HospitalInspections.org

Based on observation, the critical access hospital failed to maintain the construction requirements for the classification of construction.

Failure to maintain the construction requirements risks injury to patients, staff and visitors through passage of smoke and fire across barriers designed to contain their spread.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) There were two penetrations above the ceiling in the rated 2 hour separation between the hospital basement and the assisted living building.

2) There were two penetrations above the ceiling in the rated 2 hour separation between the hospital and the long term care building.

3) A large overhead door track opening breached the wall between the boiler room and the exit access at the west end of the basement corridor in the old building.

These findings were discussed with Maintenance Staff.

Based on observation, the critical access hospital failed to provide corridor doors that were positive latching, and were able to close and latch without obstruction.

Failure to maintain corridor doors in a condition that permits full closing and latching risks injury to patients, staff and visitors through passage of smoke and fire across barriers designed to limit their spread.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The doors at the CS-Purchasing department did not automatically close and latch.

2) The fire separation door between the Long Term Care building and the Hospital did not close and latch and a large gap was observed that would
allow the penetration of smoke.

3) The exit door from 2nd floor old building, west exit, did not close and latch when released.

These findings were discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to properly mark an exit access route of travel.

Failure to properly mark an exit access route of travel risks injury to patients, staff and visitors through delayed egress from the hospital in an emergency.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The corridor from hospital to the long term care building had exit sign with directional arrow directing traffic to an exit that has been abandoned. The long term care building contains hospital outpatient services (physical therapy).

2) The corridor from hospital to the long term care building did not have an exit sign at turn in the corridor leading to an approved existing exit.

3) The approved exit at the corridor to in the long term care building did not have an approved exit sign.

These findings were discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to provide self-closing doors to separate hazardous areas from other spaces.

Failure to provide self-closing doors to separate hazardous areas from other spaces risks injury to patients, staff and visitors through passage of smoke and fire across barriers designed to limit their spread.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The room labeled Can Washer room in the basement was actually used as a trash collection room. The door to this room was observed to be held open by an excessively large amounts of garbage bins and did not close and latch automatically.

2) The boiler room area was exposed to corridor through a door with a glass window that was not sealed against the passage of smoke.

This finding was discussed with Maintenance Staff

Based upon observation and interview, the critical access hospital failed to provide two remote exits out of the basement floor of the old hospital building.

Failure to provide two exits out of each floor risks injury to patients, staff and visitors through entrapment in the corridor during a fire or other emergency.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) Only one approved, signed exit was present in the basement corridor. This exit led to an approved stairwell and to a horizontal exit to the adjacent assisted living building.

2) Hospital facilities management stated that a second exit was located at the west end of the basement corridor and led to the hospital loading dock. However, this route was:

a) obstructed by an overhead door in the route of egress
b) exposed to the biohazardous waste storage room by a door that did not close and latch
c) exposed to the boiler room by a large opening in the boiler room wall through which the overhead door chain assembly passed
d) obstructed by construction materials stored on the loading dock ramp
e) not signed as an exit

The presence of the overhead door and the hazards and obstructions noted above renders this an unapproved exit.

These findings were discussed with Maintenance Staff.

Based on observation, the critical access hospital failed to provide protection against fire or smoke in a stairwell.

Failure to provide protection against fire or smoke in a stairwell risks injury to patients, staff and visitors through uncontrolled spread of smoke and fire in the hospital.
Findings include:

During a tour of the critical access hospital on February 14, 2011, it was observed that the second floor stairwell door in the west stairwell of the old hospital did not close and latch. The door was obstructed by warping. This stairwell was exposed to the propane tank cited elsewhere in this report, and led into the corridor that contained the hospital surgery department.

The finding was discussed with hospital maintenance staff.

Based on observation, the critical access hospital failed to provide readily accessible exits at all times.

Failure to provide readily accessible exits at all times risks inability of patients, staff and visitors to quickly evacuate in the event of a fire or other emergency.

