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A) From random observation the surveyor finds that combustible materials have been used that are incompatible with the buildings construction type and that are not permitted in Type I or Type II construction (19.1.6.2). Failure to maintain fire rated assemblies could cause early failure during a fire emergency.

Findings include:

1) The construction type for the North Clinic is Type I (332) or Type II (222). The construction type for the Center Wing of the Hospital is Type I (332) or Type II (222). The Northeast Mechanical Room that is located north of the west wing of the North Clinic is separated from both buildings by a two hour fire barrier. The roof of this mechanical room has a void in it with a plywood roof patch or plywood housing above. The plywood is not compatible with the construction type of the buildings.

B) From random observation the surveyors find a few locations where the structural steel is not protected in accordance with the Construction Type for the building, as identified by the provider. Based upon information from the provider, the North Clinic is at least Type II (222) construction as defined by NFPA 220.

1) 2nd Floor North Clinic in front of steps up to the Center Wing: Above the ceiling there portions of structure steel elements in two directions that lack fire proofing.

End

A) Based on random observation, the surveyor finds that areas and uses open to exit access corridors do not comply with 19.3.6.1.

Findings Include:

1) Basement Level Center Building - the Radiology Waiting Area is open to an exit access corridor and lacks smoke detection throughout the Waiting Area.

2) Ist Floor Center Wing East Main Lobby - This space is a large waiting area with a reception/security deck and a Volunteers 'Alcove. The space is staffed day and night, but not continuously. The provider is not able to maintain constant supervision 24 hours a day and 7 days a week. The space and nearby spaces lack smoke detection throughout in accordance with NFPA 72 and 19.3.6.1 of NFPA 101.

This deficiency includes a seat in the Hallway opposite the Wheelchair Storage Room and the Volunteers space near the west end of the Lobby.

Failure to fully observe or detect open waiting areas and use areas in corridors could allow fire to spread undetected in a fire emergency.

End


16339

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any building occupants in the exit access corridors adjacent to the rooms listed, because smoke and fire could pass from them into the corridors.

Findings include:

A. In the morning of July 18, 2012, North Tower Wing, 8th Floor near the Ped's Hospitalist, part of the exit access corridor was observed with 4 chairs (4) that are being used as a waiting area, this was observed to lack a smoke detector required by Exception 7 subpart b to 19.3.6.1 or Exception #1.

B. North Tower Wing, 6th Floor - An Alcove was observed not 24 hour manned is used to store equipment, nurses cart monitors lack a smoke detector required by Exception 6 subpart a to 19.3.6.1.

C. At 10:10AM, 07/18/2012, North Tower Wing, 4th Floor, Med/Surg Unit - The exit access corridor was observed with a wooden steps that is being used as part of the rehab treatment for patients is not separated from the corridor to comply with 19.3.6.1.



20224

Based on random observation and staff interview during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all persons in the smoke compartment, compromising the separation of patient care areas from the location of fire origin.

Findings include:

A. Afternoon of 07/18/12, 3rd floor, Parkview,Oncology: patient sleeping bays were observed to be open to the adjacent corridor (this area is not a designated suite) which does not comply with 19.3.6.1. Locations observed: Patient rooms 3324, 3322, 3320 and 3316 (as written on the Life Safety floor plans).


B. Morning of 07/18/12, 2nd floor, Concourse, Corridor located south of Recovery Stage I, was observed to be a noncompliant corridor due to a designated exit sign directing egress into an intervening room (the Recovery suite located in Parkview). This condition does not comply with 19.2.5.9 for any exit access corridor leading to two approved exits.

C. Afternoon of 07/17/12 7th floor Parkview ICU contains patient rooms provided with cubicle curtains and not separated from the egress corridor with smoke tight construction to comply with 19.3.6.1.

A) Based on random observation, the surveyor finds that corridor doors are not always positive latching in accordance with NFPA 101.

Findings include:

1) Basement Level of Mills Breast Cancer Center - near MRI: During fire alarm testing on the afternoon of 7/19/12, the surveyor observed an auto opening corridor door that did not close to latch upon activation of the fire alarm system. The auto-open/auto-hold-open functions continued to operate with the fire alarm activated. The surveyors find that the door is not positive latching in accordance with 18.3.6.3.2 with this condition.

Failure to close and latch doors to corridors could allow a fire or smoke to spread into the corridor.

End

A) From random observation the surveyors find that vertical openings and/or penetrations through fire rated floor assemblies are not installed and maintained in accordance 8.2.5 of NFPA 101.

Findings include:

1) 1st Floor Center Wing Emergency Department: There is a Medical Gas Manifold Room with two open sleeves through the floor below. The interior of the sleeves are not sealed with fire rated materials in accordance with 8.2.3.2.4.2.

2) 2nd Floor Center Wing Southeast Mechanical Room does not comply with NFPA 101 and/or NFPA 90A:

a) Three ducts penetrate the floor below
into a fire rated shaft next to Walgreens.
There is a 30" x 60" hole in the floor of
the Mechanical Room that is covered with
a plywood cap. The material used is not
compatible with non-combustible
construction and the hole in the floor is
not protected as a fire rated opening.

b) One duct penetration through the floor
below lacks a fire damper and two
insulated pipes penetrate the floor below
and are not sealed for two hour
construction (east of the Tube Station).

3) 2nd Floor Center Wing - there is a rated shaft enclosure in the southeast corner of the Cardiology Waiting Area. The shaft wall is incomplete near the duct penetrations though the floor below.

4) 2nd Floor Center Wing - there is a shaft enclosure in the Southwest corner of the Cardiology Waiting Area. This shaft has three ducts that penetrate multiple floors from the Basement to the roof of a 4th Floor Mechanical Space.

a) Fire rated shaft enclosures for multiple
floors are not identified on the Life
Safety Plans for the 1st, 2nd, 3rd, and
possibly the 4th Floor, in accordance with
NFPA 101 and NFPA 90A.

b) Fire rated shaft enclosures for multiple
floors are not provided for the 1st, 2nd,
3rd, and possible the 4th Floor, in
accordance with NFPA 101 and NFPA
90A. In some cases that shaft does not
exist. On the 2nd and 3rd Floors, the
shafts are drywalled on one side only.

c) The three ducts have fire dampers in the
floor at some floors where fire dampers
would not be permitted under NFPA
90A. See also Item 5 below.

5) 3rd Floor Center Building - Surgical Waiting Room: There is a duct shaft in the southeast corner of this room. The shaft does not comply:

a) The shaft enclosure is only drywalled on
one side; this shaft is not enclosed in fire
rated construction in accordance wish
19.3.1.1 and in accordance with NFPA
90A.

b) Three seamless 12" x 12" ducts penetrate
the floor below and above without fire
dampers. The provider did not know
what these ducts connect to and had no
information that would indicate that the
ducts could comply with the rules for
hazardous ducts instead of the rules for
fire dampers under NFPA 90A.

4) 3rd Floor Center Wing - Southeast Mechanical Room: The surveyor notes that that this space appears on plans to be part of the North Clinic at the 2nd and 3rd Floors. It is part of the Center Wing and is separated from the North Clinic by designated two hour fire barriers. This is not a deficiency.

5) 4th Floor Center Wing West Mechanical Room - three seamless 12" x 12" ducts penetrate the floor below and the roof above without a fire rated shaft enclosure in this space in accordance with NFPA 90A.

Failure to protect openings in fire rated floors and failure to maintain vertical openings could allow fire to spread from floor to floor in a fire emergency.

End




16339

Based on random observation during the survey walk-through, not all ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.These deficiencies could affect any patients, as well as any staff and visitors because the failure to provide dampers and proper installation of shaft could result in smoke or fire passing from one part of the building to another.

Finding includes:

A. North Tower Wing, 6th Floor, EVS Room contains a pipe shaft and the door to this chase is not fire rated.

B. North Tower Wing, 4th Floor, Med/Surge Unit - A ventilation shaft behind the Nurse Station near the Clean Room was observed with pipe and conduit penetrations through the two hour fire rated shaft wall, the penetrations are not rated in accordance with 8.2.3.2.4.2.

