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Based on observation and interview, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms. This deficient practice (two of 19 patient room doors) prevents staff from being able to isolate a fire to a limited area and prevent the spread of smoke, which potentially affects all staff, visitors and all patients of the first floor medical-surgical wing. The facility census was 41.

Findings included:

1. Observation on 09/16/14 at 11:15 AM showed the entrance door to patient room 122 and room 123 failed to close into the jamb due to misalignment and binding. In both cases, the door of the room was pulled closed several times and required a hard pull with considerable force to close into the jamb and latch.

2. During an interview at the same date and time, Staff DD, Director of Maintenance, agreed with the finding and stated that due to his staff being cut Maintenance personnel do not have time to perform regularly scheduled preventive maintenance rounds to ensure a high quality environment of care. He stated that there is no policy and procedure to govern preventive maintenance rounds. He stated that he used to make quarterly rounds but being short of staff, they are all busy trying to keep up with repairs.

Based on observation, interview, and record review, the facility failed to ensure annual inspection, testing and maintenance of the facility fire alarm system in accordance with NFPA 72, section 10.2.1.2, by qualified and experienced personnel. A failure of this facility-wide system could potentially jeopardize the life safety of all occupants in the multi-level hospital and directly affect staff, visitors and patients. The facility census was 41.

Findings included:

Record review on 09/17/14 at 10:15 AM showed the facility had not received an annual inspection, test and maintenance (checking backup batteries or replacing faulty pull stations) for the fire alarm system. Documents showed the last annual inspection and tests were performed on 02/14/13. Record review also revealed that the Director of Maintenance had submitted a requisition on 06/05/14 and another on 08/28/14 to have the alarm company come out and perform the scheduled annual inspection, test and maintenance.

During interviews on 09/17/14 at 10:30 AM, Staff DD, Director of Maintenance stated that he had requested the inspection but facility had been short of funds so he was never sure either requisition had gone through. He stated that generally vendors will contact the facility ahead of time so the inspection and tests can be arranged, but some vendors received late payments or had not been paid in full for their past services.

Based on observation, interview and record review, the facility failed to ensure required safety measures for designated smoking areas were implemented in accordance with 19.7.4 and enforced in one of one designated smoking area for patients in the facility's behavioral health unit. This deficient practice could potentially result in a fire from unsecured cigarette ash residue that is not emptied into proper receptacles. The facility census was 41.

Findings included:

1. Observation on 09/16/14 at 4:20 PM showed a smoking room located on the Resolutions Behavioral Health Unit. A gable vent fan attached to the window provided an exhaust to the outdoors. Three containers of ashes, each filled with numerous cigarette butts were sitting on the floor and one was balanced on the arm of a chair. One of the containers was a 10 inch square cake pan with a narrow rolled rim that was not suitable for resting a cigarette. The second container was the clamshell top of a nearby pedestal ash tray. Although the clamshell top had suitable resting places around the rim, the doors were easily opened and without the bottom half of the container to catch the hot ash, a patient could accidentally trip the doors and have a lap full of hot ashes. The third container was the bottom of the pedestal ash tray which was not a suitable safe design as it lacked any place around the narrow rim for a cigarette to balance or to be at rest unattended. Without ashtrays of safe design, patients are at risk for being burned or catching their clothing on fire, even in a supervised area.

2. Observation on 09/16/14 at 4:20 PM also showed that the room lacked an appropriate receptacle for disposal of hot ashes and spent cigarette butts. The CMS (Centers for Medicare & Medicaid Services) adopted code, NFPA (National Fire Protection Association) referenced above requires metal or non-flammable containers with self-closing cover devices into which ashtrays can be emptied to be readily available in all areas where smoking is permitted.

3. Record review of the Hospital's Policy No. 06-2.1, dated 09/01/06 states that the facility is a tobacco free facility effective September 1, 2006.

4. Record review of an undated smoking policy for the Inpatient Resolutions Behavioral Health unit states that the patient shall smoke only in an area designated specifically for smoking. It does not specify the provision for using ashtrays of safe design and a covered container of metal or other suitable fire-resistant (non-flammable) material.

4. Record review of the Hospital's policy titled "Tobacco Free Workplace" dated 09/01/06 stated that the facility claims the right to exclude a specified smoking area based on the following:

Under the Medicare Conditions of Participation 483.15(b)(3) for long-term care facilities, current residents who smoke must be allowed to continue smoking in a defined area. Residents admitted after a tobacco ban is implemented must be informed of the policy before transfer to that facility and must be notified of this policy at admission.

4. During an interview on 09/15/14, Staff UUU, Behavioral Health Unit staff stated that the ash trays are emptied daily into the regular trash.

Based on record review and interview, the facility failed to ensure the kitchen range hood received biannual (twice yearly) inspection, test and maintenance in accordance with 9.2.3. Failure to ensure this fire suppression system was deployable potentially endangers the kitchen personnel working in the area, and increases the chances of a grease fire getting out of control in an unsprinklered area of the building. The facility census was 14.

Findings included:

1. Record review on 09/17/14 at 10:15 AM showed the last two inspections for the kitchen range hood was on 06/10/14 and 04/24/13. Review of past inspections showed a semi-annual inspection of the kitchen range hood's fire suppression system would have been due in October 2013 (the sixth month), and there was no documentation to indicate a biannual inspection had been performed.

2. During an interview on 09/17/14 at 10:30 AM, Staff DD, Director of Maintenance stated that he agreed with the finding.

