John W. Adkisson | The Roanoke Times

Eddie Hartman works inside an isolation chamber to cap off a sprinkler head at Carilion Roanoke Memorial Hospital as part of an effort to correct violations found during a life safety code and fire inspection at the Roanoke hospital.

A three-month inspection revealed Carilion Roanoke Memorial Hospital had failed to comply with multiple aspects of the fire code, putting staff and patients in potential danger.

In a 351-page report, state inspectors documented approximately 1,500 instances where fire safety regulations were not properly followed. Violations were found on every floor of the Roanoke Valley's largest hospital, including in patient rooms, hallways, nurses' stations, mechanical rooms, offices, closets, laboratories and stairwells.

Problems involving the sprinkler system, smoke detectors, fire extinguishers and fire alarm system were all discovered. In several instances emergency exit signs were missing, blocked or did not lead to a proper exit.

Carilion Clinic officials said patients and staff inside the hospital are -- and have been -- safe.

Carilion officials also said they have already fixed most of the problems and have implemented several new policies to ensure the fire code is better adhered to in the future.

"This was a challenge," said N.L. Bishop, vice president of facilities for Carilion. "We decided to seize this and turn it into an opportunity for improvement."

Carilion already has spent about $750,000 since the inspection began to fix problems that have been identified and anticipates spending more than $1 million total by the time everything is corrected, said John Morris, director of engineering for Carilion.

The state fire marshal's office inspected Roanoke Memorial between Nov. 2 and Jan. 21 on behalf of the Centers for Medicare & Medicaid Services as part of an extensive process to bring the hospital back in full compliance with federal accreditation standards.

The inspection report, obtained through the Freedom of Information Act, was sent to Carilion on March 30. It is only the first phase of a multibuilding life safety code inspection that Carilion must undergo for all its Roanoke buildings that fall under the name Carilion Medical Center.

Life safety code inspections of this magnitude are rare. In addition to conducting an inspection when a hospital has fallen out of compliance with CMS, inspections are also done by a random sampling throughout the country, when there is a complaint, and when a hospital first applies to receive government reimbursements.

The Joint Commission, which accredits hospitals, also checks for violations of the fire and life safety code during its inspection of hospitals about every three years. Carilion just was accredited by the commission in March. Those inspections, however, are much shorter, lasting a few days, and look at compliance with medical rules and fire code.

Among the buildings still to be inspected is the former Roanoke Community Hospital and more than 20 outpatient office buildings. Details about how and when those inspections will be conducted are still being worked out, said Greg Stolcis, director of the acute care division for the Virginia Department of Health's Office of Licensure and Certification.

While the problems must be fixed, the violations did not rise to a level where immediate intervention had to happen to ensure the safety of the hospital occupants.

"If CMS had grave concerns about the safety of the hospital they would have taken much more extreme measures," Stolcis said. "Is it a safe place to go for procedure? Yeah. Is it up to the standards of the life safety code? No. There is a huge report that proves that."

Other violations are expected as the additional buildings are inspected, said Ronald Reynolds, chief deputy for the state fire marshal's office in the cover letter sent to Carilion CEO Dr. Ed Murphy with the report.

Reynolds was not available for comment, said Mark Buff, a spokesman for the fire marshal. Additionally, Buff would not comment on the report.

"Since CMS is really the guiding authority on this inspection it is not appropriate to comment on the seriousness of the violations," he said.

CMS spokeswoman Lorraine Ryan said she could not comment on an ongoing investigation.

The hospital has been under CMS scrutiny since July 25, 2008, when a woman hanged herself with a cord from a medical device in the hospital's emergency room.

After the suicide, Carilion was told it had lost its "deemed status" with the agency, putting the hospital in jeopardy of losing government reimbursements for Medicare and Medicaid patients. In order for the status to be restored Carilion has to undergo a medical facility inspection and a fire inspection.

"This one is unprecedented in terms of size, scope and level of deficiencies found," Stolcis said, noting that it is extremely rare for a hospital to lose its deemed status.

While problems related to the suicide have been corrected, Carilion will not be able to regain its deemed status until the fire inspections are completed and the violations are corrected.

Carilion is required to respond with a plan of correction addressing how it will come into compliance with the code for each violation. While Carilion has sent in its plan, the federal government is reviewing the response to see if it is adequate, so a copy of Carilion's response is not yet publicly available.

Carilion's response

Carilion knew the inspection was coming and figured there were going to be violations.

Two weeks before inspectors from the fire marshal's office showed up, the engineering staff started fixing problems they thought would come up, Morris said.

Morris also decided that the inspection offered an opportunity for his staff of about 50 people who work in Roanoke Memorial to learn something about the code. He sent members of his team with inspectors so they could learn firsthand what was wrong.

Morris also gave tape recorders to the inspectors and asked them to describe violations on the record. When the recorder was played back there were about 2,200 problems that were vocalized.

Of those, 98 percent have now been corrected, Morris said.

"We did a work order to address every single comment that was recorded," Morris said. "Rather than just deal with the report, we decided to go a little bit further. It was the right thing to do."

Many of the violations stem from a few overarching issues, Morris said. First the hospital, which totals about 2 million square feet, has gone through numerous renovations with parts of the building dating to 1928, 1954, 1971, 1993, 2003 and 2007.

The various ages of the building have brought about some confusion with the report. For instance, the report says it is a violation that the entire building does not have a sprinkler system. Morris said his understanding is that by law some of the older parts of the building don't require a sprinkler system.

"I've never had anything that told me we have to sprinkle the full building," he said. "If CMS comes back and says we have to sprinkle everywhere, we will."

Additionally, as the hospital has added an electronic medical record system and other technology, wires have been placed throughout the walls, and sometimes weren't properly installed.

"We are one of the most wired hospitals in the country right now and when you do wiring the contractors may or may not know about the standards that have to be met," Morris said.

Among the most common violations were areas where a designated fire wall was not properly sealed or fireproofed. Frequently those violations stemmed from issues related to wiring, Morris said.

To prevent violations in the future, Carilion has established a new program that allows it to better oversee and scrutinize all the contracted work that is being done in the building.

Another common violation detailed specific instances where wiring or construction material was not properly fireproofed. Some are minor, such as a hole in the wall that needs patching. Other violations included incomplete work when new wires were installed.

Another frequent violation included not having a written copy of the hospital's plan of protection for evacuating patients in an emergency. The plan must be available on paper and posted in a prominent place in the hospital and available on request. Inspectors asked at nurses' stations on every floor of the building for the plan and were told it was available online.

Carilion also changed how it conducts fire drills after inspectors said the hospital wasn't following established guidelines or properly documenting the drills.

Carilion had not been sounding the alarm when testing the system. Now, to follow the rules, Carilion does sound the alarm in most places. Carilion did get exemptions for sounding the alarm in areas where the noise could pose a threat to patients, such as operating rooms and the neonatal intensive care unit.