Findings include:

During a tour of the critical access hospital on February 15, 2011 at approximately noon, it was observed that:

1) The corridor in the childbirth unit had doors at the east and west ends. The east end doors were controlled by an approved delayed-egress control device, but were not provided with the required signage indicating that the doors would open in 15 seconds after an attempt to open the doors was made

2) The west end doors were locked with magnetic hold devices that required a special badge to release. The doors were not operable without the badge. There was no approved delayed egress device installed on these doors.

These findings were discussed with maintenance staff.

Based on observation, the critical access hospital failed to provide unobstructed exit access corridors in the new hospital.

Failure to provide unobstructed exit access corridors risks inability to swiftly evacuate patients, staff and visitors in the event of fire or other emergency.

Findings include:

During a tour of the critical access hospital on February 14, 2011, it was observed that the corridors of the new hospital building contained alcohol-based hand rub (ABHR) dispensers that were installed on floor stands. The ABHR stands were placed within the exit corridors and reduced the available width of the corridors below the required 8 clear feet.

This finding was discussed with hospital maintenance staff.

Based on record review and interview, the critical access hospital failed to implement the 8 requirements of a fire safety plan.

Failure to provide an accurate fire safety plan risks injury to patients, staff and visitors through unpreparedness of hospital personnel to effectively manage an emergency.

Findings include:

During review of critical access hospital policies and procedures on February 15, 2011 from 8:30 am to 12:30 pm, it was found that:

1) The fire safety plan had not been updated since 2002 and did not include the new hospital addition.

2) The fire safety plan did not include plans for implementation of partial and/or full evacuation.

3) Interviews with hospital facilities management and nursing personnel revealed that the hospital staff did not have knowledge of where the smoke compartments were located and what the evacuation plan required for patient and staff movement in the event of fire.

These findings were discussed with Maintenance Staff.

Based on record review and interview, the critical access hospital failed to provide documentation that all of the hospital personnel were participants in the required one fire drill per quarter per shift.

Failure to ensure that all hospital personnel participate in the required fire drills risks unpreparedness of hospital personnel to manage a fire emergency.

Findings include:

During review of critical access hospital fire drill records on on February 15, 2011 from 8:30 am to 12:30 pm, it was found that:

1) The hospital's fire drill records did not support a finding that the hospital staff actually held the required amount of fire drills. Some fire drill records did not have Hospital in the title, but instead had ALF (the adjacent assisted living facility).


2) Interviews with hospital facilities management revealed that some fire drills originate in either the adjacent assisted living facility or adjacent long term care facility. Although hospital personnel respond to both ALF and LTC fire drills, these drills do not originate within the hospital and do not test personnel's reaction to a fire in their area.

This finding was discussed with Maintenance Staff.

Based upon observation and interview, the critical access hospital failed to ensure that the automatic sprinkler system has been installed in accordance with NFPA 13.

Failure on the part of the facility to provide an approved sprinkler system could possibly expose the hospital to risk through an inability to extinguish a fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The CS-Purchasing warehouse room had two sprinkler heads placed approximately 18' apart over the combustible storage on shelving in the center of the room. This room contained a large quantity of combustible materials. The hospital did not provide documentation that a distance of 18' between sprinkler heads in this room was approved.

2) Interview with Maintenance Staff indicated that the laundry chute did not have sprinkler protection as required.

These findings were discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to ensure that the automatic sprinkler system has been installed in accordance with NFPA 13.

Failure on the part of the facility to provide an approved sprinkler system risks injury to patients, staff and visitors through an inadequate automatic fire sprinkler system.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) Escutcheons were missing in two closets in birthing hallway.

2) The fire sprinkler riser room door did not have an identification sign indicating "Sprinkler Riser Room".

Based on record review, the critical access hospital failed to ensure that the automatic sprinkler systems were continuously maintained in reliable operating condition and were inspected as required.

Failure to perform required maintenance and inspection risks injury to patients, staff and visitors through a potentially inoperable automatic fire sprinkler system.

