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Based on observation and interview the facility failed to provide self-closing devices on all doors to hazardous areas. This deficient practice affects all occupants in that smoke compartment. The facility census was three.

Findings included:

Observation, during a tour of the facility conducted on the afternoon of 09/09/14 at 2:37 PM, showed the door to the non-sprinkler Soiled Utility room, which opens into the acute patient corridor, was not provided with a self-closure device.

Staff H, Maintenance Manager, confirmed at that time the door to this hazardous area was not provided with a self-closure device.

Section 19.3.2.1 of the National Fire Protection Association (NFPA 101) states: Any hazardous area shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing system shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Based on record review and interview the facility failed to conduct fire drills at various times during the day for each shift. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was three.

Findings included:

Review of the fire drill records for the previous 12 months, conducted on the morning of 09/09/14, showed fire drills for the first shift, 7:00 AM to 7:00 PM, were conducted at the following times:

-12/30/13 at 1415 hours (2:15 PM)
-03/10/14 at 1405 hours (2:05 PM)
-06/27/14 at 1315 hours (1:15 PM)

During an interview on 09/09/14 at 3:16 PM, Staff H, Maintenance Manager, stated these three fire drills had been conducted within the same one hour time frame.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

Based on document review and interview the facility failed to conduct a complete inspection of the sprinkler system on at least a quarterly basis. This deficient practice affects all occupants in the facility. The facility census was three.

Findings included:

Review of the quarterly sprinkler inspection reports, conducted on the morning of 09/09/14, showed the quarterly inspection consisted of visual observations of the valves and sprinkler heads. There was no documentation to indicate the gauges, the outside fire department connections and the availability of the sprinkler wrench and spare sprinkler heads were being reviewed.

During an interview, conducted on 09/09/14 at 3:24 PM, Staff H, Maintenance Manager, confirmed a complete quarterly inspection of the sprinkler system was not being conducted.

National Fire Protection Association manual 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems list prescriptive data for the frequency of inspections.

Based on observation and interview the facility failed to ensure all portable medical gas cylinders were individually secured. This deficient practice affects the operation of the facility. The facility census was three.

Findings included:

Observation during a tour of the facility conducted on the afternoon of 09/09/14 at 1:40 PM, showed 13 "H" size portable medical gas cylinders and five "E" size portable medical gas cylinders located in the medical gas room adjacent to the facility. None of the 18 portable medical gas cylinders were observed to be individually secured.

Staff H, Maintenance Manager, confirmed at that time the 18 portable medical gas cylinders were not individually secured.

srObservation of Emergency Room (ER) #3 on 09/09/14 at 10:30 AM showed an oxygen portable gas cylinder next to the ER wall. The oxygen cylinder was unsecured.

srDuring an interview concurrent with the oxygen cylinder observation, Staff L, Registered Nurse (RN), stated that the oxygen should be in a portable holder and should not be free standing.

srObservation on 09/10/14 at 10:30 AM showed an oxygen cylinder standing unrestrained in ER #3.

srDuring an interview on 09/10/14 at 10:45 AM, Staff A, Chief Executive Officer, stated that the oxygen tank needed to be restrained, and removed the free standing oxygen cylinder.

Section 5.1.3.3.2 of the 2002 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 99) states that locations for the central supply systems and the storage of medical gas shall meet the following requirements: (7) be provided with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling.


15697

Based on interview the facility failed to develop a procedure to implement any time the facility sprinkler system in non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was three.

Findings included:

During an interview, conducted on 09/09/14 at 3:25 PM, Staff H, Maintenance Manager, stated the facility did not have a procedure to implement if the facility sprinkler system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.7.6.2 of the National Fire Protection Association (NFPA 101) states: Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.