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Based on random observation during the survey walk-through, staff interview and review of Life Safety Plans dated 10-15-10 produced by Shive-Hattery Architects in Moline, IL, the construction type of the building does not comply with NFPA 101 - 2000, 19.1.6.2. This deficiency could affect all in-patients in the facility, as well as those residents of the Long Term Care portion of the building and any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

A. The original 1934 building area is partially sprinklered and indicated to be of Type III (000) construction type and is two stories with a basement. The building construction type is not permitted under Table 19.1.6.2. Surveyor notes that the original building area is not otherwise separated from the Hospital by 2-hour rated construction on all floor levels to allow it to be classified as a separate non-healthcare occupancy building. The 2-hour separation is indicated to only exist on the 2nd floor.

B. The 1954 and 1974 building areas are indicated to be of Type II (000) construction type. These building areas are also two stories with a basement. The building construction type is not permitted under Table 19.1.6.2 without full sprinkler protection. The building areas are only partially sprinkler protected.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke reaching the facility's exit access corridors.

Findings include:

A. The basement level corridor outside the Family Clinic has a bench for seating open to the corridor. The space is not provided with smoke detection to comply with the requirements of 19.3.6.1, Exception No. 7.

B. The Ground floor Lab waiting area is open to the corridor. The waiting area is not within a sprinklered smoke compartment and is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2. The camera observation provided for the space is not considered to be "direct observation" required as an alternative to the smoke detection. The waiting space is not otherwise provided with smoke detection to comply with 19.3.6.1 Exception No. 7.

C. The Ground floor X-ray waiting area is open to the corridor. The waiting area is not within a sprinklered smoke compartment and is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2. The camera observation provided for the space is not considered to be "direct observation" required as an alternative to the smoke detection. The waiting space is not otherwise provided with smoke detection to comply with 19.3.6.1 Exception No. 7.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the ground floor non-long term care areas of the facility, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. The Ground floor Cafeteria was provided with a pair of doors which were equipped only with a double keyed dead bolt lock. The dead bolt lock does not provide a means to positively self-latch the doors upon closing to comply with 19.3.6.3.2. Alternatively, the Cafeteria does not comply with 19.3.6.1 Exception No. 1 to allow it to be considered open to the corridor.

Based on random observation during the survey walk-through, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. Miscellaneous pipe and conduit penetrations were observed not to be sealed in accordance with fire/smoke rated tested design assemblies. Locations observed include but are not necessarily limited to the following:

1. At the Boiler room above boiler #2.

2. At the Kathabar equipment room.

B. The duct shaft from the basement level boiler room thru the first floor to the roof is not noted on the Life Safety Reference Plans as being fire rated. Actual construction was not investigated due to patient use of the of the room necessary to observe.

C. The presumed duct shaft from the basement level equipment room thru the first and second floors was not noted on the Life Safety Reference Plans as being fire rated. Actual construction was not verified.

D. The Public Stair door at the basement level does not self-close to a latched condition.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the 1st and 2nd floors of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. The entire basement area north and east of the main corridor between the Public Stair/elevator and the Family Care Clinic is considered a single hazardous area. The cross corridor doors at the north end of the main corridor are not minimum 3/4-hour rated to comply with 19.3.2.1.

B. The entire basement area north and east of the main corridor between the Public Stair/elevator and the Family Care Clinic is considered a single hazardous area. The active leaf of the cross corridor doors at the east side of the main corridor is not self-closing to comply with 19.3.2.1 because the closer device is equipped with a hold-open feature. The exit sign is located over the inactive leaf of this pair of doors rather than over the active leaf.

C. The Kitchen Storage room door off the Kitchen was observed to be held open by a non-approved wedge hold-open device in non-compliance with 7.2.1.8.2.

D. The 2nd floor south wing Clean Storage area is not separated from adjacent areas by 1-hour rated construction to comply with 19.3.2.1. The walls to adjacent areas contain windows and the doors are non-rated and have louvers. The corridor door is rated but is damaged to where the fire rating can not be verified to be maintained. The door si equipped with a "helper wheel" to keep it from dragging on the floor. The closer on this door is equipped with a hold-open feature.

E. The 2nd floor south wing "Women's Patient room" bathroom area utilized as a storage area was not separated by 1-hour rated wall construction and the corridor door was not minimum 3/4-hour rated to comply with 19.3.2.1.

