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Based on observation during tour and staff verification it was determined this facility failed to ensure all exit directional signs were displayed in areas which were obvious to staff and patrons to provide concise directions for exiting the premises in the event of an emergency. This had the potential to affect all those utilizing these areas of the facility. The patient census was 145 the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the basement and within the information systems room, observation was made of an exit directional sign which directed egress flow down two steps and directly into an office. Within the office observation was made of another door which lacked an exit sign. This writer questioned staff F if the door located in the office was part of the exit egress and staff F acknowledged it was.

Within the corridor of the wound burn unit observation was made of exit access on each end, although from the east end facing west any staff or patient was not able to view the far west exit sign due to an existing door header from which the door had been removed.

These findings were verified by staff F and G during tour of this area of the facility.

21957

Based on facility tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one half hour fire resistance rating. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 145.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the first and third floors observation was made of several penetrations above the ceiling tiles in the following locations:

First floor:

*At the east end of the corridor separating the care management department from the therapy department and above the double doors and ceiling tiles, observation was made of a corrugated steel deck which lacked a fire sealant within each of the corrugations where it meets with the top of the drywall. This area was approximately four feet in length and was observed not to be sealed on either side of the doors.
*At the south end of the patient towers building and within the hazard room, observation was made of one unsealed water line at each end where it penetrated the drywall. One open end curved conduit and one green flex conduit that was not sealed around the annular space of the conduit where it penetrated the drywall.
*Within the material management conference room, observation was made of one unsealed conduit around the annular space on either side of the drywall.
*Within the northwest corridor and above the smoke barrier doors of the patient tower building, observation was made of an approximate half inch square opening in the drywall which had a wire passing through.
*Within the northeast corridor and above the smoke barrier doors of the patient tower building, observation was made of a half inch open end conduit and an approximate three inch opening in the drywall which had a pipe passing through.
*Within the gift shop and about midway of the east smoke barrier, observation was made of an approximate one inch round hole in the drywall.
*To the left at the main entrance facing toward the north corridor, observation was made of a fire rated accordion door, also know as a wan door. Observation was made of several wheelchairs located along the wall adjacent to the wan door. This writer requested from staff G to key activate the door to observe how well it sealed within the frame. Staff G had to remove a wheelchair which had been located with the foot pedal crossing the track of the wan door prior to activating the door. This writer questioned staff F about the location of the wheel chairs and staff F stated they will have to implement something to prevent staff from locating the wheelchairs too close to the wan door.
*Within room JE76 of the surgery department, observation was made of two one-half inch penetrations in the drywall, one three inch open end conduit and one four inch open end conduit. Additionally, observation was made of two three inch conduits and one wire that had what appeared to be a residential spray foam insulation within each conduit and around the wire. Staff G stated in the past they have had to remove this spray foam from other areas in which it had been used as a fire retardant.
*Above the double door just south of the waiting area and near room JE13, observation was made of an approximate eight foot section of steel corrugated roof decking with what appeared to be pink residential insulation stuffed in the fluted areas where the drywall meets the upper deck. Additionally, observation was made of a half inch open end conduit and pink insulation mixed with fire rated insulation stuffed in a penetration with wires passing through.

These findings were verified by staff members F and G during tour of these areas of the facility.



Tour of the first floor with Staff H and I on 06/05/12 at 1:15 P.M. revealed the following penetrations in the smoke barrier wall which extended above the ceiling tiles.
1. Located in the communications area, three penetrations were noted surrounding pipes which extended through the smoke barrier wall.
2. Located in the ERX area was a penetration which surrounded five orange cable lines.
3. Located near the nuclear med exam room, two penetrations were noted under electrical boxes in the smoke barrier wall.
4. Located near the cafeteria conference room, above the ceiling tiles a penetration surrounded a steel pipe.
5 Located near the cafeteria, above the ceiling tiles, four penetrations surrounded four steel wall stiffer.

All penetrations were observed and verified by Staff H and I present during the tour of the first and third floors.



