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Based on facility observation and staff verification, the facility failed to ensure that smoke/fire barriers were constructed to provide at least a half hour fire resistance rating. This had to potential to affect all persons utilizing the facility. The census was 193 patients at the time of the survey.

Findings include:

Tour of the facility was conducted on 10/01/12 between 1:05 P.M. and 4:30 P.M. and 10/02/12 between 7:50 A.M. and 4:45 P.M., with Staff A5, A6 and A7. The following observations were noted in walls designated by facility life safety drawings to have a two hour fire resistance rating.

Located on the second floor;
*A penetration was noted above the ceiling tiles in a two hour fire rated wall between the pharmacy leadership meeting room (H-L-107) and a women's restroom. The unsealed area surrounded a black plastic pipe.
* A penetration was observed above the ceiling tiles surrounding a steel conduit on both sides of a two hour fire separation between the medical office building and the main hospital. This was located on the second floor.
* Penetration was observed above the ceiling tiles in a two hour fire rated wall at H4-ST-W and a store room.

Staff present on the tour observed and verified the penetrations.

Based on facility tour and staff verification it was determined this facility failed to ensure the hazardous areas were protected with at least a one hour fire rated construction, specifically in regards to the medical records room. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 193.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the medical records room observation was made of an approximate four foot by two foot section of drywall missing around several insulated pipes. This was verified by all staff members during tour of the medical records room.

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. Potentially all patients, staff and visitors could be affected. The facility census was 193 patients at the time of the survey.

Findings include:

On 10/01/12 between 1:05P.M. and 4:30 P.M. tour of the Trudell building was conducted with Staff A5, A6 and A7. Observation of the paths of egress located on the first floor of the psychiatric unit revealed one exit discharge which required travel across an uneven grassy area.

The exit door was noted to open onto a concrete pad estimated to be approximately three feet long and nine feet wide From the concrete pad to the hard surface of the public way, it estimated to be approximately 20 to 30 feet, across the uneven and grassy area. Staff present on the tour verified the findings.

Based on facility observation and staff verification, the facility failed to ensure that patient room doors were arranged so that patients could open the door from inside without using a key. The facility had a census of 193 patients at the time of the survey.

Findings include:

On 10/02/12 between the hours of 7:50 A.M. and 3:00 P.M., tour of the secured psychiatric care unit was conducted with Staff A5, A6 and A7. Staff F conducted the tour of the unit. Staff F revealed there were 13 patient bedrooms on the unit and two special care (seclusion) rooms. During tour, one patient was observed sleeping a special care room with the door to the room open. Staff F verified the patient was using the room as a sleeping room.

Tour of the unit revealed the patient room doors had locks in place which required a key. Observation from inside a patient room revealed that once the door was locked from the corridor side by the key, there was no means to open the door from the patient's side of the door. Staff F verified the locks were present on every patient sleeping room door. Staff F further stated that patient rooms were not typically locked using the key.

Staff A5, present on tour, verified the patient room doors could not be opened, once locked, from the patient room side

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building specifically in regards to location of sprinkler heads mounted at least 18 inches above any possible obstruction. This had the potential to affect all those utilizing these areas of the facility. The facility census was 93 at the beginning of the survey.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the pharmacy mixing area observation was made of a sprinkler head located ten and a half inches above a hood system which would impede the sprinkler flow pattern in the event of an emergency. This finding was verified by staff A1 during a revisit to this area on 10/03/12.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was continuously maintained in reliable operating condition in regards to cleaning dust and debris from off the sprinkler heads and ensuring the escutcheon rings were in place. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the first floor critical care expansion areas and a portion of the radiology department took place on 10/01/12 with staff members A1, A2 and A3. During tour observation was made of dirty sprinkler heads or sprinkler heads missing the escutcheon rings in the following locations:

*Within the emergency department staff lounge.
*Within patient rooms 21, 25 and 27.
*Within the soiled utility room by the stairwell.
*Within the consultation room beside the stairwell.
*Within the triage area.
*Within the women ' s restrooms near the registration area.
*Within the control room located between the CT and MRI room.

These findings were verified by all staff members present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure that fire extinguishers were not obstructed from view and had monthly inspections according to the National Fire Protection Association (NFPA) 10 Chapter 1-6.6 and 4-3.4.2. This had the potential to affect all those utilizing these areas of the facility.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the east mechanical room observation was made of two fire extinguishers that were obstructed and/or had lacked the monthly inspection. One fire extinguisher had not been monthly inspected since 05/28/11 and it was also obstructed by contractor's supplies. The other fire extinguisher was obstructed by a table and contractor's supplies.
During tour of the first floor parallel switch room in one south, observation was made of one fire extinguisher obstructed by a large spool of contractor wire.
These findings were verified by all staff present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the large mobile soiled linen or trash collection receptacles with capacities greater than 32 gal were located in a room protected as a hazardous area when not attended. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the surgical areas took place on 10/03/12 with staff members A1, A2, A3 and A4. During tour of the surgical processing department (SPD) observation was made of a large mobile trash container filled with cardboard located adjacent to the south exit access. Observation of this container was over a period of one and one half hour to two hours in which it had not been moved. Interview with staff member A4 on 10/03/12 at approximately 4:50 P.M. revealed he/she was not aware of how often this container was emptied. Staff A4 stated the container was not stored in this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure six cylinders of carbon dioxide was properly stored according to the National Fire Protection Association 99. This had the potential to affect all those utilizing these areas of the facility. The facility census was 93 at the beginning of the survey.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the ground floor storage area located adjacent to the medical gas storage room, observation was made of six small cylinders of carbon not secured sitting on the floor. This finding was verified by all staff during tour of this storage area.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9. with regards to periodic testing of the battery powered emergency lights.

Findings include:

On 10/03/12 between 7:30 A.M.. and 9:00A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed the presence of emergency battery powered lighting.

Review of facility documentation with Staff A9 revealed emergency battery lighting was tested monthly. Documentation of the testing did not reveal that testing was completed for at least 30 seconds each month. There was no documented evidence that an annual test of 90 minutes was completed for the emergency lights

Further interview of Staff A9 verified the facility documentation did not show the length of the monthly test and that no annual test for 90 minutes had been completed .in accordance with section 7.9 requirements.

**

Based on facility observation and staff interview and verification, the facility failed to ensure that oxygen storage was in accordance with NFPA 99, Chapter 4, with regards to protection and storage of oxygen cylinders from excessive heat or freezing temperatures.


Findings include:

On 10/03/12 between 7:30 A.M.. and 9:00 A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed that oxygen for patients was provided through a manifold system and piped into the facility.

Observation of the oxygen storage area revealed the oxygen delivery system was located outside the facility in an enclosed courtyard. The manifold and oxygen cylinders were located immediately outside the door of the facility and were exposed to the weather. A piece of well-weathered plywood was placed over the top of the H size tanks to provided some protection. Two small carts capable of each holding 12 E size cylinders of oxygen were sitting next to the larger tanks of oxygen. Each smaller cart contained less than six E size oxygen tanks.

Storage of full and empty H size tanks of oxygen were noted to be chained to the fence which surrounded the courtyard area. This storage area was located behind the diesel emergency generator.

Interview of Staff A9 verified that in winter months getting to the oxygen cylinders could be somewhat difficult for staff with the presence of snow and ice.



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