F. The 2nd floor Linen Storage room (former Seclusion room) was not verified to be separated by 1-hour rated wall construction. The corridor door was not minimum 3/4-hour rated to comply with 19.3.2.1.

G. The 2nd floor Specialty Clinic Soiled Utility room door is not self-closing to a latched condition.

H. The 2nd floor Pharmacy area constitutes a hazardous area due to the storage of combustible materials. The Pharmacy was not protected by 1-hour rated construction in accordance with 19.3.2.1 or otherwise sprinklered in accordance with 8.4.1.

Based on random observation during the survey walk-through, Labrotories employing quantities of flammable, combustible materials are not protected in accordance with 19.3.2.1. These deficiencies could affect all patients on the 1st and 2nd floors of the facility, as well as any staff and visitors present, by exposing the facility to fire and smoke in the event of ignition.

Findings include:

A. The 1st floor Lab area utilizes flammable materials and stores them in cabinetry within the Lab. Four gal. of material was observed at the time of the survey. The Lab was not separated from the remainder of the building by 1-hour rated construction to comply with 19.3.2.1. The Lab was not otherwise sprinklered in accordance with 8.4.1 to comply with 19.3.2.1.

Based on random observation during the survey walk-through, not all exit ramps are constructed in accordance with the requirements of 19.2.2.6 & 7.2. These deficiencies could affect all patients on the 1st and 2nd floors of the facility, as well as any staff and visitors present, by impeding the use of the ramps during building exiting.

Findings include:

A. The exterior ramp from the basement is not provided with any handrails to comply with 19.2.2.6.1, 7.2.5.4 & 7.2.2.4.5.

B. The interior ramp at the basement is not provided with any handrails to comply with 19.2.2.6.1 and 7.2.5.4 & 7.2.2.4.5.

C. The interior ramps from the Ground floor and the 2nd floor to the exterior door are not provided with handrails on both sides to comply with 19.2.2.6.1 and 7.2.5.4 and 7.2.2.4.5.

Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. The Ground floor X-ray room door corridor door.

2. The 2nd floor west wing "Romona C Wound Care Nurse" corridor door.

B. Exterior exit doors are not operable within the force limitations required under 7.2.1.4.5. Locations observed include but are not necessarily limited to the following:

1. The basement level exterior discharge door from the west stair.

2. The Ground floor exterior discharge door from the Public Stair.

C. The cross corridor doors near the Cafeteria which allow access to the corridor leading to the exterior door at the emergency room entry swing against the direction of travel in non-compliance with 7.2.1.4.2. These doors are not otherwise identified as being part of a smoke barrier where the Exception would allow the doors to swing against the direction of travel.

Based on random observation during the survey walk-through, not all 2-hour fire barriers are maintained to afford the required 2-hour rating in accordance with 8.2.3. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by allowing the spread of fire and smoke to areas expected to be an area of safety.

Findings include:

A. The 2-hour barrier wall between the Four Seasons Long Term Care Unit and the remaining Hospital was observed not to be complete at the duct passing thru the wall above the ceiling at the "Sensory room" area of the Four Seasons Long Term Care Unit.

B. The 2-hour barrier wall between the Four Seasons Long Term Care Unit and the remaining Hospital at the Administration Conference room contained a large access door to gain access to an existing electrical panel in the original wall. The access door was not able to be closed and latched to maintain the rating of the wall and still allow it to be readily opened to access the electrical panel.

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. The designated exterior exit door from the Kitchen is not provided with lighting to comply with 7.8.1.4 and is not powered from the emergency system to comply with 7.9.

Based on document review and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. This deficiency could affect all patients in the 25 bed facility and all patients in the Four Seasons Long Term Care Unit, as well as any staff and visitors present, because the failure to maintain a clear plan could result in confusion of expected responses to a fire or smoke condition within the building.

Findings include:

A. The written Fire Plan (Code Red) policy states the following specific to the Med/Surg Unit. Similar directives are specified for other specific areas:

"Med/Surg:
Fire alarms: All but one nurse will report to front lobby and report to hospital accountability officer. One nurse will remain on the floor and will report to accountability by phone.
In event of an active Fire/smoke in building: Fire/smoke in building: Exit out closest exit, report to main parking lot. After secured only one nurse remains on floor unless smoke and/or fire are noted in the area. DO NOT ATTEMPT to remove anyone from Dept. by yourself at ANY TIME.
Duties: Securing 2nd floor Med/Surg areas, Place out of service barrier across visitor elevator if possible. Place patients in their rooms and close ALL doors and windows. Clear visitors from floor ensuring they go out their nearest exit. Close Oxygen valves on the way out of Dept."
"Incident command may order evacuation if not done by the Fire Dept. The senior person in the affected area may order departmental evacuation if necessary but only horizontally. The Fire Chief & Fire Dept. Staff have ultimate incident command after arrival along with Law Enforcement."