On 06/04/12 at 8:45 A.M., tour of the third floor, labor,delivery and pediatric areas was initiated with Staff H and I. The following penetrations were observed in the smoke barrier walls, above the ceiling tiles.

1. Located in the pediatric area, room 310/311, was an area approximately two inches square cut around a green conduit. Also in the same area, plywood estimated to be approximately four feet long and 16 inches wide secured to the wall. Staff H and I could not verify the plywood was of fire rated material.

Based on observation and staff verification it was determined this facility failed to ensure
manual fire alarm boxes were located within 5 feet of the exit doorway opening at each exit on each floor according to the National Fire Protection Association (NFPA) 72, Chapter 2-8.2.2. This had the potential to affect all those utilizing this area of the facility. The patient census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the main entrance area observation was made of a main entrance door which opened to a corridor to the left and another door to the right. The door to the right lead directly into a coffee shop which had another door leading into the hospital's main lobby area. Following this path of egress from within the main lobby observation was made that no manual fire pull station devices were located any of the three exit accesses. The nearest devices were located on each side of the lobby area on the inner part of walls which ran parallel to the exit access, approximately 20 to 30 feet away from the first exit access leading into the coffee shop.

This finding was verified by staff F and G during tour of this area of the facility.

Based on observation and staff verification it was determined this facility failed to ensure the automatic sprinkler system was installed in accordance with the National Fire Protection Association (NFPA) 13 to provide complete coverage for all portions of the building. This had the potential to affect all those utilizing these areas of the facility. The patient census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of physician's lounge located on the first floor and specifically within the electrical closet, observation was made of no sprinkler head.

This finding was verified by staff members F and G during tour of this area of the facility.

Based on observation and staff verification it was determined this facility failed to ensure the automatic sprinkler system was installed in accordance with the National Fire Protection Association (NFPA) 13 to provide complete coverage for all portions of the building. This had the potential to affect all those utilizing these areas of the facility. The patient census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the sterile room located in the basement pharmacy, observation was made of a sprinkler head mounted a few inches above the exhaust hood system. This did not meet the 18 inch distance required in order to not impede the spray pattern of the sprinkler if it was activated.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in reliable operating condition specifically regarding cleaning dust and debris from sprinkler heads, ensuring escutcheon rings were mounted properly and covers for the recessed sprinkler heads were in place. This had the potential to affect all those utilizing these areas of this facility. The facility had a patient census of 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the basement and first floor observation was made of dirty sprinkler heads, missing escutcheon rings and missing sprinkler head covers in the following locations:

Basement:
*Within the corridor adjacent to the elevators observation was made of a missing escutcheon ring.

First floor:
*Within the CAT scan area observation was made of dirty sprinkler heads in the control room and both cath labs. Additionally, cath lab # 1 had an escutcheon ring hanging down from the ceiling covering a portion of the sprinkler head.
*Within the medical library observation was made of dirty sprinkler heads and one missing escutcheon ring missing form the sprinkler head located in the librarian's office.
*Dirty sprinkler heads within the therapy department manager's office.
*Dirty sprinkler heads observed within the surgery department near operating room 11 and the scrub sink area and within the corridor parallel to the smoke barrier.
*Dirty sprinkler heads observed within the emergency department medical records office.
*Dirty sprinkler heads observed at the main entrance door and a missing escutcheon ring was observed within the main lobby.
*Sprinkler head cover was missing from sprinkler located in the old stairwell utilized for gift shop storage.
*Down the corridor to the left at the main entrance observation was made of a missing escutcheon ring from a sprinkler head.
*Within room JE76 observation was made of a missing escutcheon ring.
*Within the consultation room of the women's clinic observation was made of a missing escutcheon ring.