C. Concourse Wing, 1st Floor - Designated ventilation shaft near the Waiting Area was observed with ductwork penetrations that lack fire dampers and fire damper panels installed in accordance with NFPA 90A.

D. North Tower Wing, 1st Floor- The door label to a ventilation shaft/room located in the Storage Room is painted which does not comply with 8.2.3.2.3.1

E. North Tower Wing, First Floor - During the survey walk-through the surveyor observed a shaft identified 2-hour fire rated that is located in the Electrical Room adjacent to a Storage Room was observed with multiple access panels that are not fire rated to comply with 8.2.3.2.3.1.

F. North Tower Wing , Lower Level 1 Stair OAS3 - The door label to this required exit stair is missing.








20224

Based on random observation and staff interview during the survey walk-through on 6/13/12, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

A. Afternoon of 07/18/12 2nd floor Rogers, a Storage room associated with Cath. Lab #8 was observed to contain two vertical duct runs wrapped in 2-hour rated duct wrap. These two ducts were observed to lack through floor dampers and access panels to comply with NFPA 90A.

B. Morning of 07/17/12 5th floor Rogers, Switch gear room, a copper sanitary pipe penetrating the floor lacks the proper fire stopping in order to maintain the fire resistance rating of the floor assembly.

C. Morning of 07/18/12 5th floor Rogers, Elevator Lobby, sanitary piping for an EVS floor drain on the 6th floor, extends down and is exposed to the 5th floor elevator lobby. The through floor penetration does not maintain the fire resistance rating of the floor assembly.

D. Morning of 07/17/12, 5th floor Rogers, Shaft # 506 (as shown on the Life Safety floor plans) does not maintain the 2-hour fire resistance rating to comply with 8.2.5 due to the following:

1. Large gaps surrounding duct
penetrations.

2. Large holes surrounding pipe
penetrations.

3. The framed opening for the access panel
does not provide a continuous closure for
the shaft wall construction to seal against
fire/smoke penetration.

A) Based on fire alarm testing conducted on the afternoon of 7/19/12, and the morning of 07/20/12, with the Safety Officer and the Director of Facility Services, the surveyors find that required fire doors with hold open devices and/or auto open/auto hold open devices do not release from activation of the fire alarm system in accordance with 7.2.1.8. The surveyors observed this condition throughout most floors of most buildings.

Examples include but are not limited to

1) Basement Level North Clinic - the designed smoke barrier between the Center Wing of the Hospital and the North Clinic has a pair of smoke doors that failed to close upon activation of the fire alarm system in accordance with 7.2.1.8.

Failure to close fire doors during a fire will allow fire and smoke to spread to multiple buildings during a fire and will compromise required means of egress in a fire emergency.

End

A) Based random inspection, designated smoke barriers are not installed and maintained to comply with 19.3.7.3.

Findings include:

1) Basement Level Nuclear Medicare Room OEO22 (Note - it is not clear whether this space is located in the Center Wing of the Hospital or the North Clinic): This room was probably constructed as part of the North Clinic; however, there are no building separations on this level between the Hospital and the North Clinic. There is penetration above the ceiling, above the door to the room, that is sealed with drywall tape (not sealed with fire rated penetration construction materials in accordance with 8.2.4.4).

2) Basement Level - The designated one hour smoke barrier between Parkview and the Concourse wing at the pair of 90 minute doors near the Center Stair has multiple unsealed wall penetrations above the ceiling.

3) The designated 2nd Floor smoke barrier north of Cath Lab # 4 has multiple penetrations which are sealed with drywall mud and tape (not fire rated penetration detail) and one sprinkler penetration that is not sealed.

Failure to maintain smoke barriers will allow smoke to spread from smoke compartment to smoke compartment in a fire emergency.

End


16339

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3.

Findings include:

A. Conduit and duct penetrations were observed in smoke barrier walls that are not sealed against the passage of smoke as required by 8.3.6.1. Locations observed include:

1. North Tower Wing, Tenth Floor, Telecom Closet.

The deficiencies noted above could affect any patients, as well as any staff and visitors because the failure to maintain smoke barriers will allow to spread from smoke compartment to smoke compartment in a fire emergency.



20224

Based on random observation and staff interview during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the smoke compartments on either side of the cited wall by permitting smoke to pass between them.

Findings include:

A. Afternoon of 07/18/12, 4th floor, Concourse, the smoke barrier wall between Concourse and Parkview/Rogers does not comply with 19.3.7.3 and 8.3.2. The wall is not continuous from outside wall to outside wall due to the following:

1. The wall is not located as shown on the Life Safety floor plans.

2. Upon inspection above the ceiling, the designated smoke barrier is incomplete due to the following:

i. Large gaps surrounding ductwork

ii. Large holes surrounding pipe
penetrations.

A) Based on random the surveyor finds that hazardous areas are not protected in accordance with 19.3.2.1 and 8.4.1 of NFPA 101:

Findings include:

1) The 1st Floor Center Wing Walgreen's retail Pharmacy is located in the Main Lobby of the Hospital. It has been evaluated as an existing hazardous area [and as a mixed (Mercantile) occupancy that is not separated from the Hospital]. The doors from the Main Lobby to the Pharmacy do not comply with 19.3.2.1.

a) There is a swinging door to the space
that is self closing but is not positive
latching.

b) There is a pair of automatic sliding doors
that no longer open and close
automatically. These doors are not self
closing in accordance with 19.3.2.1 and
7.2.1.8 and the doors lack positive
latching hardware.

2) 2nd Floor Center Building - Former procedures rooms have been converted to storage rooms and do not have one hour fire rated enclosures and 3/4 hour fire rated door assemblies:

a) EP Lab # 1

b) North IVS Storage Room

3) 2nd Floor Center Building - The Clean Supply Room opposite Vascular Lab # 2 had a self closing door; however closing device has been removed.

Failure to maintain separations for hazardous areas will increase the fuel load in a fire emergency and allow fire and smoke to spread outside to the spaces with higher fuel loads.

End


16339

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. These deficiencies could affect all patients, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous areas into the building's exit access corridors.

Findings include

A. In the morning of 07/19/2012, North Tower Wing and Concourse Wing Lower Level- The corridor doors (double doors) to CPD Storage Room do not positively latch to close to comply with 19.3.6.2 and 19.3.2.1.



20224

Based on random observation and staff interview during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access during a fire condition. Findings include:

A. Morning of 07/17/2012, 9th floor Parkview, contains mechanical rooms none of which are separated from occupied areas including:

1. The exit access corridors

2. Respiratory Care Staff area

3. Lodging Occupancy used on a 24/7 basis by EMT's and Life Flight personnel.

The Life Safety drawings indicate a fire resistance rating of 1-hour surrounding the Lodging occupancy from the mechanical rooms. The perimeter wall of the Lodging Suite does not exist above the suspended acoustical tile ceiling for the Lodging occupancy.

B. Morning of 07/18/12, 9th floor Parkview Respiratory Care Clean Storage was observed not separated from the occupied spaces including the corridor leading to offices, staff break and work rooms due to the lack of rated walls and doors.

C. Morning of 07/17/12, 8th floor Rogers, the Storage Room located between patient room #8867 and # 8865 contains a pair of entry doors which do not latch.

D,. Afternoon of 07/17/12, 7th floor, Linen Closet located across from room # 7675 contains a pair of doors with a manual throw which does not allow the doors to close and latch.

E. Afternoon of 07/17/21, 7th floor, Work room adjacent to the Nurse station contains numerous shelving units with plastic covered containers and is deemed to be storage. The entry door contains a closer with a disabled arm, thus the door is not self closing.

F. Morning of 07/18/12, 5th floor, Parkview, switchgear room's perimeter fire rated wall construction is compromised by the penetration of a pneumatic tube installation which passes through the wall and ceiling. This tube remains open through the wall to the adjacent mechanical room.

