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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. Corrected 04/20/2012.

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 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. Corrected 04/20/2012.

B. Corrected 04/20/2012.

C. Corrected 04/20/2012.

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. Corrected 04/20/2012.

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, 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. Corrected 04/20/2012.

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 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. Corrected 04/20/2012.

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

Findings include:

A. Corrected 04/20/2012.
B. Corrected 04/20/2012.

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.