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Based on observation during the life safety survey completed on 12/14/2011, the hospital did not provide hazardous area separation in accordance with CMS requirements. 19.3.2.1

Findings:

1. The housekeeping dry storage room door did not close to positive latch when allowed to self-close.

2. The soiled linen holding room in the ICU area is lacking a 45 minute rated fire door as required.

These observations were made in the presence of the interim Director of Plant Operations.

Based on observation during the life safety survey completed on 12/14/2011, the hospital did not provide unimpeded egress from all areas of the hospital as required.

Findings:

Hook latch dead bolts installed on two sets of ER area power sliding doors would not allow the break-away egress function of the doors in the event of a loss of power or malfunction of the doors. 19.2.1

These observations were made in the presence of the interim Director of Plant Operations.

Based on a review of fire drill documentation during the life safety survey completed on 12/14/2011, the hospital did not conduct fir drills at one per quarter per shift as required. 19.7.1.2

Findings:

There was no documentation to verify that a fire drill was conducted during the months of July through September on the 2nd shift.

Based on observation during the life safety survey completed on 12/14/2011, the hospital did not provide integrated smoke detection at all required locations per CMS requirements. 19.3.4, 9.6

Findings:

The auxiliary fire panel located in the OB medical equipment room was not protected by an integrated smoke detector.

This observation was made in the presence of the interim Director of Plant Operations.

Based on observation during the life safety survey completed on 12/14/2011, the hospital did not maintain electrical equipment and flexible power cords in accordance with NFPA 70, The National Electrical Code. 9.1.2

Findings:

1. Extension cords were observed in use in the doctor's sleep room and in the medical records area.

2. An electrical power cord was observed to be installed ina manner where it could be subject to damage as the cord in use extending through a doorway of the purchasing office area.

These observations were made in the presence of the interim Director of Plant Operations.

Based on observation during the life safety survey completed on 12/14/2011, the hospital did not maintain elevator control rooms to be free from combustible storage as required. 19.5.3

Findings:

The purchasing area elevator control room was observed to contain oily hydraulic rags and 4 wood 8' foot long 4"x 4" posts.

This observation was made in the presence of the interim Director of Plant Operations.

Based on observation during the life safety survey completed on 12/14/2011, the hospital did not install Alcohol Based Hand Rub (ABHR) dispensers in accordance with CMS regulations.

Findings:

Two ABHR dispensers were observed to be installed directly over electrical outlets in the OR area. The dispensers were removed immediately during survey.

This observation was made in the presence of the Interim Director of Plant Operations.

Based on observation during the life safety survey completed on 12/14/2011, the hospital did not provide hazardous area separation in accordance with CMS requirements. 19.3.2.1

Findings:

1. The housekeeping dry storage room door did not close to positive latch when allowed to self-close.

2. The soiled linen holding room in the ICU area is lacking a 45 minute rated fire door as required.

These observations were made in the presence of the interim Director of Plant Operations.

Based on observation during the life safety survey completed on 12/14/2011, the hospital did not provide unimpeded egress from all areas of the hospital as required.

Findings:

Hook latch dead bolts installed on two sets of ER area power sliding doors would not allow the break-away egress function of the doors in the event of a loss of power or malfunction of the doors. 19.2.1

These observations were made in the presence of the interim Director of Plant Operations.

Based on a review of fire drill documentation during the life safety survey completed on 12/14/2011, the hospital did not conduct fir drills at one per quarter per shift as required. 19.7.1.2

Findings:

There was no documentation to verify that a fire drill was conducted during the months of July through September on the 2nd shift.

Based on observation during the life safety survey completed on 12/14/2011, the hospital did not provide integrated smoke detection at all required locations per CMS requirements. 19.3.4, 9.6

Findings:

The auxiliary fire panel located in the OB medical equipment room was not protected by an integrated smoke detector.

This observation was made in the presence of the interim Director of Plant Operations.

Based on observation during the life safety survey completed on 12/14/2011, the hospital did not maintain electrical equipment and flexible power cords in accordance with NFPA 70, The National Electrical Code. 9.1.2

Findings:

1. Extension cords were observed in use in the doctor's sleep room and in the medical records area.

2. An electrical power cord was observed to be installed ina manner where it could be subject to damage as the cord in use extending through a doorway of the purchasing office area.

These observations were made in the presence of the interim Director of Plant Operations.