A) Based on observation, the surveyor finds that required exit stairs are not installed and maintained to provide a continuous safe path of travel in accordance with Chapter 7 and Chapter 8 or NFPA 101.

Findings include:

1) North Clinic Basement Level Center Stair does not comply with 7.1.3.2:

a) The stair has a door inside the stair
identifying a Mechanical Room OE 59.
This door is not a B Label Fire door and
is not self closing in accordance with
7.1.3.2.1 and NFPA 80.

b) One or more penetrations above the
ceiling in the stair are not sealed for fire
rated construction (8.2.3.2.4).

c) One duct penetration above the ceiling
(above the door from the lobby into the
stair) lacks a fire damper in accordance
with 7.2.1.3. e), exception # 1 and
NFPA 90A.

2) North Clinic Basement Level West Stair does not comply with 7.1.3.2

a) There is a space under the stair that is
full of junk. This space under the stair is
not isolated with fire rated construction
in accordance with 7.2.2.5.3. The door
to this space under the stair is not a fire
rated, self closing opening protected
assembly. The space is not sprinklered
in accordance with NFPA 13

3) North Clinic Basement Level East Stair does not comply with 7.1.3.2. There is a duct penetration of the stair wall above the ceiling that does not have a fire damper.

Failure to maintain exit enclosures could compromise the use of these exits in a fire emergency.

End



16339

Based on random observation, the surveyor finds that required exit stair enclosures do not provide a continuous path of escape and not provided protection against fire or smoke from other parts of the building to comply with Chapter 7. These deficiencies could affect any patients from this building and
as well as any staff and visitors because designated exit stairs are not protected against fire or smoke conditions to comply with 8.2.5.2.

Findings include:

1. North Clinic, 7th Floor - Identified Stair NCW/NCE 7th Level was observed with electical junction box that does not directly serves the stair, according to staff the electrical system connects to the signage outside for the North Clinic Building.

2. North Clinic, First Floor - Exit Stair identified Stair NNC Level 1 the landing was observed with shaft that has unrated access panel.

3. North Clinic, Lower Level - Stair 0D58 conduits, wirings penetrates through this exit enclosure which do not directly serve stair in accordance with 7.1.3.2.1(e).

A) Based upon random observation, the surveyor finds that during fire alarm testing conducted on 07/19/20 and 07/20/1 with multiple hospital engineering and management staff present, doors with exit signs and magnetic locking devices failed to release the locking devices in accordance with 7.2.1.5 and/or 7.2.1.6. Based upon the number of locations above where locked failed to release, similar condition are expected on multiple floors and multiple buildings or wings throughout the facility. This deficiency is cited for all doors with an exit sign above the door and any kind of magnetic locking device (except for the magnetic locking devices installed that were observed to release from fire alarm activation on some stair doors.)

Examples include but are not limited to:

1) North Tower 11th Floor (OB): The exit access corridor between the southwest stair and the O B Unit has a pair of cross corridor control doors with magnetic locking devices that do not comply with NFPA 101

a) The doors did not unlock from activation of the fire alarm system on this floor and upon activation of the fire alarm in an adjacent zone.

b) The blue door unlock pull station device mounted on the wall does not comply with the requirements of 7.2.1.6.2 (it is not a "push to exit" device) and the operation of the pull device does not comply with 7.2.1.5 (it requires special knowledge to operate).

2) 10th floor, North Tower, delayed egress cross corridor doors did not disengage to a manual operation.


3) North Tower 8th Floor (Peds): The exit access corridor between the southwest stair and the Peds Unit has a pair of cross corridor control doors with magnetic locking devices that do not do not release from activation of the fire alarm sytem.

4) 7th Floor Parkview: The east stair door has a magnetic locking device, During fire alarm testing on the morning of 7/20/12, and in conjunction with testing without the fire alarm system, the surveyor observed that the locking device on the door has a slight "hitch" in it operation and that it did not always immediately release upon activation of the fire alarm system.

5) 4th floor Parkview LDRP, delayed egress cross corridor doors did not disengage to a manual operation.

6) 1st Floor Center Building - pair of doors near E D Nurse's Station: these doors have exit designations and magnetic locking devices that did not release from fire alarm activation

7) 1st Floor Center Building - pair of doors at the south end of the Emergency Department: these doors have exit designations and magnetic locking devices that did not release from fire alarm activation.

B) Multiple floors and multiple buildings or wings: The blue door unlock pull station device mounted on the wall does not comply with the requirements of 7.2.1.6.2 (it is not a "push to exit" device) and the operation of the pull device does not comply with 7.2.1.5 (it requires special knowledge to operate).

Failure that release locking devices during a fire emergency will delay evacuation of patients when necessary during a fire emergency.

End


16339

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 18.2.1. The North Tower Infill built in 2007 was surveyed under Chapter 18 of NFPA 101 2000. This condition could affect any patients, as well as any staff and visitors within the facility and could cause a delay of evacuation during a fire particularly for any staff, patients and visitors that are not intimately familiar with the facility

A. North Tower Wing, 9th Floor, NICU the surveyor determines that the required exit access corridors from the elevator foyer lobby to the NICU Suite has only one path of egress. The corridor may not terminate at a Suite. The exit sign above the control doors identify a path into a suite that is not permitted and the corridor is a 50 feet dead end corridor.

B. North Tower Wing, 8th Floor, Ped's Unit From random observation the surveyor finds that the exit access corridor by the Staff Rest Room lacks directional exit signage.

C. North Tower Wing, First Floor - Designated exit path from the Conference Room 1600 passes thru the required Stair 1AS4 which serves Lower Level or continues beyond level of exit discharge is not provided with interrupter gate to comply with 7.7.3.

D. Based on random observation during the survey walk-through, not all designated exits are properly maintained to ensure the dependability of the method of evacuation selected to comply with 18.7.3.

Findings include:

1. 11:00AM, 07/17/2012, North Tower Wing: Designated exit path doors equipped with magnetic hardware and secured with locking devices were not available to pass through in case of fire or other emergency situation to comply with 18.7.3 and 7.2.1.6.2 Subpart (b). Locations include: 11th Floor Post Partum and 10th Floor LDR patients. This deficiency could affect LDR and Post Patients patients because this locked door is not being maintained, and tested that this exit egress door is available especially under fire conditions at any time.







20224

Based on random observation and staff interview during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all timesto comply with 19.2.1 and Chapter 7. These deficiencies could affect all patients, staff and visitors in the facility, by preventing occupants from reaching an exit from the building.

Findings include:

A. Afternoon of 07/19/12, the tunnel connection at the North Clinic lacks a designated exit sign into the Clinic. This produces a dead end corridor condition of excessive length and does not comply with 19.2.5.9.

B. Morning of 07/18/12, Parkview, all occupied levels 2nd - 8th floors contain a dead end corridor condition of approximately 70 feet. The dead end extends from a pair of cross corridor doors locked against egress within a south end corridor to the corridor where Rogers connects to Parkview.

C. Afternoon of 07/17/12 8th floor Parkview CVCU; the direction of egress, is indicated by an exit sign located above the inactive leaf of a pair of cross corridor exit access doors.

Based on random observation during the survey walk through the surveyor noted numerous designated suites which did not appear to comply with 18.2.5. The North Tower 2nd Floor was renovated in 2007 therefore this wing has been evaluated under Chapter 18. Four designated suites do not comply.

Findings include:

A. North Tower Wing, 2nd Floor, OR / Recovery Suites: The surveyor finds that multiple suites identified as S1, S2, and S3 are probably not suites and each suite lacks access to two remote exit access corridor doors in accordance with 18.2.5.3. All three suites must pass through adjoining suites to reach a corridor door. These suites do not comply with 18.2.5.8. The two hour fire barriers that are installed between the suits do not comply with 7.2.4.3.1; the fire compartments are part of the adjacent fire compartment. The two hour fire barriers define the boundaries between suites only and not horizontal exits.

