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Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to ensure corridors were maintained to resist the passage of smoke. This in the event of fire could allow the migration of smoke, fire and toxic gasses to the exit access corridor which is intended to be maintained safe for evacuation.

The findings include:

The 300 and 400 wing mechanical room double doors had transfer grilles cut and installed into them. Transfer grilles are prohibited in corridor doors.

Based on observations made during tour of the facility, and interviews with the staff on 4/21/10, it was determined the facility failed to maintain the exits readily accessible by utilizing special locking arrangements that are not afforded to this facility.

The findings include:

A 12:20 p.m. interview with the Maintenance Director and the COO revealed the exit door at the end of the newly renovated 100 wing corridor has a magnetic lock. There is a key pad override, and an override button at the nurses' station at the other end of the hall. The magnetic locking arrangement does not disengage upon activation of the Fire Alarm System, of the Automatic Fire Sprinkler System. This constitutes a "Special Locking Arrangement." The interview further revealed The Willough's is not a Baker Act receiving facility, the 100 wing is not a locked unit in any other way.

The population of patients that house the Willough's are receiving treatment for depression and alcohol or drug detoxification. Admission, length of stay, and discharge are 100% voluntary. The clinical needs of the patients do not require specialized security measures therefore the exception allowing "Special Locking Arrangements" is not applicable to this facility and the magnetic door lock must disengage upon activation of the Fire Alarm System or fire Sprinkler System.

Based on a review of the facility records and interview with the staff on 4/21/10, it was determined the facility failed to ensure the emergency lighting was tested as required. This could delay or deny safe exiting from the facility in an emergency.

The findings include:

There was no documentation at the time of the survey to show the emergency lights were being tested for 30 seconds once a month. The Maintenance Director stated he was not performing these tests.

Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to ensure the fire alarm system was maintained in reliable operating condition. This could delay or deny the required early warning of fire in the building.

The findings include:

The fire alarm control panel was observed to be in trouble mode. The indicated trouble alarm was a smoke detector in the 400 wing. When asked, the Maintenance Director stated the trouble signal was on for 8 days, after surveyor intervention the COO called the fire alarm contractor, which revealed service was not available until outstanding billing balance was resolved. The COO spoke with the contractor and the hospital billing department. The issues were remedied and a service technician responded to the service request.

Based on a review of the facility records and interview with the staff on 4/21/10, it was determined the facility failed to ensure the automatic fire sprinkler system was tested as frequently as required. A lack of mandatory testing at the prescribed intervals renders the equipment unreliable and in the event of fire could delay or deny extinguishment.

The findings include:

There was no documentation to show the automatic fire sprinkler system 5 year items had been inspected and or tested. The Maintenance Director stated he was not aware of this requirement. The fire alarm contractor stated on the phone a quote for this inspection was presented to the facility in March of 2010, but no authorization was given to perform the work.

Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to maintain the heating, ventilating, and air conditioning system in reliable operating condition.

The findings include:

The air conditioning supply vents over the cafeteria tray line, over the ice machine, and by the steamer were observed to be condensating and dripping.

Based on a review of the facility records and interview with the staff on 4/21/10, it was determined the facility failed to maintain the commercial cooking equipment in reliable operating safe condition.

The findings include:

There was no documentation at the time of the survey to show the commercial hood system was cleaned in the last six months. The staff stated they do not presently have this done by a contractor, the Maintenance Director states he cleans the hood. The last documented cleaning by a contractor was dated 6/19/08.

Interview with the contractor by phone revealed the facility had a non-payment history and they would only provide service COD. The COO then authorized the work to be done.

Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to ensure the exit access corridors were clear and unobstructed at all times, to full instant use in case of fire or other emergency. This in the event of fire or any reason to evacuate from a portion of the facility to another section or outside for an area of refuge may be delayed or denied as a result of exit corridor obstruction.

The findings include:

Two emergency eye wash stations were installed in the 400 wing corridor. These stations projected into the corridor approximately one foot, exceeding the 3 1/2 inch allowance.

Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to ensure non-medical flammable medical gas is handled and stored in accordance with NFPA 99. Unsecured oxygen cylinders have the potential if knocked over can rupture at the neck of the cylinder causing a super oxygen enriched atmosphere, increasing the flammability of all surrounding building contents, and the cylinder itself becoming projectile endangering all building occupants.

