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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:

On 7/19/2011 the surveyor noted penetrations (holes, improperly fire stopped conduit or piping and/or missing ceiling panel) in the walls and/or ceilings of the following spaces or areas:

1) Above double doors of the cafeteria corridor;
2) Wall and ceiling of the janitors closet near the Emergency Department;
3) Ceiling of the X-ray control room;
4) Ceiling in X-ray procedure area;
5) Ceiling of the Mammography procedure area;
6) Fire wall above double doors by patient rooms 4 and 5;
7) IT (Information Technology) Alcove;
8) Courtesy stairwell wall;
9) Ceiling of the Pharmacy;
10) IT room;
11) Attic access room (open attic access panel);
12) Ceiling of kitchen pantry near refrigerator;
13) Basement boiler room above GWH-1 unit;
14) Above doors in "future" dining area; and
15) Wall and ceiling of basement IT room.

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Based on observation the facility failed to provide fire rated assemblies (doors) in compliance with the Construction and Compartmentation requirements of the Life Safety Code, NFPA 101, 2000 edition. More specifically, the facility failed to provide positive latching doors at identified fire barriers in the building.

Failure on the part of the facility to provide positive latching doors where required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings:

On 7/19/2011 the surveyor observed door assemblies that would not positively latch when released from their hold open position. Said assemblies were located at:

1) First floor stairwell door;
2) Double doors near rooms 4 and 5; and
3) Door by Staff lockeroom and the Pharmacy

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Based on observation, the hospital failed to display exit sign(s) in such a manor as to make the direction of travel to exits readily apparent.

Failure to display an exit sign directing building occupants toward the exits puts occupants of the facility at risk should exiting be required due to a fire or other emergency.

Findings:

1. On 7/19/2011 the surveyor noted that a directional sign to exit was not located above the double doors adjacent to patient rooms 4 and 5 of the new addition.

2. On 7/19/2011 the surveyor noted that a directional sign to exit with a directional arrow was not provided to direct occupants leaving the new addition through the double doors by patient rooms 4 and 5 to the designated exit (Southeast).

3. On 7/19/2011 the surveyor noted that the intersection near IT lacked a directional sign to exit.

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Based on document review the hospital failed to perform fire drills at the required frequency.

Failure to conduct quarterly fire drills as required puts patients, staff and visitors of the facility at risk of injury and death from fire, and prevents an accurate assessment of the staff's preparedness to manage a fire emergency.

Findings:

On 7/20/2011 the surveyor reviewed available documentation and noted that the facility failed to hold fire drills during the following periods:

1) First quarter day shift 2011;
2) Second quarter night shift 2011;
3) Third quarter day and night shifts 2010; and
4) Fourth quarter day and night shifts 2010.

1. Based on record review, the facility failed to inspect and test the fire alarm system on an annual basis as is required.

Failure on the part of the facility to inspect and test the fire alarm system at the frequency required puts patients, staff and visitors of the facility at risk from the effects of smoke and/or fire.

Findings:

On 7/19/2011, review of available fire life safety documentation revealed that the facility had last tested the alarm system on 6/29/2010.



2. Based on observation and interview, the facility failed to ensure smoke detectors were installed in staff sleeping rooms.

Failure to install smoke detectors in staff sleeping rooms risks the ability of occupants to safely evacuated in the event of a smoldering fire.

Reference: National Fire Protection Association (NFPA) 101, 6.1.14.2 Life Safety Code 2000 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. NFPA 101, 26.3.3.5 requires smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings:

On 7/19/2011 the surveyor noted that the Tech Work Station was arranged to be used as a staff sleeping room. It was further noted that the room lacked smoke detection and a notification appliance.

Engineering staff (Staff Member #15) verified that the room was used for sleeping purposes at the time of the survey finding.

Based on observation the facility failed to maintain its automatic sprinkler system as required. Failure on the part of the facility to maintain automatic sprinkler systems puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

On 7/19/2011 the surveyor noted the following deficiencies related to the automatic sprinkler system:

1) Dissimilar sprinkler heads (quick response and standard response) are located in the corridor by the emergency department;
2) Sprinkler heads located in the Central General Storage room were covered with masking paper;
3) Missing escutcheons were found in both the East and West General Storage rooms and the janitors closet by the kitchen;
4) No sprinkler coverage was provided in the Mammography dark room;
5) Shower/privacy curtains in the bathrooms of the new addition lacked the required minimum vertical open distance (18") between the bottom of the sprinkler deflectors and the top of the curtains; and
6) Replacement sprinkler heads were not available for all sprinkler heads types (i.e. head installed in the main entrance foyer).