B. North Tower Wing, 2nd Floor, OR Suite S3 identified 12,042 s.f. does not comply with 18.2.5.7 for the maximum allowable square footage for a non sleeping room suite, the maximum permitted is 10,000 square feet.

Failure to maintain suite boundaries and provide access to corridors doors from the suites will increase the travel distance to a corridor for horizontal evacuation during a fire emergency.

End










20224


Based on random observation and staff interview during the survey walk-through, not all designated suites are provided with exits in accordance with 19.2.5. Intervening rooms within a suite allow for a delay in becoming aware of a fire and to reach an exit access corridor. This condition could affect patients, visitors and staff on this floor level.

Findings include:

A. Afternoon of 07/18/12 3rd floor Rogers, Inpatient Therapy Services and Rehabilitation, deemed a suite by the facility, lacks the required arrangement of a means of egress to an exit access door and does not comply with 19.2.5.1 exception #2. Patient sleeping rooms have two intervening rooms to traverse in order to gain access to an exit access corridor. An example location is the semi-private room #3576 (as shown on the Life Safety floorplan) which must travel through room # 3377 and corridor #3385.

A) Based on random observation the surveyors find that designated two hour fire barriers are not installed or maintained in accordance with Chapter 8 of NFPA 101:

Findings include

1) The Basement Level Rogers Utility tunnel at the sign shop has a pair of 90 minute fire doors that lead the the Rogers east/west corridor. The two hour wall at this location has multiple penetrations that are not sealed for two hour construction.

2) The Basement Level Rogers corridor has a designated two hour corridor wall opposite the West Stair. There is an opening in the wall at ceiling height with a fire damper that is not installed in accordance with NFPA 90A. The fire damper is partially closed and is buckled at the base of the damper. Some type of penetration under the damper is not installed to maintain the two hour fire barrier and/or the corridor wall as a smoke tight barrier in accordance with Chapter 8 of NFPA 101 and/or 19.3.6.2.1.

3) 1st Floor Center Wing - The wall between the Admitting Area and the North Clinic is a designated two hour fire/smoke barrier. There is one door from the Admitting Area into the North Clinic. Multiple penetrations through the two hour wall above the door are not sealed for two hour fire rated construction.

4) 1st Floor Center Wing - The two hour barrier between the North Clinic and the Center Wing of the Hospital has a pair of 90 minute cross corridor doors in the corridor.

a) A tube system penetrates that fire barrier above the ceiling and then is capped with light gauge metal; the tube is not terminated to maintain that two hour barrier.

b) A cable tray penetration above the ceiling is not sealed for two hour construction; most of the fire rated material at the penetration has been removed.

5) 2nd Floor Center Wing - there is a designated two hour fire barrier between the Center Wing and the North Clinic. There is a pair of 90 minute cross corridor doors at this two hour fire barrier. The two hour barrier does not comply with 8.2.3.2.4.

a) Multiple penetrations above the ceiling at this location are not sealed for two hour construction.

b) Ductwork penetrates the fire barrier above the ceiling and does not comply with NFPA 90A; no fire dampers or fire damper access panels were found

6) 3rd Floor Center Wing - Southeast Mechanical Room. The surveyor notes that that this space appears on plans to be part of the North Clinic at the 2nd and 3rd Floors. It is part of the Center Wing and is separated from the North Clinic by designated two hour fire barriers.

a) The 3rd Floor door to the Mechanical room is not a 90 minute fire door.

b) Two duct penetrations above the 3rd Floor corridor door above the ceiling have fire dampers; however, there is a void in the fire wall between the two ducts and the fire dampers are not installed in accordance with NFPA 90A

Failure to maintain fire barriers will allow smoke and fire to spread throughout the building more quickly in a fire emergency.

End


16339

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers as shown on the Life Safety drawings are constructed or maintained as fire resistive assemblies as required by NFPA 101, 8.2.3.2.4.1&2. These deficiencies could affect all persons in the facility, by preventing the barriers from providing the intended separation protection.

Findings include: See also K-042

A. At 10:55AM, 07/18/2012 North Tower Wing 2nd floor Designated 2 hour fire separation wall also identified two hour horizontal exit on the drawings, walls above the ceiling do not form a complete two hour barrier by the exit access cross corridor door leading to the OR Suites near the Stair 2AS3.

B. At 1:30PM, 07/18/2012 North Tower Wing 2nd Floor OR Based on observation all double egress doors to the the designated two hour fire rated horizontal exit which is also the OR suite boundary are not 90 minute fire doors with U L Labels and these fire doors are not self closing. One door was observed to have only a 45 minute rating.

C. In the afternoon, on 07/18/2012 North tower 2nd Floor Designated 2- hour separation
wall near the OR Pharmacy was observed with pipes and conduits penetration above the ceiling that are not fire sealed. The door to the pharmacy, which is part of the fire separation wall is only 20 minute rated and does not comply with 8.2.3.2.3.1(1)


20224

Based on random observation and staff interview during the survey walk-through, not all 2-hour barriers are constructed in accordance with 8.2.2.2. These deficiencies could affect all persons in the facility, by preventing the barriers from providing the intended separation protection.

Findings include:

A. Morning of 07/20/12, 3rd floor, North Clinic at the bridge, the designated 2-hour fire barrier (as shown on the Life Safety floor plans) does not carry the minimum fire resistance rating due to the wall construction above the pair of cross corridor doors contains an unprotected structural steel member not fire proofed to comply with 19.1.6.2 and large gaps within the wall at both ends of the door frame.

B. Afternoon of 07/19/12, North Clinic at the tunnel, the designated 2-hour fire barrier (as shown on the Life Safety floor plans) does not carry the minimum fire resistance rating due to the wall construction above the pair of cross corridor doors that contains an unprotected structural steel member not fire proofed to comply with 19.1.6.2.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. North Tower Wing, 11th Floor, Nursery Corridor - The egress path was observed to not be properly identified in accordance with 7.10.1.1. No exit sign was observed to direct building occupants into the nearest exit.

B. North Tower Wing, 2nd Floor, OR - Exit sign is not provided by the OR lounge to identify egress paths as required by 7.10.1.1.

C. North Tower Wing, 1st Floor, Digestive Health Procedure Suite - The Suite's aisles lack exit signage to direct occupants to the nearest exit.

A) Written Fire Plan: The surveyor finds from document review that the provider's written fire plan is based on the R A C E acronym however the R component has been identified as REMOVE instead of RESCUE and the plan places too much emphasis at this initial step on removing people in general instead of focusing on rescue of anyone in immediate danger. Removal of people and clearing waiting areas and corridors may be more appropriate after the alarm component of RACE and the compartmentation component of RACE have been executed.

Failure to to follow the requirements in NFPA 101 for personnel response in a fire could result in a delayed response or inadequate response in a fire emergency.

B) Written Fire Plan: The provider has indicated that the building fire alarm system does not activate globally but instead activates by zone of activation and in all zones adjacent to the zone of activation. The provider lacked specific information that identifies all fire alarm zones and sprinkler zones. This information is necessary to determine which zones are adjacent to the zone of activation and is necessary to determine whether fire alarm zones, sprinkler zones match to building separations, areas or wings that are defined by fire barriers, smoke barriers, suite boundaries, etc. All components and panels of the fire alarm and sprinkler system report to a monitoring location in the E R Security Room which is constantly attended. For any fire event, in addition to automatic notification to specific zones, an overhead announcement is made (manually initiated) that identifies the location of the fire to all portions of every building or wing. The written fire plan for the Hospital does not acknowledge the above conditions and does not clearly identify the staff response for fire in that area of activation, for a fire in the adjacent zones and for a fire in the zones where the fire alarm does not automatically announce a fire (which could include two zones away from the fire and also remote locations).

Lack of a specific and detailed plan for the conditions identified above could result in a delayed response or inadequate response in a fire emergency.

