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Based on observation, building plan review, and interview, the facility failed to meet the requirements of 482.41 (b)(1)(2)(3) - Life Safety Code from Fire and the applicable provisions of the 2012 (existing) Life Safety Code of the National Fire Protection Association (NFPA) to provide a safe environment for all patients, staff and visitors. (Refer to A710)

Due to the widespread and cumulative effect of these deficient practices, which presented multiple hazards that directly affect the safety and well-being all patients, staff and visitors, it was determined that 42 CFR 482.41 Condition of Participation: Physical Environment was out of compliance. The facility census was 198.

Based on observation, interview, policy review, and review of 482.41 (b)(1)(2)(3) - Life Safety Code from Fire and the applicable provisions of the 2012 (existing) Life Safety Code of the National Fire Protection Association (NFPA) the facility failed to provide a safe environment. The facility must be in compliance with all applicable codes referenced in the Life Safety Code. Building #1 is the main hospital building and Building #2 is the in-patient acute care psychiatric unit located approximately six miles from the main hospital building. The facility census was 198.

The facility failed to ensure:


Building #2

-The building structure was safe. The residential grade building construction of the building had additional commercial building systems and components which compromise the building structure. The residential grade engineered floor joists in the basement hung from metal straps supporting the building weight and added commercial building components. The floor joists were not supported by a steel main beam. The building was not inspected prior to adding the components to determine the structure could handle the additional weight of the components. The added weight to the building structure puts all patients, staff and visitors at risk of injury or death from a structural failure or a structure failure occurring faster than expected in the event of a fire.
NFPA 101, 2012, 19.1.1.1.3, 4.2.2, NFPA 13, 9.2.1.3.1

- The health care occupancy was separated from non healthcare occupancies by a two hour fire resistant barrier and complete sprinkler coverage provided by an NFPA 13 compliant sprinkler system. The separation walls without a two hour fire resistance rating reduces the hospital construction standard to a prohibited construction standard for hospitals. The barrier wall and complete sprinkler coverage is intended to slow the spread of fire from the higher fire risk side of the structure to the hospital side of the structure to allow more time to evacuate the building in the event of a fire. The barrier wall not constructed to a two hour fire resistance rating and lack of a complete sprinkler system puts all patients, staff and visitors at risk of injury or death by increasing the speed of fire and smoke spreading from one area of the building to the patient occupied sections of the structure in the event of a fire.
NFPA 101, 19.1.3.3 2012 edition

-The building meets the building construction type to be a hospital,Type II (111). The psychiatric unit is in an unprotected wood construction type which is not allowed to be used as a hospital. The facility did not applied intumescent paint to all areas of the structural wood frame of the building to increase the fire resistance rating. The paint was intended to make the structure compliant with construction requirements. Unpainted wood frame sections, compromised barrier separations including unrated exit corridor doors and missing required sprinkler coverage reduces the required construction standard. This type of construction puts all patients, staff and visitors at a higher risk of injury or death from a fire by excluding required building systems and components intended to slow the spread of smoke, embers and fire through the structure in the event of a fire.
NFPA 101, 19.1.6.1, Table 19.1.6.1 2012 edition

-Five of five patient exit corridors in the hospital's in-patient care unit serving as exit access were 8 feet in width.
The exit corridor to the patient hall and the three exits out of the men's and women's unit was 7 ft 6 inches in width. The exit corridor where the patient therapy room was located was 6 ft wide. Narrow corridors puts all patients, staff and visitors at risk of injury or death from fire by slowing or preventing a fast exit from the building in the event of a fire.
NFPA 101, 19.2.1, 7.1.10.1 2012 edition

- A safe environment was provided when the building did not have a required complete sprinkler system, a required complete smoke detection system and that all staff had the required key cards that would release all locks in the building in an emergency. The complete sprinkler system provides fire suppression in the event of a fire, allowing time for the building occupants to exit the building. The complete smoke detection system is intended to provide warning of a fire allowing more time for the building occupants to exit the building. All staff carrying key cards which release all controlled locks in the building increases the speed of building evacuation in the event of a fire. Missing a complete sprinkler system, a complete smoke detection system and lack of all staff having key cards that would release all locks in the building puts all patients, staff and visitors at risk of injury or death from fire by slowing or preventing exiting from the building in the event of a fire.
NFPA 101,
19.2.2.2.5, 19.2.2.2.5.1, 19.2.2.2.5.2, 19.2.2.2.6, 9.6.2.9, 19.3.5.1., 19.2.2.2.5.2(2), 19.2.2.2.5.2(3) 2012 edition