Based on observation the hospital failed to inspect fire extinguishers 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:

On 7/19/2011 the surveyor noted that the portable fire extinguisher located in the CT room had not been checked on a monthly basis. This finding was based on the fact that the tag on the device had not been signed so as to indicated that an inspection(s) had been performed.

Based on document review and interview the facility failed to assure the protection of its cooking facility by maintaining the kitchen hood exhaust system as required.

Failure on the part of the facility to maintain the kitchen hood exhaust system as required puts patients, staff and visitors of the facility at risk from the effects of grease accelerated fire.

Findings:

On 7/19/2011 the surveyor noted that the service sticker located on the kitchen hood indicated that the last service was performed in July of 2006. Documentation made available indicated that hood servicing was performed by All American Fire in 2007. Subsequent to this finding the surveyor was informed that the hoods were last cleaned in February 2011. These findings were confirmed by Engineering staff (Staff Member #15) at the time of the observation.

A. Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99. And, the facility failed to properly label the medical gas storage room and outside storage area.

Failure on the part of the facility to properly secure oxygen cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death. And, not labeling oxidizing gas storage locations put patients, staff and visitors of the facility at risk from the effects of fire.

Findings:

1. On 7/19/2011 the surveyor noted that four (4) "D" size oxygen cylinders in the gas storage room were not secured in racks to prevent their toppling over.

2. On 7/19/2011 the surveyor noted that the medical gas storage room located near the boiler room was provided with a sign that only indicated "No Smoking". NFPA 99 Chapter 8-3.1.11.3 requires the following wording on the precautionary sign "Caution....Oxidizing Gas(es) Stored Within....No Smoking".

3. On 7/19/2011 the surveyor noted that the bulk oxygen holding pen lacked cautionary signage indicating " OXYGEN .... NO SMOKING .... NO OPEN FLAMES " .

Based on observation the facility failed to properly store flammable and combustible liquids in an appropriate manner.

Failure on the part of the facility to properly store flammable and combustible liquids appropriately puts patients, staff and visitors of the facility at risk from the effects of an explosion and/or fire.

Findings:

On 7/19/2011 the surveyor noted that containers of flammable liquids i.e. thinners were being stored in the egress pathway outside the Nursing Administration office (southwest exit).

Based on observation the facility has located a hyperbaric facility onto its property that has not gone through the regulatory review and approval process.

Failure on the part of the facility not to have high hazard medical treatment facilities reviewed and approved puts patients, staff and visitors of the facility at risk of physical harm.

Findings:

On 7/19/2011 the surveyor noted a pair of metal containers on the grounds of the facility (next to Physical Therapy). One container contained oxygen distribution apparatus and the other contained a hyperbaric chamber (Marine Dynamics 42" Monoplace Chamber).

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Based on record review and interview, the hospital failed to exercise its generator under load for 30 minutes per month as required.

Failure on the part of the facility to properly test and maintain fire life safety systems puts patients, staff and visitors of the facility at risk from the lack of emergency power when needed.

References:

NFPA 99 Health Care Facilities, 1999 edition; Chapter 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. Sub-section (b) Inspection and Testing, item 1 states: "Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6".

Findings Include:

1. On 7/19/2011 the surveyor reviewed service documentation for the emergency generator and found that it had received annual servicing as is required.

2. On 7/20/2011 the surveyor interviewed Engineering staff (Staff Member #15) and was advised that the generator was run for 30 minutes each month but not under load as is required. It was further indicated that operational testing of the transfer switch gear was not routinely being performed. Run logs failed to indicate test data for those items required to be tested monthly per NFPA 110. As an example run times and start to transfer time.

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A. Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

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 7/19/2011 the surveyor noted exposed wiring in uncovered/missing cover plate electrical J-boxes (junction boxes) in the following locations:

a) Nurses Admin; air-conditioning units and intercom;
b) Above double doors adjacent to patient rooms 4 and 5 in new addition;
c) IT Alcove;
d) Staff locker room;
e) Kitchen (box for hood suppression);
f) Boiler room; and
g) Shipping and Receiving

2. On 7/19/2011 the surveyor noted extension cords being used inappropriately in the following areas:

a) Surgeon's office (plugged into power strip);
b) Drug room by Nurse's station (taped to floor); and
c) Shipping and Receiving (serving printer and coffee maker)

3. On 7/19/2011 the surveyor noted a coffee maker in the Nurses Admin room plugged into an unapproved multi-plug power adapter.

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:

On 7/19/2011 the surveyor noted that an alcohol based hand rub (ABHR) dispenser in Exam Room #2 was installed directly above an electrical light switch.