C) The Life Safety Plans dated 2010 that were provided for this survey do not include the entire underground Tunnel that connects the North Clinic to the South Clinic and then to the Mills Breast Cancer Center. The Tunnel was inspected as one continuous underground tunnel from the designated fire separation at the North Clinic to the far eastern end of the Mills Breast Cancer Center.

The Tunnel is identified with a two hour fire separation from the South Clinic but is not shown with a fire separation at the Mills Breast Cancer Center. Multiple pairs of cross-tunnel fire doors were found in the tunnel; however none of these door were identified on plans as fire separations. Based upon these conditions, the surveyors have included the entire tunnel as part of the Mills Breast Cancer Center in this survey. The above is informational only, but is included under K048 because accurate Life Safety plans for the entire length of the tunnel were not available.

Lack of accurate life safety information for the Hospital could result in the failure to maintain required systems or life safety components.

End

A) The surveyor notes that the Hospital has personnel that work eight hour shifts and some personnel that work twelve hour shifts. Based upon a review of fire alarm documentation for the previous 12 months in multiple buildings, 07/20/12 with the facility safety officer, the surveyor finds that the provider conducts and observes fire drills in the zone of activation and typically in two adjacent zones.

1) The provider lacked specific information that identifies each zone and the boundaries of each zone that is being included in the zones to be observed during a fire drill.

2) Based on document review, the surveyor finds that fire drills are not conducted at varying times. Under review with the Safety Officer, the surveyor found that drills are typically conducted around 11:00AM, 2:00PM to 3:00 PM and 5:00AM to 6:00 AM.

3) The surveyor did not find documentation for any fire drills for 2012 in the Mills Breast Cancer Center.

Failure to conduct fire drills and observed performance in accordance with NFPA 101 could result in poor staff performance during a fire emergency.

End

A) From random observation and testing the surveyors find that the fire alarm system is not installed and maintained in accordance with NFPA 72. Multiple devices connected to the fire alarm system failed to respond/activate/de-active upon activation of the fire alarm system in the same zone and/or in adjacent areas where the zone boundaries are not defined.

Examples include:

1) Locking devices installed on doors on multiple floors and multiple wings or buildings failed to unlock from activation of the fire alarm system during testing on the afternoon of 7/19/12 and the morning of 7/10/12. This deficiency is also cited under K038 for conditions relative to unlocking devices from fire alarm activation. The provider also failed to detect and abate this condition during quarterly or annual fire alarm testing in accordance with NFPA 72.

2) Multiple auto-open functions and hold-open devices installed on doors on multiple floors and multiple wings or buildings failed to unlock from activation of the fire alarm system during testing on the afternoon of 7/19/12 and the morning of 7/10/12. This deficiency is also cited under K018 and K021. The provider also failed to detect and abate these conditions during quarterly or annual fire alarm testing in accordance with NFPA 72.

3) Basement Level Nutrition Bulb Room - this room provides access to an electrical room with Transfer Switch A-3EOR. A smoke detector installed three feet below the deck above is not installed in accordance with NFPA 72.

Failure to test and maintain devices and components that are tied to the fire alarm system will result in delayed responses by life safety systems and personnel in a fire emergency.

End


20224

Based on random observation and staff interview during the survey walk through, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. Afternoon of 7/19/2012, during a test of the fire alarm system, the first floor Concourse (Breezeway) lacks functioning audible notification devices from activation of the system in adjacent zones.

A) Based on random observation through the Hospital, the surveyors find the sprinkler system is not installed and maintained in accordance with NFPA 13. This includes sprinkler system deficiencies that are identified on quarterly sprinkler system inspection reports.

Examples include but are not limited to:

1) Basement Level Parkview Wing East Dinning Room: There is an electrical room in the east side of the Dining Room with an identified two hour enclosure. The room has one or more penetrations that are not sealed for two hour fire rated construction, including one penetration into the Fire Pump Room. If the two hour enclosure of this room is not maintained, it must be sprinklered in accordance with NFPA 13.

2) Basement Level Parkview Wing East Dining Room - There is an electrical room in the east side of the dining room that provides access to the Parkview Fire Pump Room.

a) The fire pump room is not identified on plans and is not constructed with a one hour fire rated enclosure in accordance with NFPA 20.

b) The fire pump room is not sprinklered in accordance with NFPA 13.

3) Basement Level Concourse Wing - The Janitor's Closet in the Kitchen is not sprinklered.

4) Basement Level Nutrition Bulb Room - this room provides access to an electrical room with Transfer Switch A-3EOR. The room is not sprinklered in accordance with NFPA 13.

5) Basement Level - there is a long electrical closet with two pairs of doors west of the Parkview Elevators. This room is not sprinklered.

6) The Basement Level Rogers Utility Tunnel at the Sign Shop has one upright and one pendent sprinkler head that are installed four feet below the deck above.

7) Basement Level Rogers South Mechanical Room has an electrical room that lacks sprinkler protection.

8) Basement Level Rogers South Mechanical Room has a small room with no door near AHU H31296. The room lacks sprinkler protection.

9) Basement of Rogers Morgue. There is a room on the backside of the Morgue walk in cooler. The space lacks sprinkler protection throughout, including the open ceiling cavity above the cooler.

10) 1st Floor Center Wing - the Emergency Room main outside entrance lobby has ceiling tiles that are regularly displace by wind pressure. This compromises the sprinkler protection in this space. Effective means to keep the tiles in place have not been implemented.

11) 1st Floor Center Wing - there is a storage room near the Center Wing Northwest Stair. A hole in the ceiling compromises the sprinkler protection in this room.

12) 1st Floor Center Wing Coffee Shop - the electrical closet in the back of the Coffee Shop lacks sprinkler protection.

13) 1st Floor Center Wing - There is an electrical closet in the Northwest corner of the Walgreens space that is not sprinklered.

14) 1st Floor Center Wing Walgreens Space - The shelving in the back of this space is closer than 18" below the sprinkler heads installed. Some of the sprinkler heads are obstructed and not installed in accordance with NFPA 13 (obstructions and/or sprinkler head spacing does not comply).

15) 1st Floor Center Wing - The Data Closet in the EVS Room near Walgreens has no ceiling and no sprinkler protection.

16) 2nd Floor Center Wing North IVS Suite - the closet opposite the EP Lab # 1, with three sliding doors have a void in the ceiling that compromises sprinkler protection in this space.

17 2nd Floor Center Wing Cardiac Diagnostics EVS Closet - a sprinkler valve in this closet lacks identification as an inspector's test valve or an auxiliary drain in accordance with NFPA 13.

Failure to maintain the sprinkler system will result in poor performance of this system in a fire emergency.

End


14416


By direct observation on the morning of 7/17/12 & 7/18/12, while in the company of the Central Plant Supervisor, the surveyor find not all building space are protected by a fire suppression system. The unprotected spaces listed below are examples and the lack of protection is not limited to only these spaces:
A. Parkview:

1. Lower Level " Mechanical Room " across from staff elevators. This room is in fact a communications equipment closet.

2. Lower Level Electrical Closet West end of the Parkview Elevators

3. 8 th Floor Electrical Closet West end of the Parkview Elevators

B. North Tower:

1. 4 th Floor Patient toilet rooms 4118 & 4130

2. 6 th Floor Patient toilet room 6245/6246



16339

Based on random observation during the survey walk-through and staff interview, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. North Tower Wing, 9th Floor NICU- Electrical Room provided with a sprinkler protection was observed to have ceiling tiles within the closet missing or not set in the grid which allows the space to be open to the ceiling cavity above compromising the activation of the sprinklers.

B. North Tower Wing, Sixth Floor OR - Staff Lounge Room, the top of metal locker shelves obstruct sprinkler head protection that could impede the proper operation of the system system.

C. 8:40AM, 07/19/2012, North Tower Wing, First Floor - Based on observation the toilet stalls in the Women's Locker Room lack sprinkler head to provide full protection in accordance with NFPA 101, 2000 Edition Section 19.3.5. as well as NFPA 13.

The surveyor finds that failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed activation. This condition may affect patients, staff and visitors within the building.