These findings were verified by both staff members during tour of these areas of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all fire extinguishers were mounted properly according to the National Fire Protection Association (NFPA) 10, Chapter 1-6.7. This had the potential to affect all those who utilized these areas of the facility.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the security office located in the basement, observation was made of two fire extinguishes, one which was sitting on the floor and the other on a shelf.
Within the large biohazard room located in the first floor shipping an receiving department and beside a trash compactor, observation was made of a portable fire extinguisher sitting on the floor.

These findings were verified by staff members F and G during tour of these areas of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all mobile linen receptacles are stored within a room protected as a hazardous area when not in use. This had the potential to affect all those utilizing this area of the facility. The patient census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the radiology department and specifically in the corridor by room JE82, observation was made of an alcove which had a large mobile linen receptacle located within. This writer questioned staff F if this was stored in the alcove and staff F stated "yes" and added that the purpose of the alcove was for this receptacle.

* Emergency illumination is provided in accordance with section 7.9. 20.2.9.1, 21.2.9.1

Based on observation of the facility, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting was provided in accordance with section 7.9 with regards to monthly and yearly testing requirements. The facility preformed 17602 procedures in 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff L, the facility was noted to have battery powered emergency lighting and exit signage throughout the building. Review of facility documentation revealed the facility had no documented evidence the battery operated emergency lighting and exit signs were tested monthly for 30 seconds or that an annual testing for 90 minutes was completed.

Interview of Staff L verified there was no documentation of the testing at the facility. On 06/07/12 at 12:30 p.m. interview of Staff F regarding the testing of the emergency lighting and signs verified there was no documented evidence the testing had been completed monthly or annually.


* NFPA 25, 2-2.1, Sprinkler Inspections

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that sprinkler system testing was completed quarterly as required. The facility preformed 17602 procedures in 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff L, the facility was noted to be equipped with an automatic sprinkler system. Review of facility documentation regarding testing and maintenance of the system revealed there was no evidence that components of the sprinkle system had been inspected quarterly.

Interview of Staff F on 06/07/12 verified there was no documented evidence the automatic sprinkler system had been inspected quarterly.

* Emergency illumination is provided in accordance with section 7.9. 20.2.9.1, 21.2.9.1

Based on observation of the facility, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting was provided in accordance with section 7.9 with regards to monthly and yearly testing requirements. The facility provided outpatient chemotherapy treatment and services for patients

Findings included:

On 06/06/12 during tour of the facility with Staff P and O, the facility was noted to have battery powered emergency lighting and exit signage throughout the building. Review of facility documentation revealed the facility had a single form that noted battery operated emergency lighting and exit signs were checked. The form was dated July 2, 2011.

Interview of Staff Q regarding the documentation revealed the emergency lighting was tested for 90 minutes but the form did not specifically state that. Staff Q verified that battery operated emergency lighting was not tested monthly for 30 seconds.




* NFPA 25, 2-2.1, Sprinkler Inspections

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that sprinkler system testing was completed quarterly as required. The facility provided outpatient chemotherapy treatment and services for patients

Findings included:

On 06/06/12 at 9;30 A.M. tour of the facility was initiated with Staff P and O. The facility was noted to be equipped with an automatic sprinkler system. Review of facility documentation regarding testing and maintenance of the system revealed there was no evidence that components of the sprinkle system had been inspected quarterly in 2011 and to date in 2012.

Interview of Staff F on 06/07/12 verified there was no documented evidence the automatic sprinkler system had been inspected quarterly in 2011 and to date in 2012.



*NFPA 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1.

Based on facility observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The facility provided outpatient chemotherapy treatment and services for patients

Findings included:

On 06/06/12 at 9;30 A.M. tour of the facility was initiated with Staff P and O. The facility was noted to be equipped with a smoke detection system. Observation of the treatment area revealed two smoke detectors placed significantly less than 36 inches from the air diffusers.

Staff Q verified the placement was approximately 18 inches from the airflow devices.

