devices were untested.

Interview with Staff AA completed on 05/19/16 at 1:30 PM revealed the bi-annual smoke sensitivity testing was not completed.

Interview with Staff AA completed on 05/19/16 at 2:40 PM revealed after speaking with the company that does the testing that these 33 items, which include heat detectors, pull stations, smoke detectors, and speaker/strobes, were not tested.

Based on documentation review, and staff interview the facility failed to ensure 5 year sprinkler system testing and inspections were completed as per NFPA 25. This has the potential to affect all patients receiving services at the facility. The facility census was 50.

Findings include:

During documentation review completed on 05/19/16 there was no documentation that sprinkler system 5 year testing and inspections were completed.

Interview with Staff AA completed on 05/19/16 at 11:05 AM revealed the 5 year testing on the sprinkler system was not completed since taking occupancy of the building.

Based on documentation review, and staff interview the facility failed to document a followup humidity level after adjustments/repairs were made to the HVAC when out of range. This has the potential to affect all patients receiving surgical services at the facility. The facility census was 50.

Findings include:

Review of the documentation of temperature and humidity levels in the operating rooms completed on 05/19/16 revealed multiple readings of 14% or lower for the humidity level. The documentation shows maintenance was contacted about the low levels but no documentation of any followup readings after the work order was completed.

Interview with Staff AA completed on 05/19/16 at 2:00 PM revealed that a followup humidity level is not documented after the HVAC system is adjusted due to low humidity levels. Staff AA also stated that currently the operating rooms are not being used and have not been used since April 2016.