The above procedure is confusing. The policy does not specifically reference the "RACE" procedure but does contain similar components. It is not clear why "fire alarms" may be reponded to differently than "an active fire/smoke in the building" condition. The policy appears to call for the evacuation of the facility under an "active Fire/smoke in building" condition but then the "duties" calls to "place patients in their rooms and close all doors and windows." The policy appears to call for both vertical and horizontal evacuation of affected areas but does not define how or when each type is to be used. A clear and concise procedure for a fire alarm condition should merit the same response from staff regardless of circumstances of fire alarm activation. The evacuation orders should clarify when horizontal movement is expected and when building evacuation is expected.

Based on random observation during the survey walk-through conducted in the afternoon on July 5th and the morning of July 6th 2011, not all portions of the facility's fire alarm system are installed and maintained in accordance with NFPA 72 1999.

Findings include:

A. During the afternoon walk-through on July 5th of the Ground and First floors, several smoke detectors were observed to be installed less than 3' from supply diffusers, thus not in accordance with 2-3.5.1. Locations include:

1. Two detectors in the Ground floor corridor that leads to the South Stairwell.

2. One detector in the First floor Dining Room.

3. One detector in the East corridor to the West Elevator on First floor.

4. One detector by the East Stairwell on First floor.

B. During the morning walk-through on July 6th of the Second floor, several smoke detectors were observed to be installed less than 3' from supply diffusers, thus not in accordance with 2-3.5.1. Locations include:

1. One detector by the North stairwell on Second floor.

2. One detector in the the corridor by the South Stairwell on Second floor.

The above listed deficiencies could cause detectors to fail due to air flow and endangering staff and patients of smoke related injury.

C. During the Morning walk-through on July 6th fire alarm manual pull stations were observed to be more than 5' from the exit door and not in accordance with 2-8.2.2. Locations include:

1. The station by the Northwest Stairwell.

2. The station in the Lobby at the Front Entrance.

The alarm activation at such locations could endanger the person due to the travel distance to reach the outside.

D. During the afternoon walk-through on July 5th the main Fire Alarm Control Panel was observed to be powered from an identified breaker which was not mechanically locked in the on position in accordance with 1-5.2.5.2.

This deficiency could cause accidental tripping to the "off position" that could run down the battery, endangering alarm activation and patient safety.

Based on random observation the morning of July 6, 2011, not all portions of the facility's wet sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

A. During an attempt to conduct a sprinkler flow test about 11:00 am it was discovered the 1" inspector test connection located at the ground floor Family Clinic was not orificed to represent the flow from the smallest sprinkler in the zone, thus not in accordance with 5-15.4.2.

This deficiency would cause faster alarm time than a sprinkler head and could cause a false sense of safety for staff and patients.

Based on document review and staff interview, the facility's fire dampers are not inspected, tested, and maintained in accordance with 9.2 and 90A. These deficiencies could affect all patients in the 25 bed facility and all patients in the Four Seasons Long Term Care Unit as well as any staff and visitors present, because the failure to maintain the building's fire dampers could result in the failure of the devices to function as intended to contain fire and smoke in an emergency condition.

Findings include:

A. A review of the Fire Damper inspection report conducted by Life Safety Services of Louisville, KY on 9/3/08 revealed that 7 dampers were identified as "fail" due to being "seized, obstructed or bound-up". Staff indicated that no resolution of the failed condition of the dampers has taken place since the inspection.

Based on random observation during the survey walk-through, not all means of egress atr maintained free of obstructions or impediments to provided the full instant use to comply with 7.1.10. These deficiencies could affect all persons in the Four Seasons Long Term Care Unit by preventing safe and unimpeded access to the exits.

Findings include:

A. Corridors of the 1st floor Four Seasons Long Term Care Unit were observed to contain numerous stored carts, linen hampers and equipment which reduced the usable width of the corridor.

Based on random observation during the survey walk-through, not all furnishings and decorations could be confirmed to comply with required flammability ratings in accordance with 19.3.3 and 10.2. These deficiencies could affect all persons in the facility by being the source of and contributing to the spread of fire and smoke.

