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Based on observation and interview, the facility failed to ensure that the fire exit access remained clear and unobstructed at all times in case of fire or an evacuation emergency.

Finding:

On November 27, 2012, the evaluator conducted an inspection of the facility basement and observed that the staff had stored boxes and two beds in the corridor located near the fire exit and smoke barrier doors near the disaster water storage room and utility room.

An interview was held with the Building Supervisor and he stated that the equipment would be relocated as soon as possible.

Based on record review and interview, the facility failed to provide documentation that the staff were drilled at unexpected times and under varied conditions.

Finding:

On November 27, 2012, at 11:30 a.m., the evaluator conducted a review of the hospital fire drills. There was no documentation that fire drills were being conducted under varied conditions.

An interview was held with the staff member in charge of conducting the fire drills and he stated the fire drill forms would be modified to reflect the varied conditions as soon as possible.

Based on observation and interview, the facility failed to ensure that all areas of the hospital (i.e. Recovery and Post Operative suite) were protected by an audible fire alarm system at all times.

Finding:

On November 28, 2012, at 10:54 a.m., the evaluator observed the testing of the fire alarm system. The Building Supervisor activated a smoke detector located in a sixteen bed Recovery and Post Operative suite. The smoke barrier doors closed but the evaluator did not hear an audible fire alarm within the smoke compartment.

An interview was conducted with the Building Supervisor and he stated that they did not notice that the fire alarm did not sound and that it had been that way for a long time.

In case of a fire or evacuation, an emergency fire alarm system is required to be fully functional at all times.

(1) NFPA 25, 2-3.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples shall be submitted to a recognized testing laboratory acceptable to the Authority Having Jurisdiction (AHJ) for operational testing. Test procedures shall be repeated thereafter at 10-year intervals.
"Exception #1: Sprinklers manufactured prior to 1920 shall be replaced. "
"Exception #2: Fast response sprinklers that have been in service for 20 years shall be tested. They shall be retested at 10-year intervals. "
"Exception #3: Representative samples of solder-type sprinklers with temperature classification of extra high (325?F) or greater that are exposed to semicontinuous to continuous maximum allowable ambient temperature conditions shall be tested at 5- year intervals."

Based on observation, record review, and interview, the facility failed to provide documentation that the 50 year and older fire sprinklers were replaced or tested.

Finding:
On November 27, 2012, the evaluator conducted an investigation of the facility's fire sprinkler system. The evaluator observed that a section of the hospital had original fire sprinklers that were over 50 years old and located in room 08.

A review of the fire sprinkler inspection report, dated August 26, 2010, revealed a 50 year old fire sprinkler "service pass" document. The evaluator requested another document from a "recognized testing laboratory" approved by the Authority Having Jurisdiction for operational testing.

An interview was held with the Building Supervisor and he stated that he was not aware of the 50 year fire sprinkler testing requirement and he would contact the service company as soon as possible.

(2) NFPA 13, 1999 Edition, 5-5.4.1 Distance below Ceilings. The distances between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. 5-5.4.1 Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. 5-5.5.3 Obstructions that prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inch below the sprinkler deflector in a manner to limit the distrubution from reaching the protected hazard shall comply with 5-5.5.3

Based on observation and interview, the facility failed to ensure that all the fire sprinkler heads water discharge pattern were not impeded by being recessed into the ceiling opening.

Finding:

On November 27, 2012, the evaluator conducted an inspection of the hospital life safety code system. The evaluator inspected the Emergency Room storage area and observed one fire sprinkler head recessed into the ceiling which impeded the water discharge pattern.

An interview was held with the Building Supervisor and he stated that he would have the sprinkler head serviced as soon as possible.

NFPA 10, 1998 Edition, Monthly Inspection, Chapter 4 Inspection, Maintenance, and Recharging, 4-3.2* Procedures. Periodic inspection of fire extinguishers
shall include a check of at least the following items: (a) Location in designated place (b) No obstruction to access or visibility.

NFPA 10, Standard for Portable Fire Extinguishers 1998 Edition, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the
top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Based on observation and interview, the facility failed to ensure that all the portable fire extinguishers were immediately available and accessible at all times.

Finding:

On November 27, 2012, the evaluator conducted an inspection of the facility Life Safety Code System. The evaluator observed the following: Histopathology Room - One portable fire extinguisher mounted 5 ft 4 inches above the floor and the device access was blocked by equipment.

An interview was held with the Building Supervisor and he stated that the portable fire extinguisher would be made accessible as soon as possible.

(1) NFPA 99 Health Care Facilities 1999 edition

4-3.5.2.2(b)(2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

This requirement was not met as evidenced by:

Based on observation, the facility failed to ensure nonflammable gases were stored in accordance with NFPA (National Fire Protection Association) 99 by not segregating empty cylinders from full cylinders.