Based on observation and interview, the facility failed to ensure all self-closing doors to an unsprinklered soiled linen chute that traversed three floors were maintained to operate as designed in accordance with 8.2.4.2. This deficient practice defeats the purpose of the enclosed shaft by allowing a penetration through an unprotected gap (the open soiled linen chute door) and has the potential to spread fire quickly to other floors in the building, affecting all staff, visitors and patients. The facility census was 14.

Findings included:

1. Observation on 09/16/14 at 1:30 PM showed a metal door to a linen chute in a small soiled linen closet off of the second floor core area was jammed partially open and could not close automatically as designed.

2. During an interview on 09/16/14 at 1:30 PM, Staff DD, Director of Maintenance stated that the soiled linen chute had been there since the hospital was built and was not sprinklered. He acknowledged the finding and stated that the chain was broken again.

Based upon observation and interview, the facility failed to store flammable liquids in an approved container suitable for storage of flammable and combustible liquids, in accordance with NFPA 30 and NFPA 99. This deficient practice-the storage of flammables in an unprotected, unsprinklered room along with paper and plastic combustible products are stored potentially affects the safety of all staff and patients. The patient census was 14.

Findings included:

1. Observations on 09/16/14 1:00 PM in the kitchen's dry goods storage room showed a partially used case of Sterno,(flammable gelatin in a can, used for warming casseroles or dutch ovens), a case of butane canisters for a small cooking stove (highly flammable pressurized gas) and a partial case of charcoal lighter fluid. The cases of highly flammable products were all sitting in their original cardboard containers on open shelves in a small unsprinklered room where all of the kitchens paper products, paper and plastic dinnerware, foam cups and holiday decorations were stored.

2. During an interview on 09/16/14 at 1:05 PM, Staff L, Director of Food Services, stated that he probably used the fuel once or twice a week, he had never been advised to get a special cabinet to store them in and he did not have a policy or procedure on storage and use of flammable gas products.

Based on observation and interview, the facility failed to post appropriate, readable precautionary signs in accordance with NFPA 99, section 8-3.1.11.3 on the door to a corridor room where flammable compressed gases are stored for use by respiratory therapy. Warning signs are mandated for listed hazards to protect fire-fighters and first responders who are responding to a fire and failure to provide signage endangers all staff, visitors, and patients. The patient census was 14.

Findings included:

1. Observation on 09/16/14 at 10:12 AM showed no warning sign on the door of a storage room used by Respiratory Therapy that contained numerous racks of "E" sized cylinders of compressed oxygen, a flammable gas product that supports combustion. The room was appropriately constructed to the product stored; of concrete block, concrete ceiling and vented to the outside. NFPA 99, section 8-3.1.11.3 states that at a minimum, the warning sign should contain the following:
CAUTION
OXIDIZING GASES STORED WITHIN
NO SMOKING

2. During an interview on 09/16/14 at 10:15 AM, Staff DD, Director of Maintenance acknowledged the finding and stated that there had never been a sign on the door. He stated there was no approved facility policy regarding placement of warning signs on stored hazards.

Based on observation, record review and interview, the facility failed to show documentation that the diesel fueled generator received an annual load bank test during the past 12 months in accordance with 2002 NFPA 99, Chapter 8.4.2.3 to ensure reliability of the facility's single source of emergency power. The deficient practice of an unreliable source of emergency power affects the entire facility, patients and staff and impedes the performance of their duties. The facility census was 14.

All hospitals are considered Level I facilities. Level I facilities are expected to have life support capability and to have a minimum of two separate electrical systems backed up by one or more power plants (generators), which support the emergency (Life Safety) branch and the critical branch. The emergency branch system is limited to circuits essential to life safety and critical patient care. The critical branch is for remaining essential systems; HVAC, pumps, utility support equipment, etc.

1. Observation on 09/16/14 at 10:00 AM showed the facility had a large diesel fueled emergency generator with a power rating of 350 Kilowatts.

2. Record review on 09/17/14 at 10:15 AM of generator performance logs showed the generator was being exercised weekly and load tested monthly under the facility load, which was less than the nameplate rating of 350 Kilowatts. Records showed that the last full load bank test on the generator was conducted on 03/14/12 by an outside company.

3. During interviews on 09/16/14 and 09/17/14, Staff DD, Director of Maintenance acknowledged that the generator was new in 2010 and was considerably larger than the former emergency power plant. He stated that he thought he remembered the initial load bank test but due to budget cuts and shortage of funds, they had not performed a full load test for at least 12 months.

Based on observation, interview and record review the facility failed to have the elevator inspected in accordance with 2000 NFPA 101, Chapter 9.4.6 and ASME/ANSI A17.3, the Safety Code for Existing Elevators and Escalators, which requires that elevator safety inspections not exceed, at a minimum 12 month intervals. The facility has three elevators in frequent use daily. Should a catastrophic equipment failure occur, this deficient practice could result in a serious injury or death to one or more staff, visitors or patients. The facility census was 14.

Findings included:

1. Observation during tours on 09/16/14 at 9:30 AM through 09/17/14 at 1:00 PM showed the facility had three of three passenger elevators in operating condition.

2. Record review on 09/17/14 at 10:15 AM of maintenance logs and inspection certifications showed the elevators had last been inspected on 04/1/13 and licensed by the Division of Fire Safety's Elevator Inspection Division.

3. During interviews on 09/17/14 at 10:30 AM, Staff DD, Director of Maintenance stated that he had requested the inspection and the inspector told him that he would get back to him with a date for the inspection. He stated that the inspector has not contacted him since. He stated that the facility had been short of funds. He stated that generally vendors will contact the facility ahead of time so the inspection and tests can be arranged, but some vendors received late payments or had not been paid in full for their past services.