-Self closing devices were installed on all doors located in smoke barriers and hazardous areas. The facility failed to provide a self closing device on a compartment access hatch in the one hour wall located in the attic between the women's sleeping wing and the space above the seclusion room. Additionally, the door between the Break room hall and the clean storage room in a barrier wall did not have a self closing device to keep the door closed. The facility did not have a complete sprinkler system. The facility did not have a complete smoke detection system. Failure to provide self closing devices on all doors located in smoke barriers and hazardous areas in the building structure puts all patients, staff and visitors at a higher risk of injury or death from a fire by excluding required building systems and components intended to slow the spread of smoke, embers and fire through the structure in the event of a fire.
NFPA 101, 19.2.2.2.7, 7.2.1.8.2. 2012 edition

-Five of five patient exit corridors in the hospital's in-patient care unit serving as exit access were 8 feet in width.
The exit corridor to the patient hall and the three exits out of the men's and women's unit was 7 ft 6 inches in width. The exit corridor where the patient therapy room was located was 6 ft wide. Narrow corridors puts all patients, staff and visitors at risk of injury or death from fire by slowing or preventing a fast exit from the building in the event of a fire.
NFPA 101, 19.2.3.4, 19.2.3.5 2012 edition

-Four of six patient exit doors had a opening clear width of 41.5 inches wide. Three exit doors in the patient care unit were 36 inches wide and the exit door out of the therapy room exit corridor was 32 inches wide, Failure to provide 41.5 inch clear width opening puts all patients, staff and visitors at risk of injury or death from a fire by slowing or preventing access to the exit doors to quickly exit the building in the event of a fire.
NFPA 101, 19.2.3.6, 19.2.3.7 2012 edition

-All designated exits were marked by exit signs. The connecting corridor between the Patient unit and the cafeteria was not provided with lighted exit signs on both ends of the corridor to direct patients, staff and visitors to an outside exit. Failure to provide lighted exit signs puts all patients, staff and visitors at risk of injury or death from a fire by slowing or preventing access to the exit doors to quickly exit the building in the event of a fire.
NFPA 101, 7.10.1.5, 7.10.1.5.1 2012 edition

-All vertical openings between the floor and the roof of the structure were protected. Vertical openings between the occupied floor and the attic space continuing through the false roof deck which are unprotected allows the passage of smoke and products of combustion to pass through the structure, increasing the probability of a fire spreading through the structure. This violation in conjunction with an unprotected wood frame, lack of code compliant smoke and fire barrier walls and lack of complete sprinkler coverage within the same attic space increases the risk of fire propagation in the event of a fire. The unprotected vertical openings provide a passage for air to fuel a fire within the interstitial space between the unrated lay in ceiling and the missing sheetrock barrier which protects the wood frame of the building and provides a passage for a fire to spread in the attic space. Failure to protect vertical openings in the building structure puts all patients, staff and visitors at a higher risk of injury or death from a fire by excluding required building systems and components intended to slow the spread of smoke, embers and fire through the structure in the event of a fire.
NFPA 101, 19.3,19.3.1, 19.3.1.1 through 19.3.1.8., 8.6.2, 2012 edition

-Hazardous areas were enclosed with smoke barriers. The door between the Break room hall and the clean storage room in a barrier wall did not have a self closing device to keep the door closed. Two roll down pass thru windows in the one hour separation wall between the kitchen and dining room did not have a self closing devices to keep the windows closed. The building did not contain a complete sprinkler system. The one hour barrier wall in the attic between the dining room and kitchen had an exposed unprotected board supporting the barrier wall frame. Failure to enclose hazardous areas are enclosed with smoke barriers in the building structure puts all patients, staff and visitors at a higher risk of injury or death from a fire by excluding required building systems and components intended to slow the spread of smoke, embers and fire through the structure in the event of a fire.
NFPA 101, 19.3.2.1, 7.2.1.8, 8.4, 8.7, 9.7 2012 edition

-Interior ceiling and wall finishes met Class A or Class B flame spread requirements. All patient accessible and designated exit corridors had wood board wainscoting on the corridor walls. A wood ceiling was in the dining room, Men's sleeping Unit and the Women's sleeping unit. The facility did not have a complete sprinkler system. Lack of a complete sprinkler system does not allow a reduction from Class A or B flame spread requirements. Independent third party testing of any coatings applied to the ceilings and walls showing a Class A or B rating was not available. Failure to ensure wall and ceiling coverings had a flame spread rating puts all patients, staff and visitors at a higher risk of injury or death from a fire by excluding required building systems and components intended to slow the spread of smoke, embers and fire through the structure in the event of a fire.
NFPA 101, 19.3.3.2, 10.2 2012 edition