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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:

On 7/19/2011 the surveyor noted penetrations (holes, improperly fire stopped conduit or piping and/or missing ceiling panel) in the walls and/or ceilings of the following spaces or areas:

1) Above double doors of the cafeteria corridor;
2) Wall and ceiling of the janitors closet near the Emergency Department;
3) Ceiling of the X-ray control room;
4) Ceiling in X-ray procedure area;
5) Ceiling of the Mammography procedure area;
6) Fire wall above double doors by patient rooms 4 and 5;
7) IT (Information Technology) Alcove;
8) Courtesy stairwell wall;
9) Ceiling of the Pharmacy;
10) IT room;
11) Attic access room (open attic access panel);
12) Ceiling of kitchen pantry near refrigerator;
13) Basement boiler room above GWH-1 unit;
14) Above doors in "future" dining area; and
15) Wall and ceiling of basement IT room.

.
.

Based on observation the facility failed to provide fire rated assemblies (doors) in compliance with the Construction and Compartmentation requirements of the Life Safety Code, NFPA 101, 2000 edition. More specifically, the facility failed to provide positive latching doors at identified fire barriers in the building.

Failure on the part of the facility to provide positive latching doors where required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings:

On 7/19/2011 the surveyor observed door assemblies that would not positively latch when released from their hold open position. Said assemblies were located at:

1) First floor stairwell door;
2) Double doors near rooms 4 and 5; and
3) Door by Staff lockeroom and the Pharmacy

.

Based on observation, the hospital failed to display exit sign(s) in such a manor as to make the direction of travel to exits readily apparent.

Failure to display an exit sign directing building occupants toward the exits puts occupants of the facility at risk should exiting be required due to a fire or other emergency.

Findings:

1. On 7/19/2011 the surveyor noted that a directional sign to exit was not located above the double doors adjacent to patient rooms 4 and 5 of the new addition.

2. On 7/19/2011 the surveyor noted that a directional sign to exit with a directional arrow was not provided to direct occupants leaving the new addition through the double doors by patient rooms 4 and 5 to the designated exit (Southeast).

3. On 7/19/2011 the surveyor noted that the intersection near IT lacked a directional sign to exit.

.

Based on document review the hospital failed to perform fire drills at the required frequency.

Failure to conduct quarterly fire drills as required puts patients, staff and visitors of the facility at risk of injury and death from fire, and prevents an accurate assessment of the staff's preparedness to manage a fire emergency.

Findings:

On 7/20/2011 the surveyor reviewed available documentation and noted that the facility failed to hold fire drills during the following periods:

1) First quarter day shift 2011;
2) Second quarter night shift 2011;
3) Third quarter day and night shifts 2010; and
4) Fourth quarter day and night shifts 2010.

1. Based on record review, the facility failed to inspect and test the fire alarm system on an annual basis as is required.

Failure on the part of the facility to inspect and test the fire alarm system at the frequency required puts patients, staff and visitors of the facility at risk from the effects of smoke and/or fire.

Findings:

On 7/19/2011, review of available fire life safety documentation revealed that the facility had last tested the alarm system on 6/29/2010.



2. Based on observation and interview, the facility failed to ensure smoke detectors were installed in staff sleeping rooms.

Failure to install smoke detectors in staff sleeping rooms risks the ability of occupants to safely evacuated in the event of a smoldering fire.

Reference: National Fire Protection Association (NFPA) 101, 6.1.14.2 Life Safety Code 2000 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. NFPA 101, 26.3.3.5 requires smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings:

On 7/19/2011 the surveyor noted that the Tech Work Station was arranged to be used as a staff sleeping room. It was further noted that the room lacked smoke detection and a notification appliance.

Engineering staff (Staff Member #15) verified that the room was used for sleeping purposes at the time of the survey finding.

Based on observation the facility failed to maintain its automatic sprinkler system as required. Failure on the part of the facility to maintain automatic sprinkler systems puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

On 7/19/2011 the surveyor noted the following deficiencies related to the automatic sprinkler system:

1) Dissimilar sprinkler heads (quick response and standard response) are located in the corridor by the emergency department;
2) Sprinkler heads located in the Central General Storage room were covered with masking paper;
3) Missing escutcheons were found in both the East and West General Storage rooms and the janitors closet by the kitchen;
4) No sprinkler coverage was provided in the Mammography dark room;
5) Shower/privacy curtains in the bathrooms of the new addition lacked the required minimum vertical open distance (18") between the bottom of the sprinkler deflectors and the top of the curtains; and
6) Replacement sprinkler heads were not available for all sprinkler heads types (i.e. head installed in the main entrance foyer).