17659

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

A. Five of five fire pump locations were surveyed.

1. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7 for any of the fire pumps.

2. The fire pump rooms do not have a battery operated emergency light as required by NFPA 20-2-7.4.

3. The transfer switch for the fire pump in the Parkview Wing is not located in the pump room as required by NFPA 20-6-6.4.





20224

Based on random observation and staff interview during the survey walk through not all portions of the building are sprinkler protected. This could result in delayed activation of the sprinkler system. This condition may affect patients, staff and visitors within the building.
Findings include:

A. Morning of 07/17/2012 5th floor Parkview mechanical room, sprinkler heads were observed below a duct greater than 48 inches in width in which one head was not in the correct position. This condition does not comply with NFPA 90A 1999 1-3.1 (1) and (2).

B. Morning of 07/18/2012, The facility failed to provide fire suppression for the following areas:

1. 2nd floor Rogers, PAR/DUR room across from female lockers, this room is converted to a soiled utility and lacks sprinkler protection.

2. 9th floor Parkview, Mechanical room #911 (as shown on Life Safety floor plan) lacks sprinkler protection below ductwork greater than 48 inches in width. Example location - entry located north of corridor #910 contains an aisle to the left which dead ends and is surrounded by ductwork overhead.

3. 4th floor Rogers, room adjacent to room # 4465 and #4466 lacks sprinkler coverage.

4. 6th floor Parkview, patient room closets (floor to ceiling) lack sprinkler coverage, example location room #6616 (as shown on Life Safety floorplan). The closest sprinkler head is located more than 5 feet away beyond the privacy curtain.


5. 9th floor Parkview, Mechanical room #931 (located adjacent to Respiratory clean storage) lacks sprinkler coverage.

A) Based on document review of sprinkler maintenance and testing for reports dated 5/14/20012, the surveyor finds that the sprinkler system in multiple buildings is not being tested, serviced and maintained in accordance with NFPA 25 - 1999.

Examples include:

1) The sprinkler inspection report dated 5/14/2012, for the North Clinic sprinkler system identifies eight deficiencies identified in the report that include previously cited main drain deficiencies and also deficiencies with tamper switches that did not report to the fire alarm and sprinkler heads that were not installed in accordance with NFPA 13.

2) The sprinkler inspection report dated 5/14/2012, for the North Clinic sprinkler system identifies under item "4 c" that visible sprinkler piping is not in good condition. There was no further explanation for this condition.

The sprinkler system may not perform correctly in a fire emergency if it is not tested and maintained in accordance with NFPA 13/NFPA 25.

End

A) Based on random observation, the surveyors find that mechanical systems are not installed, tested and maintained in accordance with NFPA 101 and NFPA 90A:

Findings include:

1) Basement Level Parkview Wing east Dining Room - There is an electrical room in the east side of the dining room with an identified two hour enclosure. The room has an outside air intake louver that was 90% obstructed by debris and grime.

2) Basement Level CDU Mechanical Room (across from Cafeteria): Two ducts penetrate the fire rated floor above. Fire dampers were not found in accordance with NFPA 90A.

3) Basement Level Rogers and Center Wing: There is a north and south Mechanical Room in the east side of the building. One or both rooms are open to a vertical shaft enclosure. These mechanical rooms are defined on the Life Safety Plans with two hour fire barriers.

a) Multiple ducts penetrate these two hour
barriers without fire dampers and do not
comply with NFPA 90A.

4) Basement Level Rogers and Center Wing: The north and south Mechanical Room in the east side of the building has a tee shaped room in the middle of the Mechanical Rooms that is part of an air intake plenum and air intake shaft that extends to the 3rd Floor Roof above.

a) All portions of the air intake shaft
enclosure on multiple floors are not
identified as fire rated enclosures on the
Life Safety Plan. Not enough
information is not provided to
demonstrate how this shaft complies
with NFPA 101 and NFPA 90A The
shaft location is missing on the 1st and
2nd Floors.

b) These air intake shaft are required to be
enclosed from the Basement Level to the
roof (minimum - one hour shaft
enclosure). Fire dampers were not found
at air intake louvers or openings in the
Basement Level Mechanical Room in
accordance with NFPA 90. Fire
dampers were not found on all floors
where ducts or openings penetrate this
shaft.

c) A fire rated shaft enclosure was not
found at the 1st Floor (with multiple
sealed penetrations into the shaft. Also,
The door to this shaft at the 1st Floor
is not a fire rated B Label fire door
and it lacks self closing hardware.

d) No fire rated shaft enclosure was found
on the 2nd Floor. The shaft appears to
be open to adjacent ceiling cavities,
assess doors are not fire rated and ducts
lack fire dampers.

5) There is a 1st Floor Mechanical Room on the north side of the west Wing of the North Clinic. The mechanical space is separated from portions of the 1st Floor of the North Clinic and the Center Wing of the Hospital by two hour fire barriers. However, in the Basement Level the North Clinic is only separated from the Center Wing by a one hour smoke barrier. This does not constitute a building separation. Multiple duct penetrations through the 1st Floor two hour fire barriers (3 ducts at the north wall and 2 ducts at the south wall) lack fire dampers in accordance with NFPA 90A.

6) 1st Floor Center Wing - The is a large duct shaft in the Northwest corner of the Walgreens Pharmacy. The shaft has multiple ducts with fire dampers at the floor. The access panel for one of the ducts was left open. Access to this shaft for inspection and maintenance is through an shaft access door that is three feet above the floor and that is mostly blocked by a shelf in the Walgreens space. Access to the fire dampers was not provided in accordance with NFPA 90A. An inspection of the fire dampers and shaft could not be conducted; access could not be provided.

Failure to maintain vertical openings and failure to install and maintain fire dampers where required will allow fire to spread from floor to floor in a fire emergency.

End




20224


Based on random observation and staff interview during the survey walk-through, not all air handling equipment is maintained to restrict the movement of smoke or fire from one floor to another to comply with 19.5.2.1. This condition could affect any patients, staff, or visitors on the floor above by extending a fire or smoke incident from the floor below.

Findings include:

A. Morning of 07/17/2012 5th floor Parkview mechanical room, an air handling unit was observed open to the mechanical room which houses it. The unit serves the inpatient floor above. The air handling unit's access panel was observed laying on the mechanical room floor. This condition does not comply with NFPA 90A 1999 1-3.1 (1) and (2) in order to restrict the spread of smoke and fire within a building.

A) Based on document review the surveyor finds that kitchen hood suppression systems are not tested in accordance with NFPA 17A and NFPA 96:

1) 1st Floor Coffee Shop/Main Lobby of the Center Wing: The kitchen hood suppression system in this space was documented on the semi-annual inspection dated 4/16/11 has having both gas fueled and electrically fueled appliances under the hood that were tested for automatic shut down. The testing documentation dated 4/16/12 indicates that there are no gas fired appliances under the hood.

Failure to test and maintain kitchen hood suppression systems correctly could result in failure of the suppression system in a fire.

2) 1st Floor Coffee Shop/Main Lobby of the Center Wing - The combination grill/fryer is protect by a front capture type hood which requires the protected equipment to be inside of the two sides. On 7/18/12, the surveyor observed that the grill was positioned several inches outside of the left wall of the hood.

Failure to maintain cooking appliances under a kitchen hood could result in a fire beyond the hood and the protection under the hood.