Findings include:

A. Decorative dried plant/flower arrangements were observed on corridor walls and areas which could not be confirmed to be of Class A or B rating. Primaryly observed in the Four Seasons Long Term Care area of the building.

Based on random observation during the survey walk-through on the morning of July 6th 2011, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. During the survey of the ground floor mechanical room, the medical vacuum system piping was observed without labeling to identify the medical gas in accordance with 4-3.1.2.14 (a).

B. During the survey of the ground floor mechanical room, the medical vacuum system was observed without a durable sign identifying the receiver valve as the source valve for the hospital in accordance with 4-3.1.2.14 (b).

C. During the survey of the ground floor mechanical room, the medical vacuum system was observed without a durable sign identifying the valve from the main line as to the location within the hospital it served in accordance with 4-3.1.2.14 (b).

D. During the Afternoon walk-through on July 5th the oxygen valve from the bulk supply tank was observed without a durable sign identifying it as the oxygen source valve for the Hospital in accordance with 4-3.1.2.14 (b).

The above deficiencies could lead to staff shutting of the valve without knowing for sure what patient patient care area or system they are affecting causing injury to patients requiring the system.

Based on random observation during the survey walk-through, not all portions of the Type one emergency generator installation were installed and maintained in accordance with NFPA 110 and NFPA 99 1999.

Findings include:

A. During the walk-through of the equipment room on ground floor at approximately 9:30 am on the 6th of July 2011 the generator battery charger was observed to be plugged into a wall outlet not consistantly identified as emergency power, thus not in accordance with 99 3-4.2.2.2 (a).

This deficiency could lead to failure of the starting battery to be fully charged and the generator fail to start causing injury to patients requiring electric power for treatment.

B. The generator battery charger was observed to be connected to the starting battery terminals, thus not in accordance with 110 5-12.6.

C. The generator battery charger was observed without a battery charging meter to indicate if the charger is working in accordance with 110 3-5.3.4 (d).

Deficiency B and C could lead to failure of the starting battery to be fully charged and the generator fail to start causing injury to patients requiring electric power for treatment.

D. On the afternoon walk-through of July 5th 2011 the building natural gas shut off was observed without a line and valve ahead of the building shut off valve labeled as serving the natural gas emergency generator in accordance with 110 5-9.7.

E. During the morning walk-though on the 6th of July 2011 with senior maintenance staff it was confirmed a secondary fuel supply for the natural gas generator was not provided in accordance with 110 3-1.1 (exception).

Deficiencies D and E could lead to the premature failure of the emergency generator due to man made of natural disasters causing injury to patients requiring electric power for treatment.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the document review on the morning of the 6th of July 2011, not all testing and documentation are in accordance with NFPA 110.

Findings include:

A. During the document review held in the conference room on the morning of the 6th of July it was discovered weekly electrolyte readings on the starting batteries for the generator were not documented on the weekly generator form in accordance with 110 5-9.7.

B. During the document review held in the conference room on the morning of the 6th of July it was discovered monthly operating parameters for the generator were not documented in accordance with 110 6-3.4.

C. Monthly generator load tests listed 65 amps load during an average tests with a name plate full load amps at 486 indicating less than 30% load with out documented annual load bank testing in accordance with 110 6-4.2 (a).

The 3 deficiencies listed above could cause the premature failure of the emergency generator causing injury to patients requiring emergency power for treatment during normal power failure.

Based on random observation during the survey walk-through, not all portions of the facility's electrical distribution system are in accordance with NFPA 70 1999.

Findings include:

A. During the afternoon of July 5th 2011 the medical/surgery rooms were observed to only have normal electric receptacles installed and no emergency power outlets in accordance with 517-19 (a).

This deficiency could result in patients injury due to requiring electric power for treatment during a normal power failure.

B. During the afternoon of July 5th 2011 the recovery area was observed without emergency outlets labeled with the panel and circuit number serving critical areas in accordance with 517- 19 (b).

This deficiency could result in someone opening the breaker to an unaffected circuit causing patient injury during treatment.

C. During the facility walk-through on the afternoon of July 5th 2011 the emergency power breaker panels were observed with non-essential circuits powered from them with no separation of the 3 required branches of Critical, Life Safety and Equipment branches in accordance with 517-30 (b).

This deficiency could cause the overloading of the emergency generator causing failure which could result in patient injury.

