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Based on tests to doors and observations made during the survey for life safety from fire with the facility's Safety Officer and Physical Plant Manager, it was determined that patient's doors protecting corridors at Santa Rosa II rooms #115 and #116 do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

During the tour for life safety from fire at Santa Rosa II on 3/25/10 at 9:10 am, patient's sleeping room doors were tested with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and it was found that patient's sleeping rooms #115 and #116 do not latch when the door are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at Santa Rosa I and II must be verified at least monthly and appropriate documentation must be available upon request.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Safety Officer and Physical Plant Manager, it was determined that the facility failed to ensure that a vision panel observed in the door of the cafeteria of Santa Rosa II provides appropriate fire resistance as required by the 2000 edition of the Life Safety Code of the NFPA Section 8.2.3.2.2, due to the frame made of wood and the use of plexi-glass for the vision panel.

Findings include:

The cafeteria located at Santa II was visited on 3/25/10 at 8:30 am with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence that the door that separates the cafeteria from the patient's hallway and route of escape, has a vision panel that has a wood frame and the vision panel is made of plexi-glass, "Vision panels in corridor doors shall be fixed window assemblies in approved frames".

Based on observations made during the survey for life safety from fire with the facility's Safety Officer and Physical Plant Manager, it was determined that the facility failed to provide readily visible illuminated "exit" signs where the exit or way to reach the exit is not readily apparent to its occupants such as the operating department and the Intensive Care Unit as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

There is the need of an illuminated exit sign near the double egress doors near the recovery room of the operating room department as observed on 3/24/10 at 11:50 am with the Physical Plant Manager (employee #15). Also, there is the need of two illuminated exit signs at the Intensive Care Unit as observed with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/25/10 at 10:00 am. One is needed in front of cubicle #6 and the other above the exit door. Illuminated exit signs in these areas will help to safely guide patients and staff out of these areas.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Safety Officer and Physical Plant Manager, it was determined that the facility failed to ensure that the maintenance closet doors in the operating room and in hallway of Santa Rosa I can resist the passage of smoke in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 8.3.4.1 as evidenced by louvers on these doors.

Findings include:

The maintenance closet with cleaning chemicals located in the operating room department observed on 3/24/10 at 11:45 am and the maintenance closet with cleaning chemicals located in the hallway of Santa Rosa I was observed on 3/24/10 at 2:00 pm with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) with louvers that open into the corridors. In the event of a fire in these closets, these doors would not resist the passage of smoke to the outside corridor.

Based on tests and observations made during the survey for life safety from fire with the facility's Safety Officer and Physical Plant Manager, it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in the adult and pediatric triage rooms of the emergency room, medical examination rooms of the emergency room, hallway near the cafeteria and the emergency lamps located at the operating department and in front of patient's room #217 did not illuminate when tested as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) at Santa Rosa I and II on 3/24/10 from 8:30 am till 3:45 pm and on 3/25/10 from 8:30 am till 12:00 noon in the following areas:
a. Within the adult and pediatric triage room of the emergency room.
b. Medical examination rooms #1 and #2 of the emergency room.
c. Two EBOLs are needed in the hallway in front of the cafeteria of Santa Rosa II.
d. In the Catherization department near the nursing station and routes of exit.
e. The hallways of the administration department and exit routes.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

2. The emergency battery operated lamps (EBOL) in the following areas were tested with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and did not illuminate as observed at Santa Rosa I and II on 3/24/10 from 8:30 am till 3:45 pm and on 3/25/10 from 8:30 am till 12:00 noon:
a. The EBOL located at the hallway of the operating rooms.
b. The EBOL located in front of patient room #217.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Safety Officer, it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation as required by LSC 2000 section 5.5.

Findings include:

1. Written documents about conducted fire drills for the hospital were reviewed with the Safety Officer (employee #14) on 3/25/10 at 1:35 pm and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer and Physical Plant Manager, it was determined that the facility failed to ensure that smoke detectors are available in required areas such as maintenance closets, biohazardous trash rooms, dirty linen rooms, emergency room, operating room department, smoke detectors are too close to air vents, lack of fire alarm system documentation and the Santa Rosa I and II fire alarms do not automatically notify the alarm to an approved central station in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed at Santa Rosa I and II with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 from 8:30 am till 3:45 pm and on 3/25/10 from 8:30 am till 12:00 noon:
a. All maintenance closets with cleaning chemicals and solutions.
b. The area of the emergency room where cubicles #4 through #9 are located.
c. The entire operating room department and operating rooms.
d. Dirty linen closets.
e. Biohazardous storage closets within the facility.
f. The pantry at Santa Rosa I.
g. The Administration department.
h. The general storage department.
i. The cafeteria at Santa Rosa II.

