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Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 11/1/2011 the surveyor noted penetrations in the walls or ceilings of the following locations:
a) Penetrations of the fire wall by the laboratory caused by conduit;
b) Penetrations of the fire wall above double doors by X-ray room 1 caused by conduit and cabling;
c) Penetrations of the fire wall above fire doors by the pharmacy and environmental services; and
d) Penetrations of the fire wall separating the corridor and boiler room.

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Findings include:

1. On 11/1/2011 the surveyor noted the the self closure device on the door to the bone density room had been removed.

Based on observation the facility failed to maintain a required exit door in the manner prescribed by code. More specifically, the facility failed to provide proper signage at an exit door having a delayed egress locking system.

Failure to provide appropriate signage at a delayed egress door puts patients staff and visitors of the facility at risk if the means of egress is required in an emergency.

Reference: Life Safety Code, NFPA 101 2000 edition; Chapters 7.2.2.6.1 and 19.2.2.2

Findings include:

1. On 11/2/2011 the surveyor noted that the exit door located in the Medical/Surgical unit had signage that reads: "Emergency Exit Only - The alarm will sound if the door is open". Code requires signage adjacent to the release mechanism that states: "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS".

2. Staff indicated that the door was provided with a delayed egress locking mechanism that would unlock after the delay period which was started by depressing the releasing mechanism.

Based on record review and interview the facility failed to provide a written plan for the protection of all patients and their evacuation in the event of an emergency.

Failure on the part of the facilty to provide a written evacuation plan puts patients, staff and visitors of the facility at risk of injury or death in the event of an emergency requiring full evacuation.

Findings include:

1. On 11/1/2011 while reviewing available documentation (disaster plan) in was noted by the surveyor that the plan lacked a procedure for full evacuation of the facility.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25 and Chapter 19.3.5 NFPA 101 Life Safety Code 2000 edition.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 11/1/2011 the surveyor noted the following:

a) A missing escutcheon at the emergency department reception/waiting area;
b) Sprinkler riser room not properly labeled (interior and exterior doors to area);
c) Lack of sprinkler coverage in the facility's boiler room;
d) Sprinkler obstruction by shower curtains in rooms 135, 136, 137; and 139;
e) A missing escutcheon in the medication room of the family birthing center; and
f) Sprinkler head recessed in the ceiling panel.

Based on observation the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Reference:

NFPA 101, Life Safety Code, 2000 edition; Section 19.3.5.6 states: "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1".

NFPA 101, Life Safety Code, 2000 edition; Section 9.7.4.1 states: "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".

Findings include:

1. On 11/1/2011 the surveyor noted that the "Upper Boiler Room" was not provided with a potable fire extinguisher.

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 11/2/2011 the surveyor noted a portable space heating device having a heating element that would exceed 212 degrees F. that was located in the admitting office.

Based on observation the facility failed to maintain designated means of egress free of impediments to full instant use in the case of fire or other emergency.

Failure on the part of the facility to keep the means of egress free of impediments puts patients, staff and visitors of the facility at risk in the event of fire or other emergency.

Findings include:

1. On 11/1/2011 the surveyor noted that the exit door at Receiving (by compactor) was partially blocked by a cart that prevented it from swinging to the full open position. It was also noted that the exit corridor leading to the afore mentioned door was partially blocked by another cart and miscellaneous items.

Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99; and

Failure on the part of the facility to properly secure compressed gas cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death.

Findings include:

1. On 11/1/2011 the surveyor noted that a bank of nitrous oxide cylinders were not properly secured. Cylinders were connected to the header but were not held in place with the chain restraining system.

2. Medical gas storage room containing oxygen "E" cylinders lacked proper signage on the storage room door.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 11/1/2011 the surveyor noted the following:

a) A copying machine was plugged into a power strip that was daisy chained with a second power strip.
b) An power outlet box was serving as an extension cord in the bacteriology area of the laboratory.
c) A multi-plug adaptor was serving a water cooler in the emergency department medication room.
d) An electrical junction (J) box located in the overhead above the ceiling tile at the fire wall (double doors) by X-ray room number 1 was missing a cover plate.
e) The electrical room service entrance door lack appropriate signage.