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Based on observations the facility failed to provide adequate fire protection for two areas in the hospital . Failing to have proper extinguishing systems in the facility could harm patients and staff during a fire emergency.

NFPA 101 2012 Edition, Section 8.2 Construction and Compartmentation. 8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following: (1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls, exists between the portions of the building (2) Separate buildings, if provided with previously approved separations (3) Least fire-resistive construction type of the connected portions, if separation as specified in 8.2.1.3(1) or (2) is not provided

Findings:

Observations made while on tour on June 26-28, 2023, revealed the following;

1) a large "shell" area near the emergency department. The room size was 56.9 ft by 45.9 ft totaling 2611.71 sq ft. The room did not have a rated door. The four walls were covered in drywall and the ceiling was open. The room was being used for storage, which had unused equipment, to medical single use dry sterile storage and also oxygen cylinders.
2) a large "shell" area near the Family Birthing Center entry. The room size was 38.9 ft by 73.6 ft totaling 2863.04 sq ft. The room did have a 20 minute rated fire door which the entire frame was able to be moved by hand. three of the four walls were covered with drywall with one wall having roll insulation and the ceiling was open. The room was being used for miscellaneous storage.

2) East campus revealed hole in the fire walls above the double door leading into the patient pods

3) Main campus doctors sleeping quarters electrical room does not have the piping penitrations filled.

During the exit conference June 29, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to maintain a safe means of egress in the building. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and/or staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof.

Observations made while on tour on July 26-28, 2023, revealed the following;

1) the corridor in the Surgery Department at the east campus two (2) computers on wheels and other department equipment was seen the corridor narrowing the emergency egress
2) the corridor in the Emergency Department at the west campus had several chairs and department equipment was seen in the corridor narrowing the emergency egress. On the walls were plastic signage which stated, "NO STORAGE KEEP THIS AREA CLEAR".
3) the Emergency Department Air Handler Stairwell was full of boxes, recliners, a spill kit and other items. Inside the room there was an illuminated "EXIT" directly above the door
4) East campus had two wagons and other equipment stored in the exit corridor on the north end in the PEDs unit.
5) Main campus the exitscooridors surounding the operating rooms had sterile tables and other equipment being stored in the hallways 5 foot was maintained

During the exit conference on June 29, 2023 the above findings were again acknowledged by the management team.





































43814

Based on observations during Life Safety Survey the facility failed to remove combustible material from the emergency evacuation stairwells. Failure to remove combustible materials from the stairwell could result in a fire spreading to the stairwell and could result in the death of staff or patients

NFPA 101: Life Safety Code, 2012 Edition - Chapter 7 Means of Egress
7.2.2.3 Stair Details. 7.2.2.3.1 Construction. 7.2.2.3.1.1 All stairs serving as required means of egress shall be of permanently fixed construction unless they are stairs serving seating that is designed to be repositioned in accordance with Chapters 12 and 13.
7.2.2.3.1.2 Each stair, platform, and landing, not including handrails and existing stairs, in buildings required in this Code to be of Type I or Type II construction shall be of noncombustible material throughout.

Findings include:

Observations while on tour June 26 and 27, 2023 revealed the stairwell in the facility has carpet in the stairs and landings. This carpet is old and not fire-rated.
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Employees #5,6, and #26 confirmed during the exit interview the facility had carpet in the stairs and landings and the carpet is due the next week to be removed.

Based on observation the hospital failed to ensure the kitchen hood baffle plates were being cleaned on a regular basis. Baffle plates the cafeteria grilling area was observed with an excessive buildup of oil and grease throughout the filter hood baffles. Failing to inspect and clean the kitchen hood baffles from oil and grease buildup will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and/or staff.

Findings include:

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 11, Section 11.2 Inspection and Testing, and Maintenance of Fire extinguishing Systems. Section 11.6 Cleaning of Exhaust Systems. Upon inspection, if the exhaust system is found to contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction. Section 11.6.2* Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to remove combustible contaminants prior to the surfaces becoming heavily contaminated with grease or oily sludge.