-The fire alarm system was installed per code requirements. The fire alarm design and installation records were not available. The complete fire alarm system is intended to provide warning of a fire allowing more time for the building occupants to exit the building. Missing the fire alarm system installation and design records does not show the number of devices, their location, if the components are listed for a fire alarm system, if the wiring and components can function together or if the system was designed to code requirements puts all patients, staff and visitors at risk of injury or death from fire by slowing or preventing notification of emergency services and building occupants of a fire in the event of a fire.
NFPA 101, 19.3.4.1, 9.6. 2012 edition

-The fire alarm system would be initiated by activation of the sprinkler system. The facility did not have records showing the sprinkler system and the kitchen range hood activated the fire alarm system. Missing the records showing the sprinkler system and the kitchen range hood activated the fire alarm system puts all patients, staff and visitors at risk of injury or death from fire by slowing or preventing notification of emergency services and building occupants of a fire in the event of a fire. The sprinkler system activating the fire alarm system provides fire notification of all building occupants in the event of a fire, allowing time for the building occupants to exit the building.
NFPA 101 19.3.4.2, 19.3.4.2.1, 9.6.2, 19.3.4.2.2 through 19.3.4.2.4. 2012 edition

-All devices connected to the fire alarm system were inspected and tested per code requirements. The facility did not have records showing connection function tests for the sprinkler system tamper and flow alarms, fire and smoke dampers and range hood. The facility did not have records showing the smoke detector sensitivity testing for the facility smoke detectors. The facility fire alarm system control panel was not monitored to report any problems with the fire alarm system. Failure to inspect the fire alarm system components, ensure the devices are connected and work with the fire alarm system and monitor the fire alarm system for problems and malfunctions puts all patients, staff and visitors at risk of injury or death from fire by slowing or preventing notification of emergency services and building occupants of a fire in the event of a fire, allowing time for the building occupants to exit the building.
NFPA 72, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4, 10.12, 2010 edition

-The building sprinkler system met sprinkler systems installation requirements. The facility did not provide adequate sprinkler coverage in the attic, had a painted sprinkler head in the attic, did not provide sprinkler piping horizontal or vertical support bracing for all attic sprinklers, had blocked sprinkler coverage in the basement, had sprinkler heads with different temperature ratings in the same space, had blocked sprinkler coverage in the attic, inadequate number and type of replacement sprinkler heads available onsite, no design plans for the sprinkler system, no installation records of the sprinkler system and a section of the structure attic space which was not accessible and sprinkler coverage could not be verified. A complete sprinkler system provides fire suppression in the event of a fire, allowing time for the building occupants to exit the building. Failure to provide a complete sprinkler system per code requirements puts all patients, staff and visitors at a higher risk of injury or death from a fire by excluding required building systems and components intended to slow the spread of smoke, embers and fire through the structure in the event of a fire, allowing time for the building occupants to exit the building.
NFPA 101, 19.1.6.1 2012 edition
NFPA 13, 6.2.6.2, 6.2.9, Table 6.2.5.1, 9.2.3.5.1, 9.2.3.7 2010 edition

-The sprinkler supervisory alarms were installed and monitored per code requirements. The facility did not have testing records showing the sprinkler system supervisory alarms were tested with the fire alarm. The facility did not have fire alarm plans or sprinkler plans available for review. The annual fire alarm inspections did not show a connection between the sprinkler system and the fire alarm system. The facility did not have any annual sprinkler system inspections available for review. Failure to inspect the fire alarm system components, ensure the devices are connected and work with the fire alarm system puts all patients, staff and visitors at risk of injury or death from fire by slowing or preventing notification of emergency services and building occupants of a fire in the event of a fire, allowing time for the building occupants to exit the building.
NFPA 101, 9.7.2.1 2012 edition

-The wet & dry sprinkler systems was inspected to code requirements. The facility did not have records of annual inspections for the wet sprinkler system for any year, annual inspection for the dry sprinkler system for any year, 3 year dry system full trip test, 5 year backflow/check valve inspections, 5 year internal pipe inspections or system gauge calibration or replacement records. A sprinkler system provides fire suppression in the event of a fire, allowing time for the building occupants to exit the building. Failure to test and maintain a sprinkler system per code requirements puts all patients, staff and visitors at a higher risk of injury or death from a fire by increasing the risk of system component failure in the system intended to slow the spread of smoke, embers and fire through the structure in the event of a fire, allowing time for the building occupants to exit the building.
NFPA 25, Chapters 5, 13 and 14 2011 edition