* Emergency illumination is provided in accordance with section 7.9. 20.2.9.1, 21.2.9.1

Based on observation of the facility, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting was provided in accordance with section 7.9 with regards to monthly and yearly testing requirements. The facility provided outpatient therapy services for 329 adult and pediatric patients in 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff M, the facility was noted to have three battery powered emergency lighting and exit signs throughout the building. Review of facility documentation revealed the facility had no documented evidence the battery operated emergency lighting and exit signs were tested monthly for 30 seconds or that an annual testing for 90 minutes was completed.

Interview of Staff M verified there was no documentation of the testing at the facility. On 06/07/12 at 12:30 p.m. interview of Staff F regarding the testing of the emergency lighting and signs verified there was no documented evidence the testing had been completed monthly or annually.



*NFPA, 101, 2000 Code, Chapter 4, 4.5.3.3 Awareness of Egress System.

Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner.

Based on facility observation and staff interview and verification, the facility failed to ensure the route to reach every exit was conspicuously indicated. The facility provided outpatient therapy services for 329 adult and pediatric patients in 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff M, the posted evacuation routes were noted to be lines drawn on a piece of blank paper. The lines noted "you are here" then the line was drawn and the word "exit" written. The evacuation route posted did not note rooms, corridors or any other information regarding the facility. A posted route near the back of the facility was noted to be inaccurate with the notation of where an exit door was located. Staff M, present on tour verified the route was inaccurate and looked backwards.

Further interview of Staff M verified the exit routes posted throughout the facility were not easy to follow and were not accurate. On 06/07/12, Staff F provided a small schematic of the facility that would be posted showing the way to exit from the building.



* NFPA 72, Chapter 7, 7-2.2, Inspection, Testing and Maintenance

Single Station Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

Based on facility observation and staff interview and verification, the facility failed to ensure single station smoke detectors were tested in place to ensure smoke entry into the sensing chamber and an alarm response. The facility provided outpatient therapy services for 329 adult and pediatric patientsin 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff M, the facility was observed to have battery operated smoke detectors located throughout the facility. Review of facility documentation revealed there was no documented evidence that testing or inspection of the single station smoke detectors had been completed. Staff M verified the was no known testing be the facility or the landlord of the facility.

Interview of Staff F on 06/08/12 at 10:39 A.M , verified there was no indication the single station smoke detectors had been tested for adequate smoke sensitivity.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the basement and first floor observation was made of several smoke detectors located by air flow devices in the following locations:

Basement:
*Within the corridor near the stock room storage area around the corner from the elevators near the maintenance department.
*Within the corridor near the pharmacy waiting room.
*Within the pharmacy waiting room.

First floor:
*Within the corridor of the MICU near room J29.
*Within the copy room south of central supply.
*Within the medical library two smoke detectors located by air flow devices.
*Within the corridor by room M58.
*Within the employee health room.
*Beside staff elevator # 3 and # 4.
*Within the control room of the CAT scan area.
*In front of the elevator in the main lobby.
*Within the entrance to the ultrasound department.

These findings were verified by staff members F and G during tour of these areas of the facility.

Based on facility tour and staff verification it was determined this facility failed to ensure the emergency battery operated lights were tested monthly and annually according to the National Fire Protection Association (NFPA) 101 Chapter 7.9.3. This had the potential to affect all those utilizing this facility. The facility census was zero at the time of the survey.

Findings include:

Documentation review of the emergency battery operated lights took place on 06/06/12. During review observation was made of a checklist which included battery operated lights. A check mark was placed in the column which indicated a monthly test was performed but it lacked the duration of the test. This writer questioned staff J, who was in charge of the testing of the emergency lights, as to how long he/she performed the monthly tests. Staff J answered he/she did not know how long the test button was engaged but "just tested it." Additionally, this writer questioned staff J about the annual testing of the emergency lights and staff J stated he/she was not aware they had to perform an annual test. This verified the 30 second monthly test and 90 minute annual test was not performed as required by the NFPA code.