Findings include:

During review of automatic sprinkler system maintenance records on February 15, 2011 from 8:30 am to 12:30 pm, it was found that:

1) There was no documentation that an acceptance test was conducted on the new sprinkler system installed throughout the new and old hospital before occupancy of the new hospital building.

2. There was no documentation that quarterly inspections were conducted on sprinkler system.

These findings were discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to provide portable fire extinguishers as required.

Failure to provide portable fire extinguishers as required risks inability of hospital personnel to quickly extinguish a fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The new hospital addition acute care unit has a BC fire extinguisher rather than an ABC fire extinguisher as required.

2) A fire extinguisher in the boiler room was discharged.

These finding were discussed with the Maintenance Staff.

Based upon observation, the critical access hospital failed to provide a laundry chute with a fire door assembly having a fire protection rating of 1 hour.

Failure to provide a laundry chute with a fire door assembly having a fire protection rating of 1 hour risks injury to patients, staff and visitors through exposure of the corridor to spreading smoke and fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that the linen chute room door did not automatically close and latch.

This finding was discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to ensure that containers greater than 32 gallons located in a room protected as a hazardous area when not attended.

Failure to ensure that containers greater than 32 gallons located in a room protected as a hazardous area when not attended risks injury to patients, staff and visitors through uncontained fire in the hospital exit corridors.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that a container greater than 32 gallons in capacity was stored in the basement corridor adjacent to the elevator. The container was observed to be full of flattened cardboard and other combustibles at the time of the observation.

This finding was discussed with the Maintenance Staff.

Based on observation, the critical access hospital failed to limit the quantity of oxygen (nonflammable medical gas) stored outside of an enclosure to 300 cubic feet or less .

Failure limit the amount of oxygen cylinders stored outside an enclosure puts patients, staff and visitors at risk from the effects of smoke and fire which would be accelerated in an oxygen rich environment.

[Reference:CMS Memorandum S&C-07-10, January 12, 2007; and NFPA 99 Health Care Facilities Chapter 9.4.3, 2005 Edition. Memorandum Summary: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured".]

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that the smoke compartment on the east end of the second floor of the old building contained at least 4 H cylinders (244 cubic feet each) and 2 E cylinders (150 cubic feet each) of compressed oxygen, exceeding the quantity of oxygen permissible to be exposed to the hospital corridor.

This finding was discussed with Maintenance Staff.

Based upon observation and interview, the critical access hospital failed to provide installation of LPG tanks in accordance with NFPA 58.

Failure to install tanks of flammable liquids in accordance with NFPA 58 exposes the hospital to an explosion hazard and risks injury to patients, staff and visitors through exposure to an accelerated fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) A tank of propane estimated by hospital facilities management to be approximately 250 gallons in capacity was placed immediately adjacent to a 3-story wall of single-pane glass comprising one wall of the old building west exit stairwell.

2) Signs indicating "No Smoking within 25 feet" were not visible in the vicinity of the propane tank.

3) Hospital personnel were observed smoking within approximately 15 feet of the propane tank.

4) There were no signs identifying the contents of the three propane tanks in the vicinity of the new generator.

5) There were no signs indicating "flammable" or such warning signs as required by NFPA 58.

These findings were discussed with Maintenance Staff.

Based on record review and interview, the critical access hospital failed to provide documentation that the hospital generators were run under load monthly.

Failure to run hospital generators under load monthly risks failure of the generators during a power outage.

Findings include:

Review of critical access hospital documentation on February 15, 2011 from 8:30 am to 12:30 pm, found that the new generator serving the new hospital building had been run under load in May, 2010 and June, 2010. No further monthly runs under load were documented. Hospital facilities management confirmed that additional runs under load were not documented and may not have occurred.

This finding was discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99, 3.4.2.2.2.

