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Based on observation the facility failed to ensure that buildings that do not have a rated separation or fire protection features are separated from the hospital by distance or two hour separation for one wood structure used as office space. The facility census was 45.

Findings included:

Observation during tour on 9/14/10 revealed a wooden structure at the rear of the hospital outside the physical plant (boilers and mechanical room) of the hospital. The wooden structure was placed within six inches of the wall of the hospital. The wooden structure had wood floors, ceiling and walls and had no smoke detectors or sprinklers. The physical plant area of the hospital has no protection by sprinklers and the exterior wall is of brick construction. The facility stores multiple containers of compressed oxygen tanks immediately next to the wooden structure. Motor vehicles park in the metal overhang that covers both the wooden structure and the ambulance parking.

Based on record review and interview the facility failed to ensure that all shifts of staff received training in fire drill at least quarterly. The facility census was 45.

Findings included:

Review of the records for fire drills in the last year indicated that only one fire drill had been held between the hours of 11:00 PM and 7:00 AM for the night shift personnel on 9/14/09. No other drills had been held for the night shift personnel.

During an interview on 9/15/10 at 9:15 AM Staff W stated that he/she could not locate a fire drill done for that shift in the records other than the 9/14/09 drill for the night shift.

Based on record review and interview the facility failed to ensure that all components of the sprinkler system have been inspected or tested according to the prescribed requirements of the Life Safety Code (LSC) published by the National Fire Protection Association (NFPA) or that all sprinklers remained unobstructed. The facility census was 45.

Findings included:

1. Review of the records of testing for the sprinkler system did not reveal a test of the components of the sprinkler system in the last year for the main drain test or backflow test. Further review of the records did not indicate that the gauges of the sprinkler system had been tested or replaced in the last five years.

During an interview on 9/15/10 at 9:15 AM Staff W stated that there had been no test on the gauges in the last five years to their knowledge. There had been no test on the main drain (flow from the whole system) in the last year and that it had been two years since work had been done on the system since this has been done. Staff W stated that there was no record of backflow testing done in the last few years.

2. Observation of a storage area in radiology revealed a wooden shelf with items placed on the top shelf which were within eight inches of the sprinkler head in this area.

3. Observation of a storage area in the respiratory department revealed boxes on top of a shelf that were within twelve inches of a sprinkler head.

A-2.2.1.2 of the 1998 edition of NFPA 25 states that obstruction to spray patterns include horizontal obstructions near the ceiling, vertical obstructions, suspended or floor-mounted obstructions and clearances between sprinklers and storage below. The clearance requirement between sprinkler deflectors and the top of storage is typically 18 inches.

Chapter 9-2.6 of the 1998 edition of the National Fire Protection Association (NFPA) code 25 states that a main drain test shall be conducted annually at each water based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.

Chapter 9-2.8 states that gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.

Chapter 9-2.8.2 states that gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge.

9-3.2.3 states that all valves shall be inspected weekly.
Chapter 9-3.4.1 states that each control valve shall be operated annually through its full range and returned to its normal position.

Chapter 9-3.4.3 states that valve supervisory switches shall be tested semiannually.

Based on observation the facility failed to ensure that all tanks of compressed medical gasses were individually secured from falling. The facility census was 45.

Findings included:

Observation on 9/14/10 of the storage area outside of the physical plant of the building revealed two wire cages containing cylinders of compressed medical gasses. There were eight larger size tanks and three smaller size tanks in one cage with one chain securing all tanks. The second cage had five smaller "E" size tanks secured by one chain.

None of the tanks were individually secured.

Based on observation the facility failed to ensure that all barriers above the ceiling remained intact and prevented the spread of smoke or fire for one of four rated separations inspected in the facility. The facility census was 45.

Findings included:

Observation on 9/14/10 during tour of the facility revealed a two hour rated separation by the Intensive care unit and operating room area. The area above the ceiling was protected by plaster and wire and the areas around a duct and conduit were noted to not be complete barriers as light was seen passing through areas of the barrier. This would not prevent the passage of smoke and fire above the area.