Observations made while on tour on June 26, 2023, revealed the following;

1) the commercial kitchen hood in the cafeteria are of the east campus had excessive grease buildup in the kitchen hood baffles. Also seen was a large amount of grease buildup on the nozzles of the suppression system
2) a card board box was seen four (4) inches away from the oven at the east campus. The box had an old coffee maker in it. The staff said the old coffee makers were being stored there until the vender could pick them up

During the exit conference on June 26, 2023, the above findings were again acknowledged by the management team.

Based on observation it was determined the facility failed to protect the entire facility with an automatic sprinkler system. This would result in the sprinkler system not being able to extinguish the fire and could result in injury or death to the building occupants.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 8 Obstructions to Sprinkler Discharge Pattern Development. Section 8.6.5.2.1.1 Continuous or noncontiguous obstructions less than or equal to 18 in. below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.6.5.2.

Findings include:

During a facility tour conducted on June 26-29, 2023 revealed the following
1) Doctors sleeping quarters electrical closit at the main campus was not protected by the sprinkler system. The sprinkler head was not installed during a recent building modification the is also no detections in that area.
2) Main campus has has numerious external lights installed in utility roome in the patients PODs were the light protrudes below the sprinkler heads blocking the heads from protecting most of the rooms. These were located in unit 4A

Employees #5, 6, 26, amnd 28 confirmed during the exit conference on June 29, 2023, the Dr sleeping quarters electrical panels coom at the main campus did not have detection or sprinkler heads installed during modification of the facility and the utility rooms have light blocking sprinkler system functions.

Based on observation the facility failed to prevent two ABC type fire extinguisher from being blocked and readily accessible in the facility. Failing to have clear access to a fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility.

Findings include:

Observations made while on tour on June 26-28, 2023, revealed the following;

1) a portable fire extinguisher located in the EVS Hall was being obstructed by a shelving unit and a storage cabinet. The fire extinguisher was not visible from the corridor.
2) a portable fire extinguisher seen the emergency department being blocked by a scale.

During the exit conference on June 29, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to repair several penetrations throughout both hospital campuses. Failing to the penetrations, holes in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients and/or staff in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations made while on tour on June 26-28, 2023, revealed the following;

East
1) corridor between the Imaging and the Hospitalist was a 2 inch by 3 inch hole above the ceiling tiles in the fire wall
2) corridor near the Family Birthing Center entry was two (2) 3 inch by 3 inch holes which had flex conduit going through them
3) yellow foam was seen filling gaps and openings throughout

West
1) above the fire doors on a two (2) hour fire wall was three (3) one inch round holes and one (1) 2 inch by 3 inch hole
2) corridor CT 1 Hall near door IMG141 was a 3 inch by 8 inch hole
3) corridor near door IMG135 was a 2 inch hole and a one (1) inch hole
4) the Emergency Department front entry was a 2 foot opening.
5) yellow foam was seen filling gaps and openings throughout

During the exit conference on July 26-28, 2023, the above findings were again acknowledged by the management team.

*******************CONDITIONAL***********************

Based on observation the facility failed to ensure electrical high voltage wiring from being exposed. Failure to have the appropriate protection around exposed wires could cause a fire which could harm to patients and/or staff. .

NFPA 101, 2012 Edition Chapter 19. "19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1" " 9.1 Utilities. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface."

Findings include:

Observations made while on tour on June 27, 2023, revealed an open electrical junction box which was above the ceiling tiles in the corridor near MRI door 1FL239. The box was open exposing a large gauge high voltage electrical wire.

During the exit conference on June 27, 2023, the above findings were again acknowledged by the management staff. .







43814

Based on Observation, the facility failed to provide a protective guard on light bulbs located in the 3rd and 4th-floor utility rooms. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage."In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

Findings include:

During a facility tour conducted on June 26-29, 2023 revealed the light bulbs in the utility rooms on the 3rd and 4th floors were exposed with no protective guards on the light bulb.

