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Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/4/2011 the surveyor noted in the Operating Room (OR) electrical room that a conduit was penetrating the wall without being sealed properly with fire stop material.

2. On 1/5/2011 the surveyor noted in the Outpatient Specialty fan room penetration in the overhead and high wall.

3. On 1/5/2011 the surveyor noted in the Outpatient Specialty Clinic reception office that a ceiling tile was missing.

4. On 1/5/2011 the surveyor noted in the kitchen (kitchen to pantry) that an IT cable had been installed without being sealed properly with fire stop material.

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 1/4/2011 the surveyor noted that 2 doors in the Medical Records Room (Chart Room) were propped open without the use of holds that would release and cause the doors to close upon activation of the fire alarm system.

2. On 1/4/2011 the surveyor noted that fire doors (double doors) near the gift shop failed to properly close and latch due to a malfunctioning sequencer.

3. On 1/4/2011 the surveyor noted that the front door leading into the Jefferson Orthopedic Group/Office Clinic was propped open with a chair making it unable to close upon activation of the fire alarm system.

4. On 1/5/2011 the surveyor noted that a set of double smoke doors located near the main reception area (basement to reception) had an excessive gap (> 1/8 inch to approximately 1/2 inch) between the doors that would allow for the passage of smoke.

5. On 1/5/2011 the surveyor noted that the fire door at the kitchen serving line had been modified (closure removed, handles and other hardware removed) preventing it from resisting the passage of smoke/fire and allowing it to close and latch properly.

6. On 1/5/2011 the surveyor noted that the door leading from the kitchen scullery area into the adjacent corridor would not latch properly.

7. On 1/5/2011 the surveyor noted that the kitchen dry goods storage room door had been propped open with a trash container preventing it to close upon activation of the fire alarm system. It was further noted that the door would not latch properly.

8. On 1/5/2011 the surveyor noted that the 3rd floor center exit door of the 1929 building failed to latch properly.

9. On 1/5/2011 the surveyor noted that the 2nd floor elevator lobby doors had missing hardware and one of the doors had been propped open.

10. On 1.5.2011 the surveyor noted the the 2nd floor exit door failed to latch properly.

Based on observation the facility failed to maintain an exit stairway as is required. Failure on the part of the facility to maintain exit stairways puts patients, staff and visitors of the facility at risk in the event of fire.

Findings include::

1. On 1/5/2011 the surveyor noted that the NE stairwell had items stored at the bottom floor beneath the stairs. Items such as empty water carboys and a water cooler were noted.

2. On 1/5/2011 the surveyor noted that lift equipment was being stored in the Physical Therapy exit stairwell.

Based on observation the facility failed to maintain exit access in such a manner as to prevent an impediment in the way of travel to exit.

Failure on the part of the facility to maintain an exit access free of impediments puts patients, staff and visitors of the facility at risk from the effects of smoke, fire and other situations requiring emergency exiting.

Findings include:

1. On 1/4/2011 while touring the facility the surveyor noted that the 3rd floor stairway exit serving the LDRP unit was inaccessible to persons located outside the LDRP unit. Both exit access corridors leading into the unit had doors with magnetic locks that could not be opened without an alarm being set off, loss of power or the locks being released by staff.

It was further noted by the surveyor that the stairwell exit door was served by a delayed access locking device.

Based on observation the facility failed to provide emergency lighting as required. Failure to provide emergency lighting puts staff at risk in the event of an emergency and where exiting is required.

Findings include:

1. On 1/5/2011 the surveyor noted that the battery powered emergency light unit in the apartment located above the laundry was not functioning properly. One bulb of the unit did not light upon testing.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/4/2011 the surveyor noted that a sprinkler head in Emergency Room number 2 was missing an escutcheon.

2. On 1/4/2011 the surveyor noted that a sprinkler riser room (Room 270) was improperly labeled "Mechanical Room".

Based on observation and interview the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers that were being inspected as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/5/2011 the surveyor noted that a portable fire extinguisher located in the elevator mechanical room has not been inspected monthly as required. The last date of inspection as indicated on the the tag was 2/13/2011.

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 1/4/2011 the surveyor noted a portable space heater of an unacceptable type located in Room 1 of Jefferson Healthcare Orthopaedic.

2. On 1/5/2011 the surveyor noted a portable space heater of an unacceptable type located in Massage Therapy, 2nd floor 1929 building.

Based on observation the facility failed to prevent decorations of a highly flammable character from being used. Failure on the part of the facility to prevent decorations of a highly flammable character from being used in the facility puts patients, staff and visitors of the facility at risk from the effects of fire.

Findings include:

1. On 1/5/2011 the surveyor noted a Christmas wreath mounted behind the main entrance reception desk. The wreath was made of natural untreated materials.

Based on observation the facility failed to prohibit the placement of trash collection receptacles of greater than 32 gallons in the facility. Failure on the part of the facility to prohibit receptacles of greater than 32 gallons puts patients, staff and visitors of the facility at risk from the effects of fire

Findings include:

1. On 1/4/2011 the surveyor noted a trash receptacle having a capacity of greater than 32 gallons located in the Emergency Department.

2. On 1/4/2011 the surveyor noted two (2) 55 gallon drums in the Imaging Department being used for the collection of film negatives that were to be disposed of by a contractor.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code. More specifically, the facility improperly used extension cords to certain equipment.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 1/4/2011 the surveyor noted that a printer in the ICU case manager's office was plugged into an extension cord.

2. On 1/4/2011 the surveyor noted that a sink in the Day Surgery recovery area was not supplied with a GFCI receptacle.

3. On 1/4/2011 the surveyor noted that a sink at the Emergency Room reception desk was not supplied with a GFCI receptacle.

4. On 1/4/2011 the surveyor noted that a multi-plug adapter of an unapproved type was being used in the Medical Records area.

5. On 1/4/2011 the surveyor noted that in the Gift shop an extension cord that had been taped to the floor was being used.

6. On 1/4/2011 the surveyor noted that in the Imaging Department film storage area that a power cord and IT cable was taped to the floor.

7. On 1/4/2011 the surveyor noted that electrical breakers were not properly labeled in breaker panels (3rd floor electrical room,; 2nd floor panel ELB#13)

8. On 1/5/2011 the surveyor noted that a kitchen sink near the Dietitian's office was not provided with a GFCI receptacle.

9. On 1/5/2011 the surveyor noted that in the IT storage room on the 3rd floor of the 1929 building a cooler was plugged into an extension cord.

10. On 1/5/2011 the surveyor noted that in an office on the 3rd floor of the 1929 building a power strip was connected (plugged into) another power strip.

11. On 1/5/2011 the surveyor noted that a junction box in the generator room was missing a cover plate.

12. On 1/5/2011 the surveyor noted in the dinning area of the cafeteria a power strip connected to an extension cord.

13. On 1/5/2011 the surveyor noted a halogen lamp in the Peri-op Services office.

Based on observation the facility failed to install an alcohol based hand rub (ABHR) dispenser in an appropriate manner.

Failure to install ABHR dispensers appropriately puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

1. On 1/4/2011 the surveyor observed an Alcohol Based Hand Rub (ABHR) dispenser that was installed over an ignition source (electrical recepticle) in the "Old Nursery" 3rd floor.

2. On 1/4/2011 the surveyor observed an ABHR dispenser that was installed over (adjacent) an ignition source (electrical recepticle) at the nurses station in the ICU.