Based on observation during tour and staff verification it was determined this facility failed to ensure all exit directional signs were displayed in areas which were obvious to staff and patrons to provide concise directions for exiting the premises in the event of an emergency. This had the potential to affect all those utilizing these areas of the facility. The patient census was 145 the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the basement and within the information systems room, observation was made of an exit directional sign which directed egress flow down two steps and directly into an office. Within the office observation was made of another door which lacked an exit sign. This writer questioned staff F if the door located in the office was part of the exit egress and staff F acknowledged it was.

Within the corridor of the wound burn unit observation was made of exit access on each end, although from the east end facing west any staff or patient was not able to view the far west exit sign due to an existing door header from which the door had been removed.

These findings were verified by staff F and G during tour of this area of the facility.

21957

Based on facility tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one half hour fire resistance rating. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 145.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the first and third floors observation was made of several penetrations above the ceiling tiles in the following locations:

First floor:

*At the east end of the corridor separating the care management department from the therapy department and above the double doors and ceiling tiles, observation was made of a corrugated steel deck which lacked a fire sealant within each of the corrugations where it meets with the top of the drywall. This area was approximately four feet in length and was observed not to be sealed on either side of the doors.
*At the south end of the patient towers building and within the hazard room, observation was made of one unsealed water line at each end where it penetrated the drywall. One open end curved conduit and one green flex conduit that was not sealed around the annular space of the conduit where it penetrated the drywall.
*Within the material management conference room, observation was made of one unsealed conduit around the annular space on either side of the drywall.
*Within the northwest corridor and above the smoke barrier doors of the patient tower building, observation was made of an approximate half inch square opening in the drywall which had a wire passing through.
*Within the northeast corridor and above the smoke barrier doors of the patient tower building, observation was made of a half inch open end conduit and an approximate three inch opening in the drywall which had a pipe passing through.
*Within the gift shop and about midway of the east smoke barrier, observation was made of an approximate one inch round hole in the drywall.
*To the left at the main entrance facing toward the north corridor, observation was made of a fire rated accordion door, also know as a wan door. Observation was made of several wheelchairs located along the wall adjacent to the wan door. This writer requested from staff G to key activate the door to observe how well it sealed within the frame. Staff G had to remove a wheelchair which had been located with the foot pedal crossing the track of the wan door prior to activating the door. This writer questioned staff F about the location of the wheel chairs and staff F stated they will have to implement something to prevent staff from locating the wheelchairs too close to the wan door.
*Within room JE76 of the surgery department, observation was made of two one-half inch penetrations in the drywall, one three inch open end conduit and one four inch open end conduit. Additionally, observation was made of two three inch conduits and one wire that had what appeared to be a residential spray foam insulation within each conduit and around the wire. Staff G stated in the past they have had to remove this spray foam from other areas in which it had been used as a fire retardant.
*Above the double door just south of the waiting area and near room JE13, observation was made of an approximate eight foot section of steel corrugated roof decking with what appeared to be pink residential insulation stuffed in the fluted areas where the drywall meets the upper deck. Additionally, observation was made of a half inch open end conduit and pink insulation mixed with fire rated insulation stuffed in a penetration with wires passing through.

These findings were verified by staff members F and G during tour of these areas of the facility.



Tour of the first floor with Staff H and I on 06/05/12 at 1:15 P.M. revealed the following penetrations in the smoke barrier wall which extended above the ceiling tiles.
1. Located in the communications area, three penetrations were noted surrounding pipes which extended through the smoke barrier wall.
2. Located in the ERX area was a penetration which surrounded five orange cable lines.
3. Located near the nuclear med exam room, two penetrations were noted under electrical boxes in the smoke barrier wall.
4. Located near the cafeteria conference room, above the ceiling tiles a penetration surrounded a steel pipe.
5 Located near the cafeteria, above the ceiling tiles, four penetrations surrounded four steel wall stiffer.

All penetrations were observed and verified by Staff H and I present during the tour of the first and third floors.



On 06/04/12 at 8:45 A.M., tour of the third floor, labor,delivery and pediatric areas was initiated with Staff H and I. The following penetrations were observed in the smoke barrier walls, above the ceiling tiles.