Based on observation the hospital failed to inspect fire extinguishers 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:

On 7/19/2011 the surveyor noted that the portable fire extinguisher located in the CT room had not been checked on a monthly basis. This finding was based on the fact that the tag on the device had not been signed so as to indicated that an inspection(s) had been performed.

Based on document review and interview the facility failed to assure the protection of its cooking facility by maintaining the kitchen hood exhaust system as required.

Failure on the part of the facility to maintain the kitchen hood exhaust system as required puts patients, staff and visitors of the facility at risk from the effects of grease accelerated fire.

Findings:

On 7/19/2011 the surveyor noted that the service sticker located on the kitchen hood indicated that the last service was performed in July of 2006. Documentation made available indicated that hood servicing was performed by All American Fire in 2007. Subsequent to this finding the surveyor was informed that the hoods were last cleaned in February 2011. These findings were confirmed by Engineering staff (Staff Member #15) at the time of the observation.

A. Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99. And, the facility failed to properly label the medical gas storage room and outside storage area.

Failure on the part of the facility to properly secure oxygen cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death. And, not labeling oxidizing gas storage locations put patients, staff and visitors of the facility at risk from the effects of fire.

Findings:

1. On 7/19/2011 the surveyor noted that four (4) "D" size oxygen cylinders in the gas storage room were not secured in racks to prevent their toppling over.

2. On 7/19/2011 the surveyor noted that the medical gas storage room located near the boiler room was provided with a sign that only indicated "No Smoking". NFPA 99 Chapter 8-3.1.11.3 requires the following wording on the precautionary sign "Caution....Oxidizing Gas(es) Stored Within....No Smoking".

3. On 7/19/2011 the surveyor noted that the bulk oxygen holding pen lacked cautionary signage indicating " OXYGEN .... NO SMOKING .... NO OPEN FLAMES " .

Based on observation the facility failed to properly store flammable and combustible liquids in an appropriate manner.

Failure on the part of the facility to properly store flammable and combustible liquids appropriately puts patients, staff and visitors of the facility at risk from the effects of an explosion and/or fire.

Findings:

On 7/19/2011 the surveyor noted that containers of flammable liquids i.e. thinners were being stored in the egress pathway outside the Nursing Administration office (southwest exit).

Based on observation the facility has located a hyperbaric facility onto its property that has not gone through the regulatory review and approval process.

Failure on the part of the facility not to have high hazard medical treatment facilities reviewed and approved puts patients, staff and visitors of the facility at risk of physical harm.

Findings:

On 7/19/2011 the surveyor noted a pair of metal containers on the grounds of the facility (next to Physical Therapy). One container contained oxygen distribution apparatus and the other contained a hyperbaric chamber (Marine Dynamics 42" Monoplace Chamber).

.

Based on record review and interview, the hospital failed to exercise its generator under load for 30 minutes per month as required.

Failure on the part of the facility to properly test and maintain fire life safety systems puts patients, staff and visitors of the facility at risk from the lack of emergency power when needed.

References:

NFPA 99 Health Care Facilities, 1999 edition; Chapter 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. Sub-section (b) Inspection and Testing, item 1 states: "Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6".

Findings Include:

1. On 7/19/2011 the surveyor reviewed service documentation for the emergency generator and found that it had received annual servicing as is required.

2. On 7/20/2011 the surveyor interviewed Engineering staff (Staff Member #15) and was advised that the generator was run for 30 minutes each month but not under load as is required. It was further indicated that operational testing of the transfer switch gear was not routinely being performed. Run logs failed to indicate test data for those items required to be tested monthly per NFPA 110. As an example run times and start to transfer time.

.

A. Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

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 7/19/2011 the surveyor noted exposed wiring in uncovered/missing cover plate electrical J-boxes (junction boxes) in the following locations:

a) Nurses Admin; air-conditioning units and intercom;
b) Above double doors adjacent to patient rooms 4 and 5 in new addition;
c) IT Alcove;
d) Staff locker room;
e) Kitchen (box for hood suppression);
f) Boiler room; and
g) Shipping and Receiving

2. On 7/19/2011 the surveyor noted extension cords being used inappropriately in the following areas:

a) Surgeon's office (plugged into power strip);
b) Drug room by Nurse's station (taped to floor); and
c) Shipping and Receiving (serving printer and coffee maker)

3. On 7/19/2011 the surveyor noted a coffee maker in the Nurses Admin room plugged into an unapproved multi-plug power adapter.