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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 include:

1. On 3/13/2012, the surveyor noted in the "short hall" storage closet a penetration of the overhead that requires fire stop material.

2. On 3/13/2012, the surveyor noted a penetration of the wall under the counter (front desk) of the business office.

Based on observation the facility failed to provide exit and/or directional signs that were provided with sufficient illumination.

Failure to ensure that exit signs are displayed with continuous illumination risks inability of staff and patients to rapidly locate exits in a fire.

Findings include:

1. On 3/13/2012, the surveyor noted the the exit sign located above the door of the main shop stairwell was not illuminated in a manner that would render the sign legible in the event of a power outage.

Based on document review the facility failed to show that the fire alarm system had been installed and tested as required.

Failure on the part of the facility to document the installation and testing of the fire alarm system puts patients, staff and visitors of the facility at risk from the effects of smoke and/or fire.

Findings include:

1. On 3/15/2012, the facility was unable to provide the surveyor with documentation showing that the fire alarm system had been inspected and tested annually as is required. It was noted however that sensitivity testing of the smoke detectors had been performed for the most current period.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25 and Chapter 19.3.5 NFPA 101 Life Safety Code 2000 edition.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/13/2012, the surveyor noted that the sprinkler riser room(s) were not properly labeled at the riser room doors.

Based on observation the facility failed to maintain the means of egress and its access free of obstructions and impediments. Failure on the part of the facility to maintain the means of egress and its access free of obstructions and or impediments puts patients, staff and visitors of the facility at risk of death in the event of fire.

References:

NFPA 101, 2000 Edition; Chapter 7.1.10.1 states: "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency".

Findings include:

1. On 3/13/2012, the surveyor noted that the west exit door of the LTC unit was covered by a window shade.

Based on record review, the hospital failed to exercise its generator (LTC 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 3/15/2012, the surveyor noted that the generator run log for the swing bed area generator lacked documentation to show that a 30 minute load test of the generator had been performed for the following months of 2011: April, September and December.

Based on observation the facility failed to 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 3/13/2012, the surveyor noted that the doors to the main electrical control room were not labeled as is required ("DANGER - HIGH VOLTAGE - KEEP OUT").

2. On 3/13/2012, the surveyor noted that the main electrical control panels located in the electrical room were not provided with the necessary clear working space. Ceiling tiles had been stacked in front of and against the control panels.

3. On 3/13/2012, the surveyor noted that the electrical panel box serving the Emergency Department was not locked as is required. It was also noted that breaker 18 was in the "on" position and its service was not labeled.

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 include:

1. On 3/13/2012, the surveyor noted in the "short hall" storage closet a penetration of the overhead that requires fire stop material.

2. On 3/13/2012, the surveyor noted a penetration of the wall under the counter (front desk) of the business office.

Based on observation the facility failed to provide exit and/or directional signs that were provided with sufficient illumination.

Failure to ensure that exit signs are displayed with continuous illumination risks inability of staff and patients to rapidly locate exits in a fire.

Findings include:

1. On 3/13/2012, the surveyor noted the the exit sign located above the door of the main shop stairwell was not illuminated in a manner that would render the sign legible in the event of a power outage.

Based on document review the facility failed to show that the fire alarm system had been installed and tested as required.

Failure on the part of the facility to document the installation and testing of the fire alarm system puts patients, staff and visitors of the facility at risk from the effects of smoke and/or fire.

Findings include:

1. On 3/15/2012, the facility was unable to provide the surveyor with documentation showing that the fire alarm system had been inspected and tested annually as is required. It was noted however that sensitivity testing of the smoke detectors had been performed for the most current period.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25 and Chapter 19.3.5 NFPA 101 Life Safety Code 2000 edition.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/13/2012, the surveyor noted that the sprinkler riser room(s) were not properly labeled at the riser room doors.

Based on observation the facility failed to maintain the means of egress and its access free of obstructions and impediments. Failure on the part of the facility to maintain the means of egress and its access free of obstructions and or impediments puts patients, staff and visitors of the facility at risk of death in the event of fire.

References:

NFPA 101, 2000 Edition; Chapter 7.1.10.1 states: "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency".

Findings include:

1. On 3/13/2012, the surveyor noted that the west exit door of the LTC unit was covered by a window shade.

Based on record review, the hospital failed to exercise its generator (LTC 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 3/15/2012, the surveyor noted that the generator run log for the swing bed area generator lacked documentation to show that a 30 minute load test of the generator had been performed for the following months of 2011: April, September and December.

Based on observation the facility failed to 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 3/13/2012, the surveyor noted that the doors to the main electrical control room were not labeled as is required ("DANGER - HIGH VOLTAGE - KEEP OUT").

2. On 3/13/2012, the surveyor noted that the main electrical control panels located in the electrical room were not provided with the necessary clear working space. Ceiling tiles had been stacked in front of and against the control panels.

3. On 3/13/2012, the surveyor noted that the electrical panel box serving the Emergency Department was not locked as is required. It was also noted that breaker 18 was in the "on" position and its service was not labeled.