The findings include:

Three unsecured e-tank oxygen cylinders were observed in the 100 wing medication room. Two more were observed in the 200 wing medication room.

Based on a review of the facility records and interview with the staff on 4/21/10, it was determined the facility failed to train all staff in disaster preparedness. The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise potential for negative outcomes to the patients and staff, and other building occupants.

The findings include:

1. The documentation presented to show the facility had conducted internal disaster drill in the last twelve months revealed the 6/17/09 bomb threat scenario had sign in sheets to indicate 47 of the 150 staff members were active participants in the disaster scenario exercise.

2. The documentation presented to show the facility had conducted external disaster drill in the last twelve months revealed the 12/23/09 tornado scenario had sign in sheets to indicate only 63 of the 150 staff members were active participants in the disaster scenario exercise.

1. Based on a review of the facility records and interview with the staff during the Fire Life Safety survey on 4/21/10, it was determined the facility failed to ensure all patient care medical equipment was tested as frequently as required. Patient care equipment not tested as frequently as required renders the equipment unreliable, and undetected faulty equipment could cause electrical shock to both resident and staff utilizing the equipment, and in the case of therapy equipment could cause improper current flow or heat penetration leading to tissue and muscle injury.

The findings include:

There was no documentation at the time of the survey to show the patient care medical equipment was tested as required. The Maintenance Director was unaware of any contract service or any testing of the equipment being tested. One ultrasound, 3 electronic muscle stimulators, and 1 EKG were not stickered, indicating testing.


2. Based on a review of the facility records, and interview with the staff during the Fire Life Safety survey on 4/21/10, it was determined the facility failed to ensure that all essential electrical equipment was tested as frequently as required. Essential electrical equipment not tested as frequently as required renders the equipment unreliable, and undetected faulty equipment could cause the safety features of the equipment to fail.

The findings include:

A. There was no documentation at the time of the survey to show the main & feeder circuit breakers were exercised annually as required. The Maintenance Director was unaware of the requirement and stated this was not performed.

B. There was no documentation at the time of the survey to show the electrical receptacles were tested as required. The Maintenance Director was unaware of the requirement and stated that this testing was not performed.

Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to ensure corridors were maintained to resist the passage of smoke. This in the event of fire could allow the migration of smoke, fire and toxic gasses to the exit access corridor which is intended to be maintained safe for evacuation.

The findings include:

The 300 and 400 wing mechanical room double doors had transfer grilles cut and installed into them. Transfer grilles are prohibited in corridor doors.

Based on observations made during tour of the facility, and interviews with the staff on 4/21/10, it was determined the facility failed to maintain the exits readily accessible by utilizing special locking arrangements that are not afforded to this facility.

The findings include:

A 12:20 p.m. interview with the Maintenance Director and the COO revealed the exit door at the end of the newly renovated 100 wing corridor has a magnetic lock. There is a key pad override, and an override button at the nurses' station at the other end of the hall. The magnetic locking arrangement does not disengage upon activation of the Fire Alarm System, of the Automatic Fire Sprinkler System. This constitutes a "Special Locking Arrangement." The interview further revealed The Willough's is not a Baker Act receiving facility, the 100 wing is not a locked unit in any other way.

The population of patients that house the Willough's are receiving treatment for depression and alcohol or drug detoxification. Admission, length of stay, and discharge are 100% voluntary. The clinical needs of the patients do not require specialized security measures therefore the exception allowing "Special Locking Arrangements" is not applicable to this facility and the magnetic door lock must disengage upon activation of the Fire Alarm System or fire Sprinkler System.

Based on a review of the facility records and interview with the staff on 4/21/10, it was determined the facility failed to ensure the emergency lighting was tested as required. This could delay or deny safe exiting from the facility in an emergency.

The findings include:

There was no documentation at the time of the survey to show the emergency lights were being tested for 30 seconds once a month. The Maintenance Director stated he was not performing these tests.

Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to ensure the fire alarm system was maintained in reliable operating condition. This could delay or deny the required early warning of fire in the building.

The findings include:

The fire alarm control panel was observed to be in trouble mode. The indicated trouble alarm was a smoke detector in the 400 wing. When asked, the Maintenance Director stated the trouble signal was on for 8 days, after surveyor intervention the COO called the fire alarm contractor, which revealed service was not available until outstanding billing balance was resolved. The COO spoke with the contractor and the hospital billing department. The issues were remedied and a service technician responded to the service request.

