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Based on tests and observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in the triage room and medication preparation rooms as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour on 2/10/10 and 2/11/10 from 8:00 am till 4:00 pm in the following areas:
a. Within the triage room of the hospitals' emergency room.
b. Medication preparation rooms throughout the hospital.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).
(On 2/10/10 and 2/11/10 the facility mounted various EBOLs that were identified during the observational tour).

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that smoke detectors are available in required areas such as maintenance closets, smoke detectors are too close to air vents and there is a lack of fire alarm system documentation in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed on 2/10/10 and 2/11/10 from 8:00 am till 4:00 pm with the Physical Plant Manager:
a. All maintenance closets with cleaning chemicals and solutions.
b. All areas where personnel have microwaves, coffee makers and refrigerators.
(On 2/11/10 the facility's fire alarm company was installing the smoke detectors that were identified during the observational tour and they were also arranging the fire alarm to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade).

2. The smoke detectors located on the ceiling on the third floor near the nursing station, in the operating department and intensive care unit were found on 2/10/10 and 2/11/10 from 8:00 am till 4:00 pm with the Physical Plant Manager located within one foot from ceiling air vents; due to the air flow from these vents at least three feet is needed.

3. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 2/11/10 at 1:20 pm, however no evidence was found of the following:
a. A detailed description of tests performed and readings.
b. Smoke detector sensitivity tests.
c. Installation documentation.

Based on tests and observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides emergency illumination is placed above the electrical generator as required by NFPA 70 Section 9.1.2.

Findings include:

An emergency battery operated lamp (EBOL) is needed above the electrical generator as observed on 2/11/10 at 10:30 am to provide illumination in the event that there is a power failure at night and the electrical generator has mechanical trouble and does not start automatically. The emergency lamp will provide illumination for personnel to work on the generator to get it started.

Based on observations during the survey for Life safety from fire with the facility's Physical Plant Manager, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to a ground fault receptacle, sprinkler system and evacuation plans.

Findings include:

1. The area across from the nursing station on the third floor where the ice maker is located was observed on 2/10/10 at 1:20 pm with the Physical Plant Manager. A regular receptacle is located next to a water source and a ground fault receptacle is needed in the event of water contact.

2. Review of documentation and observations of the sprinkler system on 2/10/10 at 11:00 am and on 2/11/10 at 1:30 pm the following was determined related with NFPA 13 for the hospital with the Physical Plant Manager:
a. No evidence was found that the facility has spare sprinklers (at least six), a sprinkler wrench or a cabinet to place them in.
b. No evidence was provided of sprinkler installation documentation.
c. No evidence was found of weekly no-flow tests of the fire pump.

3. The evacuation plans observed on 2/10/10 and 2/11/10 from 8:00 am till 4:00 pm must show the most direct exit route (with an alternate route) from a point of reference (you are here) and the arrows, location of exit doors and other symbols shall be big enough too see with ease, read and follow.

Based on tests and observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in the triage room and medication preparation rooms as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour on 2/10/10 and 2/11/10 from 8:00 am till 4:00 pm in the following areas:
a. Within the triage room of the hospitals' emergency room.
b. Medication preparation rooms throughout the hospital.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).
(On 2/10/10 and 2/11/10 the facility mounted various EBOLs that were identified during the observational tour).

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that smoke detectors are available in required areas such as maintenance closets, smoke detectors are too close to air vents and there is a lack of fire alarm system documentation in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed on 2/10/10 and 2/11/10 from 8:00 am till 4:00 pm with the Physical Plant Manager:
a. All maintenance closets with cleaning chemicals and solutions.
b. All areas where personnel have microwaves, coffee makers and refrigerators.
(On 2/11/10 the facility's fire alarm company was installing the smoke detectors that were identified during the observational tour and they were also arranging the fire alarm to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade).

2. The smoke detectors located on the ceiling on the third floor near the nursing station, in the operating department and intensive care unit were found on 2/10/10 and 2/11/10 from 8:00 am till 4:00 pm with the Physical Plant Manager located within one foot from ceiling air vents; due to the air flow from these vents at least three feet is needed.

3. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 2/11/10 at 1:20 pm, however no evidence was found of the following:
a. A detailed description of tests performed and readings.
b. Smoke detector sensitivity tests.
c. Installation documentation.

Based on tests and observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides emergency illumination is placed above the electrical generator as required by NFPA 70 Section 9.1.2.

Findings include:

An emergency battery operated lamp (EBOL) is needed above the electrical generator as observed on 2/11/10 at 10:30 am to provide illumination in the event that there is a power failure at night and the electrical generator has mechanical trouble and does not start automatically. The emergency lamp will provide illumination for personnel to work on the generator to get it started.

Based on observations during the survey for Life safety from fire with the facility's Physical Plant Manager, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to a ground fault receptacle, sprinkler system and evacuation plans.

Findings include:

1. The area across from the nursing station on the third floor where the ice maker is located was observed on 2/10/10 at 1:20 pm with the Physical Plant Manager. A regular receptacle is located next to a water source and a ground fault receptacle is needed in the event of water contact.

2. Review of documentation and observations of the sprinkler system on 2/10/10 at 11:00 am and on 2/11/10 at 1:30 pm the following was determined related with NFPA 13 for the hospital with the Physical Plant Manager:
a. No evidence was found that the facility has spare sprinklers (at least six), a sprinkler wrench or a cabinet to place them in.
b. No evidence was provided of sprinkler installation documentation.
c. No evidence was found of weekly no-flow tests of the fire pump.

3. The evacuation plans observed on 2/10/10 and 2/11/10 from 8:00 am till 4:00 pm must show the most direct exit route (with an alternate route) from a point of reference (you are here) and the arrows, location of exit doors and other symbols shall be big enough too see with ease, read and follow.