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Based on record review and interview, the facility failed to ensure 4 of 4 third shift fire drills were held at varying times over the past year to protect 22 of 22 patients. This deficient practice could affect all patients in the facility.

Findings include:

Based on a review of the Monthly Fire Drill Reports with the director of engineering on 10/13/11 at 7:40 a.m., the Monthly Fire Drill Reports for third shift were held at the following similar times; 02/25/11 at 12:00 a.m., 05/31/11 at 11:00 p.m., 08/30/11 at 11:45 p.m., and 12/31/10 at 12:50 a.m. Based on an interview with the director of engineering on 10/13/11 at 8:00 a.m., the third shift starts at 11:00 p.m. and ends at 7:00 a.m. The similar times for the fire drills held on third shift were acknowledged by the director of engineering during the record review at 7:40 a.m. on 10/13/11.

Based on observation and interview, the facility failed to ensure 7 of 52 smoke detectors were not located where airflow could prevent the operation of the detector. LSC 9.6.1.3 says the provisions of 9.6 cover the basic functions of a fire alarm system and 9.6.1.4 refers to NFPA 72. NFPA 72, 2-3.5.1 requires, in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect all patients on the Medical Surgery Hall and all patients using the dining room located near the gift shop in the Central Hall.

Findings include:

Based on observations on 10/13/11 during a tour of the facility from 7:50 a.m. to 11:50 a.m. with the director of engineering, the Service Hall smoke detector near the communication room, the Medical Surgery Hall smoke detector by room 1019, the Medical Surgery Hall smoke detector by the soiled linen room, the Kitchen Hall smoke detector by the gift shop, the Central Hall smoke detector by the laboratory, the Central Hall smoke detector by the smoke barrier doors, and the Central Hall smoke detector by the ultrasound room were each located within the airflow of the adjacent air supply ducts. This was verified by the director of engineering at the time of observations.

Based on record review and interview, the facility failed to ensure 4 of 4 third shift fire drills were held at varying times over the past year to protect 22 of 22 patients. This deficient practice could affect all patients in the facility.

Findings include:

Based on a review of the Monthly Fire Drill Reports with the director of engineering on 10/13/11 at 7:40 a.m., the Monthly Fire Drill Reports for third shift were held at the following similar times; 02/25/11 at 12:00 a.m., 05/31/11 at 11:00 p.m., 08/30/11 at 11:45 p.m., and 12/31/10 at 12:50 a.m. Based on an interview with the director of engineering on 10/13/11 at 8:00 a.m., the third shift starts at 11:00 p.m. and ends at 7:00 a.m. The similar times for the fire drills held on third shift were acknowledged by the director of engineering during the record review at 7:40 a.m. on 10/13/11.

Based on observation and interview, the facility failed to ensure 7 of 52 smoke detectors were not located where airflow could prevent the operation of the detector. LSC 9.6.1.3 says the provisions of 9.6 cover the basic functions of a fire alarm system and 9.6.1.4 refers to NFPA 72. NFPA 72, 2-3.5.1 requires, in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect all patients on the Medical Surgery Hall and all patients using the dining room located near the gift shop in the Central Hall.

Findings include:

Based on observations on 10/13/11 during a tour of the facility from 7:50 a.m. to 11:50 a.m. with the director of engineering, the Service Hall smoke detector near the communication room, the Medical Surgery Hall smoke detector by room 1019, the Medical Surgery Hall smoke detector by the soiled linen room, the Kitchen Hall smoke detector by the gift shop, the Central Hall smoke detector by the laboratory, the Central Hall smoke detector by the smoke barrier doors, and the Central Hall smoke detector by the ultrasound room were each located within the airflow of the adjacent air supply ducts. This was verified by the director of engineering at the time of observations.