Based on a review of the facility records and interview with the staff on 4/21/10, it was determined the facility failed to ensure the automatic fire sprinkler system was tested as frequently as required. A lack of mandatory testing at the prescribed intervals renders the equipment unreliable and in the event of fire could delay or deny extinguishment.

The findings include:

There was no documentation to show the automatic fire sprinkler system 5 year items had been inspected and or tested. The Maintenance Director stated he was not aware of this requirement. The fire alarm contractor stated on the phone a quote for this inspection was presented to the facility in March of 2010, but no authorization was given to perform the work.

Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to maintain the heating, ventilating, and air conditioning system in reliable operating condition.

The findings include:

The air conditioning supply vents over the cafeteria tray line, over the ice machine, and by the steamer were observed to be condensating and dripping.

Based on a review of the facility records and interview with the staff on 4/21/10, it was determined the facility failed to maintain the commercial cooking equipment in reliable operating safe condition.

The findings include:

There was no documentation at the time of the survey to show the commercial hood system was cleaned in the last six months. The staff stated they do not presently have this done by a contractor, the Maintenance Director states he cleans the hood. The last documented cleaning by a contractor was dated 6/19/08.

Interview with the contractor by phone revealed the facility had a non-payment history and they would only provide service COD. The COO then authorized the work to be done.

Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to ensure the exit access corridors were clear and unobstructed at all times, to full instant use in case of fire or other emergency. This in the event of fire or any reason to evacuate from a portion of the facility to another section or outside for an area of refuge may be delayed or denied as a result of exit corridor obstruction.

The findings include:

Two emergency eye wash stations were installed in the 400 wing corridor. These stations projected into the corridor approximately one foot, exceeding the 3 1/2 inch allowance.

Based on observations made during tour of the facility on 4/21/10, it was determined the facility failed to ensure non-medical flammable medical gas is handled and stored in accordance with NFPA 99. Unsecured oxygen cylinders have the potential if knocked over can rupture at the neck of the cylinder causing a super oxygen enriched atmosphere, increasing the flammability of all surrounding building contents, and the cylinder itself becoming projectile endangering all building occupants.

The findings include:

Three unsecured e-tank oxygen cylinders were observed in the 100 wing medication room. Two more were observed in the 200 wing medication room.

Based on a review of the facility records and interview with the staff on 4/21/10, it was determined the facility failed to train all staff in disaster preparedness. The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise potential for negative outcomes to the patients and staff, and other building occupants.

The findings include:

1. The documentation presented to show the facility had conducted internal disaster drill in the last twelve months revealed the 6/17/09 bomb threat scenario had sign in sheets to indicate 47 of the 150 staff members were active participants in the disaster scenario exercise.

2. The documentation presented to show the facility had conducted external disaster drill in the last twelve months revealed the 12/23/09 tornado scenario had sign in sheets to indicate only 63 of the 150 staff members were active participants in the disaster scenario exercise.

1. Based on a review of the facility records and interview with the staff during the Fire Life Safety survey on 4/21/10, it was determined the facility failed to ensure all patient care medical equipment was tested as frequently as required. Patient care equipment not tested as frequently as required renders the equipment unreliable, and undetected faulty equipment could cause electrical shock to both resident and staff utilizing the equipment, and in the case of therapy equipment could cause improper current flow or heat penetration leading to tissue and muscle injury.

The findings include:

There was no documentation at the time of the survey to show the patient care medical equipment was tested as required. The Maintenance Director was unaware of any contract service or any testing of the equipment being tested. One ultrasound, 3 electronic muscle stimulators, and 1 EKG were not stickered, indicating testing.


2. Based on a review of the facility records, and interview with the staff during the Fire Life Safety survey on 4/21/10, it was determined the facility failed to ensure that all essential electrical equipment was tested as frequently as required. Essential electrical equipment not tested as frequently as required renders the equipment unreliable, and undetected faulty equipment could cause the safety features of the equipment to fail.

The findings include:

A. There was no documentation at the time of the survey to show the main & feeder circuit breakers were exercised annually as required. The Maintenance Director was unaware of the requirement and stated this was not performed.

B. There was no documentation at the time of the survey to show the electrical receptacles were tested as required. The Maintenance Director was unaware of the requirement and stated that this testing was not performed.