End


14416


North Tower:
By direct observation in the 3rd Floor Mechanical Room on the morning of 7/17/12 while in the company of the Central Plant Supervisor, the surveyor finds the facility failed to install the kitchen grease hood ventilation systems in compliance with NFPA 96, 1998:

1. It could not be determined that the rated enclosing duct shaft, from the Lower Level Kitchen hood exhaust system is vented to the exterior of the building. (NFPA 96, 1998, 4-7.1)

2. The four grease laden vapor exhaust ducts, for the Kitchen Hoods, from the enclosing shaft to the utility fan sets (Fan Nos. 21, 22, 23 & 24) and from the fan sets to the exterior are not separated with rated construction from other parts of the facility's mechanical systems located within this mechanical room (i.e. air handlers, pumps and compressors). The ducts were covered with thermal insulation. (NFPA 96, 1998, 4-7.1)

3. The four Kitchen hood exhaust fans (Fan Nos. 21, 22, 23 & 24) are not connected to the duct runs with flanges and bolts. The connections are made by flexible canvas connectors. The surveyor noted the canvas connectors were saturated with grease. (NFPA 98, 1998, 5-3.1)

A) Based on random observation the surveyor finds that exit access corridors are not maintained free of obstructions in accordance with 7.1.10.

Findings include

1) The Basement Level exit access corridor near R/F Closet OE121 was constructed as a required 8'-0" corridor; it was obstructed on 7/19/12 with five gurneys in the corridor.

2) 2nd Floor Center Wing Cardiac Diagnostics - three corridors were obstructed by gurneys, computers on wheels that were unattended, ultrasound equipment, chairs and by one unattended patient parked in a chair.

End


16339

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 18.2.3.3. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

Findings include

A. North Tower Wing, 9th Floor NICU- Furnishings, carts, and equipment were observed in the Suites aisles that obstruct egress and the required 8'-0" clear width required for aisles are not being maintained to comply with 18.2.3.3. and 7.1.10.2.2.



20224


Based on random observation and staff interview during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. or 39.2.3.2. These deficiencies could affect any patients, staff, or visitors attempting to utilize these corridors under emergency conditions by impeding egress.

Findings include:

A. Morning of 07/18/2012, 5th floor Rogers, equipment was observed in the egress corridor, which does not comply with 19.2.3.3. and 7.1.10.2.1. Items observed include 9 pieces of equipment all charging from a wall hung distribution outlet strip.

B. Afternoon of 07/18/2012, 8th floor Parkview, CVCU (Cardio-Vascular Critical Care Unit which is not a designated suite) Through staff interview, and observation there is no designated clean utility and all materials are stored on multiple shelving units within the centrally located nurses station.

C. Afternoon of 07/18/2012, 7th floor Parkview, ICU (which is not a designated suite) Through staff interview, and observation there are numerous materials stored on multiple shelving units within the centrally located nurses station and throughout the exit access corridors.

D. Afternoon of 07/17/12, 2nd floor, Concourse Stage I Recovery, contains numerous materials stored throughout the exit access corridor between Recovery and Surgery (adjacent to the Doctor's Lounge). Example materials are a refrigerator, a blue cart and equipment. These items reduce the required 8 foot width of the exit access corridor.

E. Afternoon of 07/17/2012, 6th floor Parkview, patient care floor (which is not a designated suite) Through staff interview, and observation there are numerous materials stored throughout the exit access corridors and adjacent to patient room doors. The surveyor attempted access into patient rooms and found the amount of equipment, tables and carts directly adjacent to patient room doors conflicts with patient room egress, example location room # 6625.

A) Based on random observation the surveyor finds that oxygen tanks are not stored in accordance with NFPA 99-1999.

1st Floor Center Wing - There is a storage room near the Northwest Stair. On 7/18/12, this room had multiple oxygen tanks stored closer than five feet from all combustibles.

Basement storage room (says CT MRI with an arrow) - the room has bottled oxygen in a rack that is store closer than five feet to combustible and does not comply with NFPA 99.

Parkview 2nd Floor Suite 8 as shown on the Life Safety documents provided:

By direct observation the surveyor finds not all medical gas zone valves are labeled to reflect the outlets/inlets they serve (NFPA 99, 1999, 4-3.1.2.14 (b) 3) and in some cases depending on correct labeling the valve location may not meet NFPA 99, 1999, 4-3.1.2.3 in that the zone valves are not separated by an intervening wall from the outlets/inlets they serve.

K106 - The facility does not comply with the 1999 Editions of NFPA 70, 99, 110 and NFPA 101 - 2000, Section 21.2.9:

A) The Surgery Center and Recovery Care Center have a shared emergency power system that is supplied from an exterior, pad mounted, diesel generator. This generator is not installed to comply with NFPA 70. NFPA 99, NFPA 110 and/or OSHA.

1. The generator is mounted on belly tank and the controls are elevated. A wood electrical spool serves as a stoop to allow observation of the generator controls. A permanent, stable platform is not provided.

2. The generator has a remote alarm panel near the nurse's station in the Surgery Center. However, a remote alarm is not installed in the Recovery Care Center. The Recovery Care Center will be occupied during hours much later or earlier than the hours for the Surgery Center and the Surgery Center nurse's station does not constitute a constantly attended location for alarm conditions that are applicable to the Recovery Care Center. No generator alarm panel is provide within the Recovery Care Center in accordance with NFPA 99-3-4.1.1.15, NFPA 110-3-5

3. The surveyor did not find an engine block heater from inspection. There is no evidence in the documentation for testing that indicates that an engine block heater is installed and tested in accordance with 3-3.1 of NFPA 110-1999

4. The surveyor did not find a battery warmer from inspection. There is no evidence in the documentation for testing that indicates that a battery warmer is installed and tested in accordance with with 3-3.1 of NFPA 110-1999

5. The emergency power electrical distribution system for the Surgery Center and for the Recovery Care Center has two transfer switch. The emergency electrical service does not have three separate branches (with panels and circuit identification) for equipment branch, critical branch and life safety branch, as required by NFPA 70-517 - 1999 and NFPA 99 - 1999. The same requirements were found in NFPA 70 as far back as the 1970 Editions. The provider lacks detailed information identifying how the facility complies.

6. No emergency power one-line diagram was available on site in accordance with NFPA 70, NFPA 99 and 250.2430 4 of the Hospital Licensing Requrements. A one-line-diagram must be submitted to the Department.

End

A) This citation is K114 in the regulation sets for Ambulatory Surgical Centers. The facility does not comply with Section 21.3.7.1 of NFPA 101 - 2000

The Recovery Care Center is is separated from the Surgery Center by a one hour fire barrier with a pair of 60 minute fire doors. This one hour wall is identified on the original construction documents dated February 15, 2000.

1) The construction documents do not identify a continuous one hour fire barrier to separate the surgery center from the recovery center as a one hour tenant separation wall (as required by 21.3.7.1 of NFPA 101 - 2000). The wall is not shown as a continuous one hour wall along the west side of the corridor wall between the surgery center and the recovery center.

2) The designated one hour wall has cable penetrations and holes that are not sealed for fire rated construction , above the ceiling, above the pair of doors in this wall.

3) The above referenced 60 minute fire doors have vision panels that lack labeling identifying the glazing as 60 minute fire rated glazing (or a minimum of 45 minutes rating for 3/4 hour rated doors in accordance with 21.3.7.1) fire rated glazing in accordance with NFPA 80.

B) The facility is identified as a fully sprinklered building, however a portion of the building does not comply with NFPA 13- 1999: The Electrical Room is protected with sprinkler heads. However, the room does not have a ceiling and the walls of this space do not extend to the deck (as smoke tight construction). The room is open to the ceiling cavities of adjacent spaces and the sprinkler protection is not installed throughout in accordance with NFPA 13.

End

K144 - The facilities emergency power system is not installed and maintained in accordance with the 1999 Editions of NFPA 70, 99 and 110, in accordance with 21.2.9 NFPA 101- 2000.

A) The Surgery Center and Recovery Care Center have a shared emergency power system that is supplied from an exterior, pad mounted, Level I, emergency generator. Based upon document review for 12 to 16 months, the surveyor finds that the emergency generator is not tested, serviced and maintained in accordance with NFPA 99 and NFPA 110:

1) The documentation for weekly visual inspection was not immediately available and does not including checking of oil levels and testing for specific gravity of the batteries.

2) The documentation of monthly load testing of the generator does not include that amperage load for three of three phases.