Based on random observation during the survey walk-through, staff interview and review of Life Safety Plans dated 10-15-10 produced by Shive-Hattery Architects in Moline, IL, the construction type of the building does not comply with NFPA 101 - 2000, 19.1.6.2. This deficiency could affect all in-patients in the facility, as well as those residents of the Long Term Care portion of the building and any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

A. The original 1934 building area is partially sprinklered and indicated to be of Type III (000) construction type and is two stories with a basement. The building construction type is not permitted under Table 19.1.6.2. Surveyor notes that the original building area is not otherwise separated from the Hospital by 2-hour rated construction on all floor levels to allow it to be classified as a separate non-healthcare occupancy building. The 2-hour separation is indicated to only exist on the 2nd floor.

B. The 1954 and 1974 building areas are indicated to be of Type II (000) construction type. These building areas are also two stories with a basement. The building construction type is not permitted under Table 19.1.6.2 without full sprinkler protection. The building areas are only partially sprinkler protected.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke reaching the facility's exit access corridors.

Findings include:

A. The basement level corridor outside the Family Clinic has a bench for seating open to the corridor. The space is not provided with smoke detection to comply with the requirements of 19.3.6.1, Exception No. 7.

B. The Ground floor Lab waiting area is open to the corridor. The waiting area is not within a sprinklered smoke compartment and is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2. The camera observation provided for the space is not considered to be "direct observation" required as an alternative to the smoke detection. The waiting space is not otherwise provided with smoke detection to comply with 19.3.6.1 Exception No. 7.

C. The Ground floor X-ray waiting area is open to the corridor. The waiting area is not within a sprinklered smoke compartment and is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2. The camera observation provided for the space is not considered to be "direct observation" required as an alternative to the smoke detection. The waiting space is not otherwise provided with smoke detection to comply with 19.3.6.1 Exception No. 7.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the ground floor non-long term care areas of the facility, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. The Ground floor Cafeteria was provided with a pair of doors which were equipped only with a double keyed dead bolt lock. The dead bolt lock does not provide a means to positively self-latch the doors upon closing to comply with 19.3.6.3.2. Alternatively, the Cafeteria does not comply with 19.3.6.1 Exception No. 1 to allow it to be considered open to the corridor.

Based on random observation during the survey walk-through, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. Miscellaneous pipe and conduit penetrations were observed not to be sealed in accordance with fire/smoke rated tested design assemblies. Locations observed include but are not necessarily limited to the following:

1. At the Boiler room above boiler #2.

2. At the Kathabar equipment room.

B. The duct shaft from the basement level boiler room thru the first floor to the roof is not noted on the Life Safety Reference Plans as being fire rated. Actual construction was not investigated due to patient use of the of the room necessary to observe.

C. The presumed duct shaft from the basement level equipment room thru the first and second floors was not noted on the Life Safety Reference Plans as being fire rated. Actual construction was not verified.

D. The Public Stair door at the basement level does not self-close to a latched condition.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the 1st and 2nd floors of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. The entire basement area north and east of the main corridor between the Public Stair/elevator and the Family Care Clinic is considered a single hazardous area. The cross corridor doors at the north end of the main corridor are not minimum 3/4-hour rated to comply with 19.3.2.1.

B. The entire basement area north and east of the main corridor between the Public Stair/elevator and the Family Care Clinic is considered a single hazardous area. The active leaf of the cross corridor doors at the east side of the main corridor is not self-closing to comply with 19.3.2.1 because the closer device is equipped with a hold-open feature. The exit sign is located over the inactive leaf of this pair of doors rather than over the active leaf.

C. The Kitchen Storage room door off the Kitchen was observed to be held open by a non-approved wedge hold-open device in non-compliance with 7.2.1.8.2.

D. The 2nd floor south wing Clean Storage area is not separated from adjacent areas by 1-hour rated construction to comply with 19.3.2.1. The walls to adjacent areas contain windows and the doors are non-rated and have louvers. The corridor door is rated but is damaged to where the fire rating can not be verified to be maintained. The door si equipped with a "helper wheel" to keep it from dragging on the floor. The closer on this door is equipped with a hold-open feature.

E. The 2nd floor south wing "Women's Patient room" bathroom area utilized as a storage area was not separated by 1-hour rated wall construction and the corridor door was not minimum 3/4-hour rated to comply with 19.3.2.1.