Failure to provide accurate branches on generators exposes the hospital to non-operational systems in the event of a power outage.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, the hospital essential electrical system emergency power distribution branches were followed from the automatic transfer switches to the end-user panels. It was found that:

The automatic transfer switch labeled "X" (Life Safety branch) led to panel BX2A. This panel had an inventory that included the following functions that are not approved for the Life Safety branch:

Exterior lighting
Communications room receptacles
HVAC controls
Water softener

The automatic transfer switch labeled "Y" (Critical branch) led to panel BY2A. This panel had an inventory that included the following functions that are not approved for the Critical branch:

Security panel
CCTV panel
CCTV power
Exterior canopy lights
Trap primers
Fuel oil pump
Equipment (DWCP 1 and 2)

This finding was discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to
maintain emergency lighting in the operating room, and electrical wiring in the boiler room as required by code.

Failure to maintain emergency lighting in the operating room risks injury to patients in the event that the hospital emergency generator fails to operate properly during a power outage. Failure to maintain electrical wiring in the boiler room risks injury to staff through shock or fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The battery-powered 90-minute emergency light in the operating room failed to illuminate when the test button was pushed. Hospital facilities management stated that there was no maintenance program to test the lights for 90 minutes to ensure their proper operation.

2) Several areas of exposed electrical wiring were observed in the hospital boiler room.

These findings were discussed with the Maintenance Staff.

Based on record review and interview, the critical access hospital failed to provide a written plan for actions to implement a fire watch in the event the automatic sprinkler system were to be out of service for more than 4 hours in a 24 hour period.

Failure to provide an action plan to implement a fire watch risks injury to patients, staff and visitors in the event that a fire occurs but the automatic sprinkler system was not available to extinguish the fire.

Findings include:

During review of policies and procedures on February 15, 2011 from 8:30 am to 12:30 pm, it was found that the critical access hospital did not have a policy in place for a fire watch in the event the automatic sprinkler system were to be out of service for greater than 4 hours in a 24 hour period. Hospital facilities management confirmed the finding.

This finding was discussed with Maintenance Staff.

Based on record review and interview, the critical access hospital failed to provide a written plan for actions to implement a fire watch in the event the fire alarm system were to be out of service for more than 4 hours in a 24 hour period.

Failure to provide an action plan to implement a fire watch risks injury to patients, staff and visitors in the event that a fire occurs but the fire alarm system was not available to notify occupants of the fire.

Findings include:

During review of policies and procedures on February 15, 2011 from 8:30 am to 12:30 pm, it was found that the critical access hospital did not have a policy in place for a fire watch in the event the fire alarm system were to be out of service for greater than 4 hours in a 24 hour period. Hospital facilities management confirmed the finding.

This finding was discussed with Maintenance Staff.

Based on observation, the critical access hospital failed to maintain the construction requirements for the classification of construction.

Failure to maintain the construction requirements risks injury to patients, staff and visitors through passage of smoke and fire across barriers designed to contain their spread.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) There were two penetrations above the ceiling in the rated 2 hour separation between the hospital basement and the assisted living building.

2) There were two penetrations above the ceiling in the rated 2 hour separation between the hospital and the long term care building.

3) A large overhead door track opening breached the wall between the boiler room and the exit access at the west end of the basement corridor in the old building.

These findings were discussed with Maintenance Staff.

Based on observation, the critical access hospital failed to provide corridor doors that were positive latching, and were able to close and latch without obstruction.

Failure to maintain corridor doors in a condition that permits full closing and latching risks injury to patients, staff and visitors through passage of smoke and fire across barriers designed to limit their spread.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The doors at the CS-Purchasing department did not automatically close and latch.

2) The fire separation door between the Long Term Care building and the Hospital did not close and latch and a large gap was observed that would
allow the penetration of smoke.

3) The exit door from 2nd floor old building, west exit, did not close and latch when released.

These findings were discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to properly mark an exit access route of travel.

Failure to properly mark an exit access route of travel risks injury to patients, staff and visitors through delayed egress from the hospital in an emergency.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The corridor from hospital to the long term care building had exit sign with directional arrow directing traffic to an exit that has been abandoned. The long term care building contains hospital outpatient services (physical therapy).

2) The corridor from hospital to the long term care building did not have an exit sign at turn in the corridor leading to an approved existing exit.