2. The smoke detector located on the ceiling in front of the medical evaluation rooms of the emergency room was found on 3/24/10 at 9:15 am with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) located within one foot from ceiling air conditioner vents; due to the air flow from these vents at least three feet is needed.

3. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 3/25/10 at 1:30 pm with the Safety Officer (employee #14), however no evidence was found of the following:
a. A detailed description of tests performed and readings.
b. Smoke detector sensitivity tests .
c. Installation documentation.

4. The fire alarm system of Santa Rosa I and II lacks annunciation to an approved central station as reviewed on 3/25/10 at 1:40 pm with the Safety Officer (employee #14). The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

Based on observations during the survey for Life safety from fire with the facility's Safety Officer and Physical Plant Manger and interview, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-S related to the storage of oxygen tanks, fire extinguishers with only English instructions, ground fault receptacle needed in the emergency room, the back door of Administration department needs a push pad, electrical circuit breaker panels found unlocked, breakers are not identified as to their function and breaker slots are empty, two bottles of rubbing alcohol was found in the emergency room and the cafeteria at Santa Rosa II does not have a hood extractor extinguishing system and no type K fire extinguisher.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of Santa Rosa I and II with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 from 8:30 am till 3:45 pm and on 3/25/10 from 8:30 am till 12:00 noon, type E oxygen tanks were found in areas that do not meet minimum requirements:
a. Two type E oxygen cylinders located in the communication closet of the emergency room.
b. One type E oxygen cylinder was found in suite #3 of the operating room.

2. A regular receptacle was found near the sink in the emergency room in front of cubicle #5 on 3/24/10 at 9:50 am with the Safety Officer (employee #14) and Physical Plant Manager (employee #15). A ground fault receptacle is needed due to its close proximity to a water source.

3. The instruction labels on the fire extinguishers related to their use is only in "English" as observed on 3/24/10 from 8:30 am till 3:30 pm and on 3/25/10 from 8:30 am till 12:00 noon with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and not in "Spanish" the predominant language spoken in Puerto Rico.

4. The back exit door of the administration department was found with a key lock on 3/25/10 at 11:05 am with the Safety Officer (employee #14) and Physical Plant Manager (employee #15). A push pad is needed to ensure that the door of this exit route will open in the event of an emergency.

5. Electrical circuit breaker panels located at Santa Rosa I and II were observed on 3/24/10 from 8:30 am till 3:30 pm and on 3/25/10 from 8:30 am till 12:00 noon with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) unlocked and breakers are not identified as to their function. Circuit breakers are to be secured from unauthorized access and all slots are to be covered to prevent accidental injury.

6. Two bottles of rubbing alcohol were found in the minor surgery room in the emergency room on 3/24/10 at 10:20 am with the emergency room supervisor (employee #13). The emergency room supervisor (employee #13) stated during an interview on 3/24/10 at 10:21 am that the rubbing alcohol is used to disinfect the operating bed between patients. Rubbing alcohol shall be limited in hospital settings due to its volatile nature.

7. The cafeteria located at Santa Rosa II was visited with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/25/10 at 8:30 am and provided evidence that the fryer does not have a hood extractor above it nor an extinguishing system. Also, no evidence was found of a type K fire extinguisher for this area.

Based on the review of written documents during the survey for life safety from fire with the facility's Safety Officer and Physical Plant Manager, it was determined that the facility failed to ensure that personnel perform weekly and monthly inspections of the electrical generator as required by the NFPA 99, section 3.4.4.1.

Findings include:

1. The facility lacks written evidence of the weekly inspections of the generator as reviewed with the Physical Plant Manager (employee #15) on 3/25/10 at 1:15 pm. The facility did not have a check list which includes batteries condition, coolant level, belts, oil pressure and oil change, battery contacts, hoses and pipes, main fuel tank level, leaks if any, oil filter, air filter and other checks from NFPA-99. During the past year of 2009 and the months of 2010 the facility could not provide evidence of weekly tests.

2. No evidence was found on 3/25/10 at 1:10 pm with the Physical Plant Manager (employee #15) related to tests performed on the electrical generator under load conditions for 30 minutes on a monthly basis.

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Safety Officer and Physical Plant Manager, it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence reviewed on 3/25/10 at 2:05 pm with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) related to preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances. The six month and annual tests must be performed by a qualified electrician and the varied tests that are performed must be documented and handed to the facility.