Findings:

On November 27, 2012, at 11:00 a.m., accompanied by the Building Supervisor, the evaluator observed 4 full oxygen cylinders and 2 empty oxygen cylinders stored together in the basement Recovery Area.

An interview was held with the Building Supervisor and he stated that he would provide a clearer separation as soon as possible.

(2) NFPA 2000, 101, 7.10.8.1 No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO Exit. Such sign shall have the word NO in letters 2-inches high with a stroke width of 3/8 inches and the word EXIT in letters 1-inch high, with the word EXIT below the NO.

Based on observation and interview, the facility failed to ensure that a fire exit access was apparent in case of a fire or evacuation emergency at all times.

Finding:

On November 29, 2012, at 1:00 p.m., the evaluator inspected the facility's 2nd floor fire exit access staircase and observed no directional arrow or information regarding means of egress (i.e. down and/or up the staircase).

An interview was held with the Building Supervisor regarding access to the roof. The Building Supervisor stated the roof access door was locked and the evacuation route was down the stairs.

In case of a fire, smoke, or evacuation emergency the direction of exit access travel shall be clearly indicated in all areas leading to a safe area where it may not be apparent.

(3) NFPA 99, 2000, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1 (b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation and interview, the facility failed to properly secure all medical gas cylinders at all times.

Finding:

On November 27, 2012, at 2:30 p.m., the evaluator conducted an inspection of the facility's emergency room storage area and observed a free standing oxygen medical gas cylinder being stored in between the wall and a crash cart. The medical gas cylinder was not secured. The evaluator inspected the Post Anesthesia Care Unit and observed an oxygen medical gas cylinder lying on the floor. An interview was conducted with Licensed Nurse 3 and she stated "I know we don't have a standard and we just lie it on the floor".

An interview was held with the Building Supervisor and he stated that he would have the oxygen cylinders secured as soon as possible.

NFPA 70, National Electrical Code 1999, 110-26. Spaces about Electrical Equipment, Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to ARTICLE 110-REQUIREMENTS FOR ELECTRICAL INSTALLATIONS 70-29 require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code. (1) Depth of Working Space.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space shall be suitably guarded.

Based on observation and interview, the facility failed to ensure that the basement electrical panel remained accessible and safe at all times.

Finding:

On November 27, 2012, at 9:42 a.m., the evaluator inspected the basement clean linen storage room. The evaluator observed an adjacent storage room that also housed an electrical panel that was blocked by two clean linen carts.

An interview was held with the Building Supervisor and he stated that he would have the two linen carts removed as soon as possible.

Based on observation and interview, the facility failed to ensure that the fire exit access remained clear and unobstructed at all times in case of fire or an evacuation emergency.

Finding:

On November 27, 2012, the evaluator conducted an inspection of the facility basement and observed that the staff had stored boxes and two beds in the corridor located near the fire exit and smoke barrier doors near the disaster water storage room and utility room.

An interview was held with the Building Supervisor and he stated that the equipment would be relocated as soon as possible.

Based on record review and interview, the facility failed to provide documentation that the staff were drilled at unexpected times and under varied conditions.

Finding:

On November 27, 2012, at 11:30 a.m., the evaluator conducted a review of the hospital fire drills. There was no documentation that fire drills were being conducted under varied conditions.

An interview was held with the staff member in charge of conducting the fire drills and he stated the fire drill forms would be modified to reflect the varied conditions as soon as possible.

Based on observation and interview, the facility failed to ensure that all areas of the hospital (i.e. Recovery and Post Operative suite) were protected by an audible fire alarm system at all times.

Finding:

On November 28, 2012, at 10:54 a.m., the evaluator observed the testing of the fire alarm system. The Building Supervisor activated a smoke detector located in a sixteen bed Recovery and Post Operative suite. The smoke barrier doors closed but the evaluator did not hear an audible fire alarm within the smoke compartment.

An interview was conducted with the Building Supervisor and he stated that they did not notice that the fire alarm did not sound and that it had been that way for a long time.

In case of a fire or evacuation, an emergency fire alarm system is required to be fully functional at all times.

(1) NFPA 25, 2-3.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples shall be submitted to a recognized testing laboratory acceptable to the Authority Having Jurisdiction (AHJ) for operational testing. Test procedures shall be repeated thereafter at 10-year intervals.
"Exception #1: Sprinklers manufactured prior to 1920 shall be replaced. "
"Exception #2: Fast response sprinklers that have been in service for 20 years shall be tested. They shall be retested at 10-year intervals. "
"Exception #3: Representative samples of solder-type sprinklers with temperature classification of extra high (325?F) or greater that are exposed to semicontinuous to continuous maximum allowable ambient temperature conditions shall be tested at 5- year intervals."

Based on observation, record review, and interview, the facility failed to provide documentation that the 50 year and older fire sprinklers were replaced or tested.

Finding:
On November 27, 2012, the evaluator conducted an investigation of the facility's fire sprinkler system. The evaluator observed that a section of the hospital had original fire sprinklers that were over 50 years old and located in room 08.