1. Located in the pediatric area, room 310/311, was an area approximately two inches square cut around a green conduit. Also in the same area, plywood estimated to be approximately four feet long and 16 inches wide secured to the wall. Staff H and I could not verify the plywood was of fire rated material.

Based on observation and staff verification it was determined this facility failed to ensure
manual fire alarm boxes were located within 5 feet of the exit doorway opening at each exit on each floor according to the National Fire Protection Association (NFPA) 72, Chapter 2-8.2.2. This had the potential to affect all those utilizing this area of the facility. The patient census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the main entrance area observation was made of a main entrance door which opened to a corridor to the left and another door to the right. The door to the right lead directly into a coffee shop which had another door leading into the hospital's main lobby area. Following this path of egress from within the main lobby observation was made that no manual fire pull station devices were located any of the three exit accesses. The nearest devices were located on each side of the lobby area on the inner part of walls which ran parallel to the exit access, approximately 20 to 30 feet away from the first exit access leading into the coffee shop.

This finding was verified by staff F and G during tour of this area of the facility.

Based on observation and staff verification it was determined this facility failed to ensure the automatic sprinkler system was installed in accordance with the National Fire Protection Association (NFPA) 13 to provide complete coverage for all portions of the building. This had the potential to affect all those utilizing these areas of the facility. The patient census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of physician's lounge located on the first floor and specifically within the electrical closet, observation was made of no sprinkler head.

This finding was verified by staff members F and G during tour of this area of the facility.

Based on observation and staff verification it was determined this facility failed to ensure the automatic sprinkler system was installed in accordance with the National Fire Protection Association (NFPA) 13 to provide complete coverage for all portions of the building. This had the potential to affect all those utilizing these areas of the facility. The patient census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the sterile room located in the basement pharmacy, observation was made of a sprinkler head mounted a few inches above the exhaust hood system. This did not meet the 18 inch distance required in order to not impede the spray pattern of the sprinkler if it was activated.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was maintained in reliable operating condition specifically regarding cleaning dust and debris from sprinkler heads, ensuring escutcheon rings were mounted properly and covers for the recessed sprinkler heads were in place. This had the potential to affect all those utilizing these areas of this facility. The facility had a patient census of 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the basement and first floor observation was made of dirty sprinkler heads, missing escutcheon rings and missing sprinkler head covers in the following locations:

Basement:
*Within the corridor adjacent to the elevators observation was made of a missing escutcheon ring.

First floor:
*Within the CAT scan area observation was made of dirty sprinkler heads in the control room and both cath labs. Additionally, cath lab # 1 had an escutcheon ring hanging down from the ceiling covering a portion of the sprinkler head.
*Within the medical library observation was made of dirty sprinkler heads and one missing escutcheon ring missing form the sprinkler head located in the librarian's office.
*Dirty sprinkler heads within the therapy department manager's office.
*Dirty sprinkler heads observed within the surgery department near operating room 11 and the scrub sink area and within the corridor parallel to the smoke barrier.
*Dirty sprinkler heads observed within the emergency department medical records office.
*Dirty sprinkler heads observed at the main entrance door and a missing escutcheon ring was observed within the main lobby.
*Sprinkler head cover was missing from sprinkler located in the old stairwell utilized for gift shop storage.
*Down the corridor to the left at the main entrance observation was made of a missing escutcheon ring from a sprinkler head.
*Within room JE76 observation was made of a missing escutcheon ring.
*Within the consultation room of the women's clinic observation was made of a missing escutcheon ring.

These findings were verified by both staff members during tour of these areas of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all fire extinguishers were mounted properly according to the National Fire Protection Association (NFPA) 10, Chapter 1-6.7. This had the potential to affect all those who utilized these areas of the facility.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the security office located in the basement, observation was made of two fire extinguishes, one which was sitting on the floor and the other on a shelf.
Within the large biohazard room located in the first floor shipping an receiving department and beside a trash compactor, observation was made of a portable fire extinguisher sitting on the floor.