Employees 5, 6, and 26 confirmed during the exit conference conducted on June 29, 2023, that the facility was missing the protective covers in the utility rooms on the 3rd and 4th floors.

Based on findings from a recent hospital survey the facility failed to comply with NFPA 13 requirements for cubicle curtains in sprinklered areas. Failing to provide NFPA 701 cubicle curtains in sprinklered areas could cause the sprinkler to be blocked from areas of the room and could result in injury or death due to rapid fire spread in the unprotected areas.

NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.3.5.10 * Sprinklers shall not be required in clothes closets of patient sleeping rooms in hospitals where the area of the closet does not exceed 6 ft2 (0.55 m2), provided that the distance from the sprinkler in the patient sleeping room to the back wall of the closet does not exceed the maximum distance permitted by NFPA 13, Standard for the Installation of Sprinkler Systems.
19.3.5.11 * Newly introduced cubicle curtains in sprinklered areas shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition - Chapter 8 Installation Requirements
8.6.5.2.2.1 * In light hazard occupancies, privacy curtains, as shown in Figure 8.6.5.2.2, shall not be considered obstructions where all of the following are met:
(1) The curtains are supported by fabric mesh on ceiling track.
(2) Openings in the mesh are equal to 70 percent or greater.
(3) The mesh extends a minimum of 22 in. (559 mm) down from the ceiling.

Findings include:

Observations while on tour June 26-29. 2023, revealed the patient care areas in the Pre-Ope and PACU areas had curtain cubicles with only 6-inch mesh coverage and other areas in compliance with NFPA 13 requirements.

Employees # 5, 6, and 26 confirmed during the exit conference on June 29th, 2023 the Pre-Ope PACU privacy curtains did not meet the 22-inch mesh requirements.

Based on record review and interview, the facility failed to provide documentation of the annual fire door inspection and drop test in accordance with NFPA 80, 2010 Edition for the rolling door at both campuses. Failing to inspect and test fire rated door assemblies annually could cause harm to the patients and/or staff.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually , and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 Horizontal sliding,Vertically Sliding, and Rolling Doors.
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

Based on record review and interview on June 29, 2023, revealed the following:
1) the facility failed to provide inspection documentation for the rolling doors located in the kitchens of both campuses.

During the exit conference on June 29, 2023, the above findings were again acknowledged by the management staff.

1) Based on observation the facility failed to protect oxygen cylinders from exposure to direct sunlight. Oxygen storage racks at both campuses helipads were not screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.
2) A large amount of oxygen cylinders was seen throughout both campuses in all departments. Failing to protect oxygen cylinders from the elements could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.5. Special Precautions - Storage of Cylinders and Containers. Section 11.6.5.4 Cylinders stored in the open shall be protected as follows: (1) Against extremes of weather and from the ground beneath to prevent rusting (2) During winter, against accumulations of ice or snow (3) During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail. 11.3.2 * Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.
11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. 11.3.2.2
Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.

11.3.2.3
Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour

Findings include:

1) Observations made while on tour on June 26-28, 2023, revealed several E and H oxygen cylinders were being stored in a mesh metal racks at the helipads at both campuses. Temperatures of the oxygen cylinders at the Prescott Valley campus were 104 degrees. Temperatures of the oxygen cylinders at the Prescott campus were 111 degrees.

2) Observations while on tour revealed a large amount of oxygen throughout both campuses. Oxygen cylinders was seen being stored outside metal storage containers, on beds, on wheel chairs and in carry carts. The hospital provided a policy which stated, "If bottles that are taken to designated floors are not used, the bottles will be returned to storage". In the Respiratory Equipment room of the west campus 12 oxygen cylinders were seen in a rack. In the room wax 6 BPAP machines and each of them had 2 oxygen cylinders on them. There was an empty oxygen storage room in the Respiratory Equipment room which was even identified by signage.

During the exit conference conducted on June 29, 2023 the above findings were again acknowledged by the management team. .