F. The 2nd floor Linen Storage room (former Seclusion room) was not verified to be separated by 1-hour rated wall construction. The corridor door was not minimum 3/4-hour rated to comply with 19.3.2.1.

G. The 2nd floor Specialty Clinic Soiled Utility room door is not self-closing to a latched condition.

H. The 2nd floor Pharmacy area constitutes a hazardous area due to the storage of combustible materials. The Pharmacy was not protected by 1-hour rated construction in accordance with 19.3.2.1 or otherwise sprinklered in accordance with 8.4.1.

Based on random observation during the survey walk-through, Labrotories employing quantities of flammable, combustible materials are not protected in accordance with 19.3.2.1. These deficiencies could affect all patients on the 1st and 2nd floors of the facility, as well as any staff and visitors present, by exposing the facility to fire and smoke in the event of ignition.

Findings include:

A. The 1st floor Lab area utilizes flammable materials and stores them in cabinetry within the Lab. Four gal. of material was observed at the time of the survey. The Lab was not separated from the remainder of the building by 1-hour rated construction to comply with 19.3.2.1. The Lab was not otherwise sprinklered in accordance with 8.4.1 to comply with 19.3.2.1.

Based on random observation during the survey walk-through, not all exit ramps are constructed in accordance with the requirements of 19.2.2.6 & 7.2. These deficiencies could affect all patients on the 1st and 2nd floors of the facility, as well as any staff and visitors present, by impeding the use of the ramps during building exiting.

Findings include:

A. The exterior ramp from the basement is not provided with any handrails to comply with 19.2.2.6.1, 7.2.5.4 & 7.2.2.4.5.

B. The interior ramp at the basement is not provided with any handrails to comply with 19.2.2.6.1 and 7.2.5.4 & 7.2.2.4.5.

C. The interior ramps from the Ground floor and the 2nd floor to the exterior door are not provided with handrails on both sides to comply with 19.2.2.6.1 and 7.2.5.4 and 7.2.2.4.5.

Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. The Ground floor X-ray room door corridor door.

2. The 2nd floor west wing "Romona C Wound Care Nurse" corridor door.

B. Exterior exit doors are not operable within the force limitations required under 7.2.1.4.5. Locations observed include but are not necessarily limited to the following:

1. The basement level exterior discharge door from the west stair.

2. The Ground floor exterior discharge door from the Public Stair.

C. The cross corridor doors near the Cafeteria which allow access to the corridor leading to the exterior door at the emergency room entry swing against the direction of travel in non-compliance with 7.2.1.4.2. These doors are not otherwise identified as being part of a smoke barrier where the Exception would allow the doors to swing against the direction of travel.

Based on random observation during the survey walk-through, not all 2-hour fire barriers are maintained to afford the required 2-hour rating in accordance with 8.2.3. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by allowing the spread of fire and smoke to areas expected to be an area of safety.

Findings include:

A. The 2-hour barrier wall between the Four Seasons Long Term Care Unit and the remaining Hospital was observed not to be complete at the duct passing thru the wall above the ceiling at the "Sensory room" area of the Four Seasons Long Term Care Unit.

B. The 2-hour barrier wall between the Four Seasons Long Term Care Unit and the remaining Hospital at the Administration Conference room contained a large access door to gain access to an existing electrical panel in the original wall. The access door was not able to be closed and latched to maintain the rating of the wall and still allow it to be readily opened to access the electrical panel.

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. The designated exterior exit door from the Kitchen is not provided with lighting to comply with 7.8.1.4 and is not powered from the emergency system to comply with 7.9.

Based on document review and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. This deficiency could affect all patients in the 25 bed facility and all patients in the Four Seasons Long Term Care Unit, as well as any staff and visitors present, because the failure to maintain a clear plan could result in confusion of expected responses to a fire or smoke condition within the building.

Findings include:

A. The written Fire Plan (Code Red) policy states the following specific to the Med/Surg Unit. Similar directives are specified for other specific areas:

"Med/Surg:
Fire alarms: All but one nurse will report to front lobby and report to hospital accountability officer. One nurse will remain on the floor and will report to accountability by phone.
In event of an active Fire/smoke in building: Fire/smoke in building: Exit out closest exit, report to main parking lot. After secured only one nurse remains on floor unless smoke and/or fire are noted in the area. DO NOT ATTEMPT to remove anyone from Dept. by yourself at ANY TIME.
Duties: Securing 2nd floor Med/Surg areas, Place out of service barrier across visitor elevator if possible. Place patients in their rooms and close ALL doors and windows. Clear visitors from floor ensuring they go out their nearest exit. Close Oxygen valves on the way out of Dept."
"Incident command may order evacuation if not done by the Fire Dept. The senior person in the affected area may order departmental evacuation if necessary but only horizontally. The Fire Chief & Fire Dept. Staff have ultimate incident command after arrival along with Law Enforcement."