These findings were verified by staff members F and G during tour of these areas of the facility.

Based on observation during tour and staff verification it was determined this facility failed to ensure all mobile linen receptacles are stored within a room protected as a hazardous area when not in use. This had the potential to affect all those utilizing this area of the facility. The patient census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the radiology department and specifically in the corridor by room JE82, observation was made of an alcove which had a large mobile linen receptacle located within. This writer questioned staff F if this was stored in the alcove and staff F stated "yes" and added that the purpose of the alcove was for this receptacle.

* Emergency illumination is provided in accordance with section 7.9. 20.2.9.1, 21.2.9.1

Based on observation of the facility, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting was provided in accordance with section 7.9 with regards to monthly and yearly testing requirements. The facility preformed 17602 procedures in 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff L, the facility was noted to have battery powered emergency lighting and exit signage throughout the building. Review of facility documentation revealed the facility had no documented evidence the battery operated emergency lighting and exit signs were tested monthly for 30 seconds or that an annual testing for 90 minutes was completed.

Interview of Staff L verified there was no documentation of the testing at the facility. On 06/07/12 at 12:30 p.m. interview of Staff F regarding the testing of the emergency lighting and signs verified there was no documented evidence the testing had been completed monthly or annually.


* NFPA 25, 2-2.1, Sprinkler Inspections

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that sprinkler system testing was completed quarterly as required. The facility preformed 17602 procedures in 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff L, the facility was noted to be equipped with an automatic sprinkler system. Review of facility documentation regarding testing and maintenance of the system revealed there was no evidence that components of the sprinkle system had been inspected quarterly.

Interview of Staff F on 06/07/12 verified there was no documented evidence the automatic sprinkler system had been inspected quarterly.

* Emergency illumination is provided in accordance with section 7.9. 20.2.9.1, 21.2.9.1

Based on observation of the facility, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting was provided in accordance with section 7.9 with regards to monthly and yearly testing requirements. The facility provided outpatient chemotherapy treatment and services for patients

Findings included:

On 06/06/12 during tour of the facility with Staff P and O, the facility was noted to have battery powered emergency lighting and exit signage throughout the building. Review of facility documentation revealed the facility had a single form that noted battery operated emergency lighting and exit signs were checked. The form was dated July 2, 2011.

Interview of Staff Q regarding the documentation revealed the emergency lighting was tested for 90 minutes but the form did not specifically state that. Staff Q verified that battery operated emergency lighting was not tested monthly for 30 seconds.




* NFPA 25, 2-2.1, Sprinkler Inspections

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that sprinkler system testing was completed quarterly as required. The facility provided outpatient chemotherapy treatment and services for patients

Findings included:

On 06/06/12 at 9;30 A.M. tour of the facility was initiated with Staff P and O. The facility was noted to be equipped with an automatic sprinkler system. Review of facility documentation regarding testing and maintenance of the system revealed there was no evidence that components of the sprinkle system had been inspected quarterly in 2011 and to date in 2012.

Interview of Staff F on 06/07/12 verified there was no documented evidence the automatic sprinkler system had been inspected quarterly in 2011 and to date in 2012.



*NFPA 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1.

Based on facility observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The facility provided outpatient chemotherapy treatment and services for patients

Findings included:

On 06/06/12 at 9;30 A.M. tour of the facility was initiated with Staff P and O. The facility was noted to be equipped with a smoke detection system. Observation of the treatment area revealed two smoke detectors placed significantly less than 36 inches from the air diffusers.

Staff Q verified the placement was approximately 18 inches from the airflow devices.