A review of the fire sprinkler inspection report, dated August 26, 2010, revealed a 50 year old fire sprinkler "service pass" document. The evaluator requested another document from a "recognized testing laboratory" approved by the Authority Having Jurisdiction for operational testing.

An interview was held with the Building Supervisor and he stated that he was not aware of the 50 year fire sprinkler testing requirement and he would contact the service company as soon as possible.

(2) NFPA 13, 1999 Edition, 5-5.4.1 Distance below Ceilings. The distances between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. 5-5.4.1 Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. 5-5.5.3 Obstructions that prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inch below the sprinkler deflector in a manner to limit the distrubution from reaching the protected hazard shall comply with 5-5.5.3

Based on observation and interview, the facility failed to ensure that all the fire sprinkler heads water discharge pattern were not impeded by being recessed into the ceiling opening.

Finding:

On November 27, 2012, the evaluator conducted an inspection of the hospital life safety code system. The evaluator inspected the Emergency Room storage area and observed one fire sprinkler head recessed into the ceiling which impeded the water discharge pattern.

An interview was held with the Building Supervisor and he stated that he would have the sprinkler head serviced as soon as possible.

NFPA 10, 1998 Edition, Monthly Inspection, Chapter 4 Inspection, Maintenance, and Recharging, 4-3.2* Procedures. Periodic inspection of fire extinguishers
shall include a check of at least the following items: (a) Location in designated place (b) No obstruction to access or visibility.

NFPA 10, Standard for Portable Fire Extinguishers 1998 Edition, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the
top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Based on observation and interview, the facility failed to ensure that all the portable fire extinguishers were immediately available and accessible at all times.

Finding:

On November 27, 2012, the evaluator conducted an inspection of the facility Life Safety Code System. The evaluator observed the following: Histopathology Room - One portable fire extinguisher mounted 5 ft 4 inches above the floor and the device access was blocked by equipment.

An interview was held with the Building Supervisor and he stated that the portable fire extinguisher would be made accessible as soon as possible.

(1) NFPA 99 Health Care Facilities 1999 edition

4-3.5.2.2(b)(2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

This requirement was not met as evidenced by:

Based on observation, the facility failed to ensure nonflammable gases were stored in accordance with NFPA (National Fire Protection Association) 99 by not segregating empty cylinders from full cylinders.

Findings:

On November 27, 2012, at 11:00 a.m., accompanied by the Building Supervisor, the evaluator observed 4 full oxygen cylinders and 2 empty oxygen cylinders stored together in the basement Recovery Area.

An interview was held with the Building Supervisor and he stated that he would provide a clearer separation as soon as possible.

(2) NFPA 2000, 101, 7.10.8.1 No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO Exit. Such sign shall have the word NO in letters 2-inches high with a stroke width of 3/8 inches and the word EXIT in letters 1-inch high, with the word EXIT below the NO.

Based on observation and interview, the facility failed to ensure that a fire exit access was apparent in case of a fire or evacuation emergency at all times.

Finding:

On November 29, 2012, at 1:00 p.m., the evaluator inspected the facility's 2nd floor fire exit access staircase and observed no directional arrow or information regarding means of egress (i.e. down and/or up the staircase).

An interview was held with the Building Supervisor regarding access to the roof. The Building Supervisor stated the roof access door was locked and the evacuation route was down the stairs.

In case of a fire, smoke, or evacuation emergency the direction of exit access travel shall be clearly indicated in all areas leading to a safe area where it may not be apparent.

(3) NFPA 99, 2000, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1 (b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation and interview, the facility failed to properly secure all medical gas cylinders at all times.

Finding:

On November 27, 2012, at 2:30 p.m., the evaluator conducted an inspection of the facility's emergency room storage area and observed a free standing oxygen medical gas cylinder being stored in between the wall and a crash cart. The medical gas cylinder was not secured. The evaluator inspected the Post Anesthesia Care Unit and observed an oxygen medical gas cylinder lying on the floor. An interview was conducted with Licensed Nurse 3 and she stated "I know we don't have a standard and we just lie it on the floor".

An interview was held with the Building Supervisor and he stated that he would have the oxygen cylinders secured as soon as possible.

NFPA 70, National Electrical Code 1999, 110-26. Spaces about Electrical Equipment, Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to ARTICLE 110-REQUIREMENTS FOR ELECTRICAL INSTALLATIONS 70-29 require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code. (1) Depth of Working Space.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space shall be suitably guarded.

Based on observation and interview, the facility failed to ensure that the basement electrical panel remained accessible and safe at all times.

Finding:

On November 27, 2012, at 9:42 a.m., the evaluator inspected the basement clean linen storage room. The evaluator observed an adjacent storage room that also housed an electrical panel that was blocked by two clean linen carts.

An interview was held with the Building Supervisor and he stated that he would have the two linen carts removed as soon as possible.