-The building contained corridor doors of substantial construction. The facility corridor doors consisted of six panel decorative doors mounted in door frames constructed of wood. The facility did not contain a complete sprinkler system. The corridor doors must be substantial doors such as 1 3/4 inch thick, have a solid core and be mounted in rated door frames and resist fire for 20 minutes unless a complete sprinkler system is provided in the building. Failure to provide substantial corridor doors puts all patients, staff and visitors at a higher risk of injury or death from a fire by excluding required building components intended to slow the spread of smoke, embers and fire through the structure in the event of a fire.
NFPA 101, Section 19.3.6.3 2012 edition

-Glass panels in smoke barrier doors had fire rated glazing or were constructed of wire backed glass. The facility 2 hour separation barrier doors between the center section of the building and the south end of the structure contained glass panels without a rating or wire backed glass and the frame was constructed of wood. Failure to provide rated or wire backed glass in metal frames in a barrier wall puts all patients, staff and visitors at risk of injury or death by excluding required building components intended to slow the spread of smoke, embers and fire through the structure allowing time for the building occupants to exit the building in the event of a fire.
NFPA 101, 19.3.7.6, 19.3.7.6.2, 8.5. 2012 edition

-Electrical equipment & wiring installations met code requirements. The facility did not mount a junction box allowing it to hang from its own wiring in the basement, left exposed wire connections above the kitchen range hood, blocked 3 electrical shutoffs mounted on a kitchen wall behind the cooking devices that the switches controlled and piled cardboard against circuit breaker panels in the computer room. Failure to ensure compliance with the electrical code increases the risk of starting a fire in the building and puts all patients, staff and visitors at risk of injury or death by increasing the risk of starting a fire in the building.
NFPA 101, 19.5.1.1, 9.1.2 2012 edition
NFPA 70, Article 110.26 , Article 300 2011 edition

-Extension cords were not used permanently. The facility contained an extension cord penetrating the one hour rated wall between the attic spaces above the seclusion room. Failure to ensure compliance with the electrical code increases the risk of starting a fire in the building and puts all patients, staff and visitors at risk of injury or death by increasing the risk of starting a fire in the building.
NFPA 70, Article 400.8 2011 edition

-Oxygen tanks were stored per code requirements. The facility stored 19 oxygen tanks size E in the designated storage room with floor covered with wall to wall carpet, multiple isles of racks with linens, decorations and miscellaneous combustible storage and the room door was not equipped with a self closing device. Storing oxygen cylinders within hazardous areas puts all patients, staff and visitors at a higher risk of injury or death from a fire by increasing the speed of a fire in the event of a fire. Any combustible materials will burn faster in the presence of oxygen.
NFPA 99, Table A.9.3.7.5.1, 5.1.3.3.2 through 5.1.3.3.3,
5.1.3.3.4.2 2012 edition

Based on observation, interview, policy review, and review of 482.41 (b)(1)(2)(3) - Life Safety Code from Fire and the applicable provisions of the 2012 (existing) Life Safety Code of the National Fire Protection Association (NFPA) the facility failed to provide a safe environment. The facility must be in compliance with all applicable codes referenced in the Life Safety Code. Building #1 is the main hospital building and Building #2 is the in-patient acute care psychiatric unit located approximately six miles from the main hospital building.

Building #1

The facility failed to ensure:


-the elevator lobby doors designed to shut with activation of the fire alarm system would operate and completely close as intended for two of five doors tested. One fire rated double separation corridor door did not close when released from the hold open mechanism. Failure of the doors to close puts all patients, staff and visitors at a higher risk of injury or death from a fire.
NFPA 101 Chapter 7.2.13.3 2012 edition

-all patient room doors closed and latched securely for 11 of the doors tested in the facility. A majority of the patient doors were tested for latching in the facility. Failure off the doors to close puts all patients, staff and visitors at a higher risk of injury or death from a fire.
NFPA 101 Chapter 19.3.6.3 2012 edition

-fire drills were conducted quarterly for all staff, so all staff would be familiar with procedures and how to react during a fire. No assessment of the effectiveness of the drills were completed for each fire drill. Failure to conduct the fire drills and assess the response puts all patients, staff and visitors at a higher risk of injury or death from a fire by staff not knowing what to do in a fire.
NFPA 101 Chapter 19.7.7.7 2012 edition


- all building systems and equipment had been assigned a risk assessment category and have formal documentation of the risk assessments. Failure to assess facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers puts all patients and caregivers at a higher risk of death or injury.
NFPA 99 Chapter 4 2012 edition