* Emergency illumination is provided in accordance with section 7.9. 20.2.9.1, 21.2.9.1

Based on observation of the facility, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting was provided in accordance with section 7.9 with regards to monthly and yearly testing requirements. The facility provided outpatient therapy services for 329 adult and pediatric patients in 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff M, the facility was noted to have three battery powered emergency lighting and exit signs throughout the building. Review of facility documentation revealed the facility had no documented evidence the battery operated emergency lighting and exit signs were tested monthly for 30 seconds or that an annual testing for 90 minutes was completed.

Interview of Staff M verified there was no documentation of the testing at the facility. On 06/07/12 at 12:30 p.m. interview of Staff F regarding the testing of the emergency lighting and signs verified there was no documented evidence the testing had been completed monthly or annually.



*NFPA, 101, 2000 Code, Chapter 4, 4.5.3.3 Awareness of Egress System.

Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner.

Based on facility observation and staff interview and verification, the facility failed to ensure the route to reach every exit was conspicuously indicated. The facility provided outpatient therapy services for 329 adult and pediatric patients in 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff M, the posted evacuation routes were noted to be lines drawn on a piece of blank paper. The lines noted "you are here" then the line was drawn and the word "exit" written. The evacuation route posted did not note rooms, corridors or any other information regarding the facility. A posted route near the back of the facility was noted to be inaccurate with the notation of where an exit door was located. Staff M, present on tour verified the route was inaccurate and looked backwards.

Further interview of Staff M verified the exit routes posted throughout the facility were not easy to follow and were not accurate. On 06/07/12, Staff F provided a small schematic of the facility that would be posted showing the way to exit from the building.



* NFPA 72, Chapter 7, 7-2.2, Inspection, Testing and Maintenance

Single Station Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

Based on facility observation and staff interview and verification, the facility failed to ensure single station smoke detectors were tested in place to ensure smoke entry into the sensing chamber and an alarm response. The facility provided outpatient therapy services for 329 adult and pediatric patientsin 2011.

Findings included:

On 06/06/12 during tour of the facility with Staff M, the facility was observed to have battery operated smoke detectors located throughout the facility. Review of facility documentation revealed there was no documented evidence that testing or inspection of the single station smoke detectors had been completed. Staff M verified the was no known testing be the facility or the landlord of the facility.

Interview of Staff F on 06/08/12 at 10:39 A.M , verified there was no indication the single station smoke detectors had been tested for adequate smoke sensitivity.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 145 at the beginning of the survey.

Findings include:

Facility tour took place on 06/04/12 through 06/08/12 with staff members F and G. During tour of the basement and first floor observation was made of several smoke detectors located by air flow devices in the following locations:

Basement:
*Within the corridor near the stock room storage area around the corner from the elevators near the maintenance department.
*Within the corridor near the pharmacy waiting room.
*Within the pharmacy waiting room.

First floor:
*Within the corridor of the MICU near room J29.
*Within the copy room south of central supply.
*Within the medical library two smoke detectors located by air flow devices.
*Within the corridor by room M58.
*Within the employee health room.
*Beside staff elevator # 3 and # 4.
*Within the control room of the CAT scan area.
*In front of the elevator in the main lobby.
*Within the entrance to the ultrasound department.

These findings were verified by staff members F and G during tour of these areas of the facility.

Based on facility tour and staff verification it was determined this facility failed to ensure the emergency battery operated lights were tested monthly and annually according to the National Fire Protection Association (NFPA) 101 Chapter 7.9.3. This had the potential to affect all those utilizing this facility. The facility census was zero at the time of the survey.

Findings include:

Documentation review of the emergency battery operated lights took place on 06/06/12. During review observation was made of a checklist which included battery operated lights. A check mark was placed in the column which indicated a monthly test was performed but it lacked the duration of the test. This writer questioned staff J, who was in charge of the testing of the emergency lights, as to how long he/she performed the monthly tests. Staff J answered he/she did not know how long the test button was engaged but "just tested it." Additionally, this writer questioned staff J about the annual testing of the emergency lights and staff J stated he/she was not aware they had to perform an annual test. This verified the 30 second monthly test and 90 minute annual test was not performed as required by the NFPA code.