The above procedure is confusing. The policy does not specifically reference the "RACE" procedure but does contain similar components. It is not clear why "fire alarms" may be reponded to differently than "an active fire/smoke in the building" condition. The policy appears to call for the evacuation of the facility under an "active Fire/smoke in building" condition but then the "duties" calls to "place patients in their rooms and close all doors and windows." The policy appears to call for both vertical and horizontal evacuation of affected areas but does not define how or when each type is to be used. A clear and concise procedure for a fire alarm condition should merit the same response from staff regardless of circumstances of fire alarm activation. The evacuation orders should clarify when horizontal movement is expected and when building evacuation is expected.

Based on random observation during the survey walk-through conducted in the afternoon on July 5th and the morning of July 6th 2011, not all portions of the facility's fire alarm system are installed and maintained in accordance with NFPA 72 1999.

Findings include:

A. During the afternoon walk-through on July 5th of the Ground and First floors, several smoke detectors were observed to be installed less than 3' from supply diffusers, thus not in accordance with 2-3.5.1. Locations include:

1. Two detectors in the Ground floor corridor that leads to the South Stairwell.

2. One detector in the First floor Dining Room.

3. One detector in the East corridor to the West Elevator on First floor.

4. One detector by the East Stairwell on First floor.

B. During the morning walk-through on July 6th of the Second floor, several smoke detectors were observed to be installed less than 3' from supply diffusers, thus not in accordance with 2-3.5.1. Locations include:

1. One detector by the North stairwell on Second floor.

2. One detector in the the corridor by the South Stairwell on Second floor.

The above listed deficiencies could cause detectors to fail due to air flow and endangering staff and patients of smoke related injury.

C. During the Morning walk-through on July 6th fire alarm manual pull stations were observed to be more than 5' from the exit door and not in accordance with 2-8.2.2. Locations include:

1. The station by the Northwest Stairwell.

2. The station in the Lobby at the Front Entrance.

The alarm activation at such locations could endanger the person due to the travel distance to reach the outside.

D. During the afternoon walk-through on July 5th the main Fire Alarm Control Panel was observed to be powered from an identified breaker which was not mechanically locked in the on position in accordance with 1-5.2.5.2.

This deficiency could cause accidental tripping to the "off position" that could run down the battery, endangering alarm activation and patient safety.

Based on random observation the morning of July 6, 2011, not all portions of the facility's wet sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

A. During an attempt to conduct a sprinkler flow test about 11:00 am it was discovered the 1" inspector test connection located at the ground floor Family Clinic was not orificed to represent the flow from the smallest sprinkler in the zone, thus not in accordance with 5-15.4.2.

This deficiency would cause faster alarm time than a sprinkler head and could cause a false sense of safety for staff and patients.

Based on document review and staff interview, the facility's fire dampers are not inspected, tested, and maintained in accordance with 9.2 and 90A. These deficiencies could affect all patients in the 25 bed facility and all patients in the Four Seasons Long Term Care Unit as well as any staff and visitors present, because the failure to maintain the building's fire dampers could result in the failure of the devices to function as intended to contain fire and smoke in an emergency condition.

Findings include:

A. A review of the Fire Damper inspection report conducted by Life Safety Services of Louisville, KY on 9/3/08 revealed that 7 dampers were identified as "fail" due to being "seized, obstructed or bound-up". Staff indicated that no resolution of the failed condition of the dampers has taken place since the inspection.

Based on random observation during the survey walk-through, not all means of egress atr maintained free of obstructions or impediments to provided the full instant use to comply with 7.1.10. These deficiencies could affect all persons in the Four Seasons Long Term Care Unit by preventing safe and unimpeded access to the exits.

Findings include:

A. Corridors of the 1st floor Four Seasons Long Term Care Unit were observed to contain numerous stored carts, linen hampers and equipment which reduced the usable width of the corridor.

Based on random observation during the survey walk-through, not all furnishings and decorations could be confirmed to comply with required flammability ratings in accordance with 19.3.3 and 10.2. These deficiencies could affect all persons in the facility by being the source of and contributing to the spread of fire and smoke.

