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Based on record review and interview, the hospital failed to maintain the facility's fuel supply for the emergency generator to ensure reliable use of the generator in an emergency. The failure to ensure emergency power puts the health and safety of patients at risk in the event of a power failure, not an uncommon event in southwest Florida. The facility failed to ensure the smoke dampers were operable.

The findings include:

1. The fuel analysis for Doctor's Hospital's emergency generator was taken on 2/25/13 from a 10,000 gallon tank. FOI Laboratories identified the presence of heavy sediment particles in the diesel fuel for the hospital's only emergency generator. The report stated that sediment in the fuel tank can cause clogged filters and may lead to failed fuel injectors. The fuel analysis was released to the facility 3/11/13.

As of 3/27/13, the facility had no plan in place to correct this condition. See standard citation at A703 and A724 for details of the deficiency.

The failure of the emergency power generator has the potential to adversely affect many patients (scope) and to result in serious injury or death (severity).

2. The fire life safety (FLS) surveyor reviewed reports to find the facility failed to maintain the fire/smoke dampers in reliable operating condition. See standard citation at A709 and A724 for details of the deficiency. This situation could place the lives of the occupants in smoke-filled environment, should a fire occur and the fire/smoke dampers failed to respond.

Based on record review and interview, the hospital failed to maintain the facility's fuel supply for the emergency generator to ensure reliable use of the generator in an emergency. The failure to ensure emergency power puts the health and safety of patients at risk in the event of a power failure, not an uncommon event in southwest Florida.

The findings include:

On 3/27/13, the fire life safety (FLS) surveyor reviewed documentation of the fuel analysis for Doctor's Hospital's emergency generator. The diesel fuel sample was taken on 2/25/13 from a 10,000 gallon tank. The documents revealed the diesel fuel had the presence of heavy sediment particles. This diesel fuel is for the hospital's only emergency generator. The company that did the fuel analysis is FOI Laboratories. This report states that sediment in the fuel tank can cause clogged filters and may lead to failed fuel injectors. The fuel analysis was released to the facility 3/11/13.

In an interview on 3/27/13, the Director of Facility Management said he had not seen this report. Some 16 days after release of the report, the facility had no plan in place to correct this condition.

On 3/27/13, a review of the facility records revealed the facility failed to provide documentation that all of the generators and ancillary equipment were tested and certified at an optimal state in accordance with National Fire Protection Association (NFPA) 101 and NFPA 110 "Standard for Emergency and Standby Power Systems" (ESPS). NFPA 110-8.4.9 requires Level 1 ESPS shall be tested for the duration of its assigned class for at least 4 hours at least once within every 36 months.

The generator was tested on 11/15/2011. The 4-hour run test is only required every three years.

Reference: NFPA 110-Standard for Emergency and Standby Power Systems 8.3.8, "A fuel quality test shall be performed at least annually using tests approved by American Society for Testing and Materials (ASTM) standards."

After the surveyor brought the problem with the fuel to the attention of the facility staff, they called an outside vendor. This company cleaned the fuel and holding tanks. This was completed on 3/27/13 at 7:00 p.m.

Based on review of the facility records and interviews with the Director of Facility Management, the facility failed to maintain the fire/smoke dampers in reliable operating condition. This situation could place the lives of the occupants in smoke environment should a fire occur and the fire/smoke dampers failed to respond.

The findings include:

During the survey on 3/27/13, the fire life safety surveyor reviewed documentation of fire/smoke dampers which revealed a few of the dampers were noted as not accessible. The report was from an outside vendor.

In an interview at 11:20 a.m., the Director of Facility Management admitted the hospital staff has no plan in place to correct these dampers noted as they were not accessible.

Reference: National Fire Protection Association (NFPA) 101 Life Safety Code (2009) 18.5.2.1, 19.5.2.1, 9.2.1, 8.4.6.2 & NFPA 90A or B (2009 editions).

Based on record review and interview, the hospital failed to maintain the facility's fuel supply for the emergency generator to ensure an acceptable level of safety. The failure to ensure emergency power puts the health and safety of patients at risk in the event of a power failure. Smoke dampers not inspected.

The findings include:

1. On 3/27/13, the fire life safety (FLS) surveyor reviewed documentation of the fuel analysis for Doctor's Hospital's emergency generator. The diesel fuel sample was taken on 2/25/13 from a 10,000 gallon tank. The documents revealed the diesel fuel had the presence of heavy sediment particles. This diesel fuel is for the hospital's only emergency generator. The company that did the fuel analysis is FOI Laboratories. This report states that sediment in the fuel tank can cause clogged filters and may lead to failed fuel injectors. The fuel analysis was released to the facility 3/11/13.

In an interview on 3/27/13, the Director of Facility Management said he had not seen this report. Some 16 days after release of the report, the facility had no plan in place to correct this condition.

On 3/27/13, a review of the facility records revealed the facility failed to provide documentation that all of the generators and ancillary equipment were tested and certified at an optimal state in accordance with National Fire Protection Association (NFPA) 101 and NFPA 110 "Standard for Emergency and Standby Power Systems" (ESPS). NFPA 110-8.4.9 requires Level 1 ESPS shall be tested for the duration of its assigned class for at least 4 hours at least once within every 36 months.

The generator was tested on 11/15/2011. The 4-hour run test is only required every three years.

Reference: NFPA 110-Standard for Emergency and Standby Power Systems 8.3.8, "A fuel quality test shall be performed at least annually using tests approved by American Society for Testing and Materials (ASTM) standards."

2. During the survey on 3/27/13, the fire life safety surveyor reviewed documentation of fire/smoke dampers which revealed that a few of the dampers were noted as not accessible. The report was from an outside vendor.

In an interview at 11:20 a.m., the Director of Facility Management admitted the hospital staff has no plan in place to correct these damper noted as they were not accessible.

Reference: NFPA 101 Life Safety Code (2009) 18.5.2.1, 19.5.2.1, 9.2.1, 8.4.6.2 & NFPA 90A or B (2009 editions).