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Based on observation the facility failed to provide corridor doors that were positive latching so as to resist the passage of smoke.

Failure on the part of the facility to provide doors that properly latch puts patients, staff and visitors of the facility at risk from the effects of smoke.

Findings include:

1. On 8/24/2010 the surveyor noted that 2 sets of elevator lobby doors near the Progressive Care Unit (PCU) would not securely latch closed when manually released from the hold open position.

2. On 8/24/2010 the surveyor noted that one (1) of the cross corridor doors near SNU room 6A/B would not securely latch closed when manually released from the hold open position. Prior to survey exit door latching errors had been corrected.

The Clinic at Elma

Based on document review and staff interview the hospital failed to perform fire drills at required intervals, by failing to conduct drills at The Clinic at Elma at least annually.

Failure to perform regular fire drills risks inadequate staff response to a fire emergency.

NOTE: Because The Clinic at Elma is located in a Business (B) occupancy, fire drills are required annually rather than once per shift per quarter as would be required in a health care (I) occupancy.

Findings include:

1. During a review of Fire Life Safety documentation on 8/26/2010 the surveyor noted that documentation for fire drills was lacking for The Clinic at Elma. During a discussion with the Director of Plant Services it was learned that an annual drill at the clinic had been missed.

Based on observation the facility failed to provide and maintain an effective fire alarm system in certain areas of the facility.

Failure on the part of the facility to provide and maintain its fire alarm system where required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Background:

NFPA 101 Life Safe Code 2000 Edition, Chapter 6.6.14.2 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. And, Chapter 26.3.3.5 requires that smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings include:

1. On 8/24/2010 the surveyor noted that the "Anesthesia Call Room" located on the 4th floor was made up to serve as a medical staff sleep room without benefit of a smoke alarm being installed as is required. Prior to survey exit an alarm had been installed.

Based on observation the facility failed to provide corridor doors that were positive latching so as to resist the passage of smoke.

Failure on the part of the facility to provide doors that properly latch puts patients, staff and visitors of the facility at risk from the effects of smoke.

Findings include:

1. On 8/24/2010 the surveyor noted that 2 sets of elevator lobby doors near the Progressive Care Unit (PCU) would not securely latch closed when manually released from the hold open position.

2. On 8/24/2010 the surveyor noted that one (1) of the cross corridor doors near SNU room 6A/B would not securely latch closed when manually released from the hold open position. Prior to survey exit door latching errors had been corrected.

The Clinic at Elma

Based on document review and staff interview the hospital failed to perform fire drills at required intervals, by failing to conduct drills at The Clinic at Elma at least annually.

Failure to perform regular fire drills risks inadequate staff response to a fire emergency.

NOTE: Because The Clinic at Elma is located in a Business (B) occupancy, fire drills are required annually rather than once per shift per quarter as would be required in a health care (I) occupancy.

Findings include:

1. During a review of Fire Life Safety documentation on 8/26/2010 the surveyor noted that documentation for fire drills was lacking for The Clinic at Elma. During a discussion with the Director of Plant Services it was learned that an annual drill at the clinic had been missed.

Based on observation the facility failed to provide and maintain an effective fire alarm system in certain areas of the facility.

Failure on the part of the facility to provide and maintain its fire alarm system where required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Background:

NFPA 101 Life Safe Code 2000 Edition, Chapter 6.6.14.2 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. And, Chapter 26.3.3.5 requires that smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings include:

1. On 8/24/2010 the surveyor noted that the "Anesthesia Call Room" located on the 4th floor was made up to serve as a medical staff sleep room without benefit of a smoke alarm being installed as is required. Prior to survey exit an alarm had been installed.