Findings include:

A. Decorative dried plant/flower arrangements were observed on corridor walls and areas which could not be confirmed to be of Class A or B rating. Primaryly observed in the Four Seasons Long Term Care area of the building.

Based on random observation during the survey walk-through on the morning of July 6th 2011, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. During the survey of the ground floor mechanical room, the medical vacuum system piping was observed without labeling to identify the medical gas in accordance with 4-3.1.2.14 (a).

B. During the survey of the ground floor mechanical room, the medical vacuum system was observed without a durable sign identifying the receiver valve as the source valve for the hospital in accordance with 4-3.1.2.14 (b).

C. During the survey of the ground floor mechanical room, the medical vacuum system was observed without a durable sign identifying the valve from the main line as to the location within the hospital it served in accordance with 4-3.1.2.14 (b).

D. During the Afternoon walk-through on July 5th the oxygen valve from the bulk supply tank was observed without a durable sign identifying it as the oxygen source valve for the Hospital in accordance with 4-3.1.2.14 (b).

The above deficiencies could lead to staff shutting of the valve without knowing for sure what patient patient care area or system they are affecting causing injury to patients requiring the system.

Based on random observation during the survey walk-through, not all portions of the Type one emergency generator installation were installed and maintained in accordance with NFPA 110 and NFPA 99 1999.

Findings include:

A. During the walk-through of the equipment room on ground floor at approximately 9:30 am on the 6th of July 2011 the generator battery charger was observed to be plugged into a wall outlet not consistantly identified as emergency power, thus not in accordance with 99 3-4.2.2.2 (a).

This deficiency could lead to failure of the starting battery to be fully charged and the generator fail to start causing injury to patients requiring electric power for treatment.

B. The generator battery charger was observed to be connected to the starting battery terminals, thus not in accordance with 110 5-12.6.

C. The generator battery charger was observed without a battery charging meter to indicate if the charger is working in accordance with 110 3-5.3.4 (d).

Deficiency B and C could lead to failure of the starting battery to be fully charged and the generator fail to start causing injury to patients requiring electric power for treatment.

D. On the afternoon walk-through of July 5th 2011 the building natural gas shut off was observed without a line and valve ahead of the building shut off valve labeled as serving the natural gas emergency generator in accordance with 110 5-9.7.

E. During the morning walk-though on the 6th of July 2011 with senior maintenance staff it was confirmed a secondary fuel supply for the natural gas generator was not provided in accordance with 110 3-1.1 (exception).

Deficiencies D and E could lead to the premature failure of the emergency generator due to man made of natural disasters causing injury to patients requiring electric power for treatment.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the document review on the morning of the 6th of July 2011, not all testing and documentation are in accordance with NFPA 110.

Findings include:

A. During the document review held in the conference room on the morning of the 6th of July it was discovered weekly electrolyte readings on the starting batteries for the generator were not documented on the weekly generator form in accordance with 110 5-9.7.

B. During the document review held in the conference room on the morning of the 6th of July it was discovered monthly operating parameters for the generator were not documented in accordance with 110 6-3.4.

C. Monthly generator load tests listed 65 amps load during an average tests with a name plate full load amps at 486 indicating less than 30% load with out documented annual load bank testing in accordance with 110 6-4.2 (a).

The 3 deficiencies listed above could cause the premature failure of the emergency generator causing injury to patients requiring emergency power for treatment during normal power failure.

Based on random observation during the survey walk-through, not all portions of the facility's electrical distribution system are in accordance with NFPA 70 1999.

Findings include:

A. During the afternoon of July 5th 2011 the medical/surgery rooms were observed to only have normal electric receptacles installed and no emergency power outlets in accordance with 517-19 (a).

This deficiency could result in patients injury due to requiring electric power for treatment during a normal power failure.

B. During the afternoon of July 5th 2011 the recovery area was observed without emergency outlets labeled with the panel and circuit number serving critical areas in accordance with 517- 19 (b).

This deficiency could result in someone opening the breaker to an unaffected circuit causing patient injury during treatment.

C. During the facility walk-through on the afternoon of July 5th 2011 the emergency power breaker panels were observed with non-essential circuits powered from them with no separation of the 3 required branches of Critical, Life Safety and Equipment branches in accordance with 517-30 (b).

This deficiency could cause the overloading of the emergency generator causing failure which could result in patient injury.