3) The documentation for monthly load testing also indicates, on some of the monthly forms, that the generator does not comply with the 30%/50% monthly load testing requirements of NFPA 110. The documentation for an annual load bank test (for the previous 12 months) was not immediately available and was not maintained on site.

Failure to test and maintain the emergency generator could result in failure during a loss of normal power to the facility.

End

Based on random observation during the survey walk-through the building emergency the surveyor finds that the emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517.

Findings include:

1. Life Safety Panels such as XLA8A, XLA7A, XLA6A in the electrical closet on each floor of the North Tower are all serving loads that include: nurse call, comm room receptacles, hall receptacles, time clocks, cameras and cart lifts that should be served by other branches to meet the requirements of NFPA70, Section 517-32 through 34.

2. The Parkview Wing of the main building has Life Safety and Critical Panels in the electrical closets on each floor, including the elevator equipment room that are serving loads that should be served by other branches in accordance with NFPA-70, Section 517-32 through 34. Panels R-1C-8RE1 and R-1C-7RE1 are examples of critical panels that are serving fire alarms that should be served by the life safety panels, and life safety panels L-1S-8RE and L-1S-7RE, and the life safety panels on each floor are serving loads such as nurse call, and room receptacles that should be served by critical panels.

3. The Rogers Wing of the main building has a single emergency panel on each floor serving a mixture of life safety, critical, and in some cases equipment which does not meet the requirements of NFPA-70, Section 517-30 through 34.

4. The Center Wing of the main building had critical panels XCD3A, and XCD1B serving med gas alarms that are required by NFPA-70, Section 517-32 to be served by the life safety branch, and life safety panel XLD2A was serving the nurse call system which is required by NFPA-70, Section 517-33 to be served by the critical branch of the emergency power system.

A) Based on random observation throughout multiple floors and multiple buildings or wings, the surveyors find that data cables above the ceiling area supported by ceiling tiles, sprinkler piping, conduit, ductwork, etc. above ceilings.

The data cables are not supported independently in accordance with NFPA 70 1999 800-52(e). The non-complying supporting elements above ceilings (ceiling tiles, conduit, ducts, sprinkler piping, etc.) are not designed to support data cables. This condition was observed and confirmed by the VP of Facilities and Support Services on 7/17/12.

Examples include but are not limited to:

1) 3rd Floor Center Building - corridor near vending machines

2) 1st Floor Center Building in corridor in front of EVS Closet (near Walgreens)

3) North Tower Wing, 11th Floor - Part of Elevator Lobby leading to OB Unit

4) North Tower Wing, 11th Floor - Post Partum Room 1110

5) North Tower Wing, 8th Floor near Telecommunication Closet

6) North Tower Wing, 4th Floor exit access corridor by Patient Room 4143

7) North Tower Wing Lower Level CPD Storage exit access corridor near the Electrical Closet

B) Based upon random observation on multiple floors and in multiple buildings or wings, the surveyors find that switch gear and electrical panels are not installed and maintained in accordance with NFPA 70:

1) Access to electrical panels and switch gear is blocked or obstructed by storage. A 3'-0" clear aisle and clear space in front of each switchgear or panel is not maintained in accordance with NFPA 70. Locations include but are not limited to:

a) 2nd Floor Center Wing IVS Storage Room (former procedure room) Access to an electrical disconnect in side this space was blocked by storage.

b) 1st Floor Center Wing - Electrical Closet in Northwest corner or Walgreens - access to electrical panels was blocked by waste materials and storage.

c) 1st Floor North Clinic Northwest Mechanical Room - access to switchgear and panels was obstructed by storage.

d) Basement Level of Rogers Wing - The space on the back side of the Morgue Cooler has a disconnect where access is obstructed by storage.

e) Basement Level Dietary Kitchen -Concourse Wing? Access to Hobart switch and multiple disconnects was obstructed by waste carts.

2) Switchgear and panels lack panel identification. Electrical panels have spares that are not identified in accordance with NFPA 70. One or more circuits in electrical panels are on and do not identify the circuit in use in accordance with NFPA 70. Based upon the pattern observed, the surveyors expect to find this condition in every electrical panel in the facility. This condition was observed and confirmed by the VP of Facilities and Support Services on 7/17/12. Locations include but are not limited to:

a) 4th Floor West Mechanical Penthouse - Panel D4A and XQ4D

b) 3rd Floor Center Wing Electrical Closet (H-40477) - six of six electrical panels including Panel XLD3A and DP3A.

c) 2nd Floor Center Wing two story Mechanical Room near the fire separation in the corridor between the North Clinic and the Center Wing - Panel R-IE-R2

d) 2nd Floor Center Wing Clean Supply Room opposite Vascular Lab 2 - Panel XCD2A

e) 2nd Floor Center Wing Equipment Room for EP Lab 3 and 4 - the electrical disconnect next to Panel XCD2PA has no identification label.

C) Based on random observation the surveyors find that electrical systems and materials are not installed and maintained in accordance with NFPA 70: Examples include:

1) 3rd Floor Center Wing/3 North Clinic - the two story mechanical room (HVAC systems) near the fire separation in the corridor has multiple electrical junction boxes that lack covers.

2) Basement Level Rogers/Center Wing South Mechanical Room - one fluorescent light fixture (in the south end of the Mech Room?) is suspended from a chain that is attached to ductwork above and is not supported in accordance with NFPA 70.

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Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. The deficiencies may lead to a lack of power for critical care areas which could affect patients, staff and visitors during a fire event.

Findings include:

A. 10:15AM, 07/18/2012 North Tower Wing, 4th Floor- Electrical panels were observed at which a clear space of 3'-0" is not being maintained due to a 4 foot ladder that is being stored in front of the panel to comply with NFPA 70 1999 110-26(a)

C. In the afternoon, 07/18/2012 North Tower Wing, 2nd Floor near the OR Supervisor's Room - Electrical panels A2D, A2S and CA2S were observed that are being blocked with a chair and a cart which the required 3'-0" clear space is not being maintained to comply with NFPA 70 1999 110-26(a)

A) Based upon document review (and the lack of documentation), based upon interview of hospital personnel along with elevator and fire alarm contractors onsite and based on random testing the surveyors find that the elevators in multiple buildings are not installed and tested in accordance with 19.5.3 and 9.4.3.2 of NFPA 101 and ASME/ANSI A17.3, Safety Code for Existing Elevators.

1) The provider was not able to provide documentation for annual testing and maintained of each elevator in that includes Phase I Fire Department Recall to the designated primary floor and alternate floor in accordance ASME/ANSI A17.3.

2) The Center Stair of the North Clinic has a door in the stair at the Basement Level that is identified as "Mechanical Room OE 59". This door provides access under the stair to a Sump Room and the elevator pit for two of four elevators. The space under the stair does not comply with ASME/ANSI A17.3, NFPA 101 and NFPA 13.

a) The elevator pit is open to the Sump Room. The drywall partition between the Sump Room and the elevator pit has been partially removed in the portion of the Sump Room with low head room. The lack for a two hour fire separation makes the elevator pit part of a space that is not permitted to be under the stair in accordance 7.1.3.2.3 and 7.2.2.5.3

b) The Sump Room has a sprinklered head but lacks sprinkler protection in two low ceiling areas of the room in accordance with NFPA 13.

b) The above elevator pit had debris piled up neatly in one corner of the pit with a broom against the wall.

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A) Based upon document review (and the lack of documentation), based upon interview of hospital personnel along with elevator and fire alarm contractors onsite and based on random testing the surveyors find that the elevators in multiple buildings are not installed and tested in accordance with 19.5.3 and 9.4.3.2 of NFPA 101 and ASME/ANSI A17.1, Safety Code for New Elevators.

1) The provider was not able to provide documentation for annual testing and maintained of each elevator in the Mills Breast Cancer Center that includes Phase I Fire Department Recall to the designated primary floor and alternate floor in accordance ASME/ANSI A17.3/A17.1.

Failure to maintain elevator recall functions could result in a delay in fire fighter response during a fire emergency.

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