3) The approved exit at the corridor to in the long term care building did not have an approved exit sign.

These findings were discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to provide self-closing doors to separate hazardous areas from other spaces.

Failure to provide self-closing doors to separate hazardous areas from other spaces risks injury to patients, staff and visitors through passage of smoke and fire across barriers designed to limit their spread.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The room labeled Can Washer room in the basement was actually used as a trash collection room. The door to this room was observed to be held open by an excessively large amounts of garbage bins and did not close and latch automatically.

2) The boiler room area was exposed to corridor through a door with a glass window that was not sealed against the passage of smoke.

This finding was discussed with Maintenance Staff

Based upon observation and interview, the critical access hospital failed to provide two remote exits out of the basement floor of the old hospital building.

Failure to provide two exits out of each floor risks injury to patients, staff and visitors through entrapment in the corridor during a fire or other emergency.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) Only one approved, signed exit was present in the basement corridor. This exit led to an approved stairwell and to a horizontal exit to the adjacent assisted living building.

2) Hospital facilities management stated that a second exit was located at the west end of the basement corridor and led to the hospital loading dock. However, this route was:

a) obstructed by an overhead door in the route of egress
b) exposed to the biohazardous waste storage room by a door that did not close and latch
c) exposed to the boiler room by a large opening in the boiler room wall through which the overhead door chain assembly passed
d) obstructed by construction materials stored on the loading dock ramp
e) not signed as an exit

The presence of the overhead door and the hazards and obstructions noted above renders this an unapproved exit.

These findings were discussed with Maintenance Staff.

Based on observation, the critical access hospital failed to provide protection against fire or smoke in a stairwell.

Failure to provide protection against fire or smoke in a stairwell risks injury to patients, staff and visitors through uncontrolled spread of smoke and fire in the hospital.
Findings include:

During a tour of the critical access hospital on February 14, 2011, it was observed that the second floor stairwell door in the west stairwell of the old hospital did not close and latch. The door was obstructed by warping. This stairwell was exposed to the propane tank cited elsewhere in this report, and led into the corridor that contained the hospital surgery department.

The finding was discussed with hospital maintenance staff.

Based on observation, the critical access hospital failed to provide readily accessible exits at all times.

Failure to provide readily accessible exits at all times risks inability of patients, staff and visitors to quickly evacuate in the event of a fire or other emergency.

Findings include:

During a tour of the critical access hospital on February 15, 2011 at approximately noon, it was observed that:

1) The corridor in the childbirth unit had doors at the east and west ends. The east end doors were controlled by an approved delayed-egress control device, but were not provided with the required signage indicating that the doors would open in 15 seconds after an attempt to open the doors was made

2) The west end doors were locked with magnetic hold devices that required a special badge to release. The doors were not operable without the badge. There was no approved delayed egress device installed on these doors.

These findings were discussed with maintenance staff.

Based on observation, the critical access hospital failed to provide unobstructed exit access corridors in the new hospital.

Failure to provide unobstructed exit access corridors risks inability to swiftly evacuate patients, staff and visitors in the event of fire or other emergency.

Findings include:

During a tour of the critical access hospital on February 14, 2011, it was observed that the corridors of the new hospital building contained alcohol-based hand rub (ABHR) dispensers that were installed on floor stands. The ABHR stands were placed within the exit corridors and reduced the available width of the corridors below the required 8 clear feet.

This finding was discussed with hospital maintenance staff.

Based on record review and interview, the critical access hospital failed to implement the 8 requirements of a fire safety plan.

Failure to provide an accurate fire safety plan risks injury to patients, staff and visitors through unpreparedness of hospital personnel to effectively manage an emergency.

Findings include:

During review of critical access hospital policies and procedures on February 15, 2011 from 8:30 am to 12:30 pm, it was found that:

1) The fire safety plan had not been updated since 2002 and did not include the new hospital addition.

2) The fire safety plan did not include plans for implementation of partial and/or full evacuation.

3) Interviews with hospital facilities management and nursing personnel revealed that the hospital staff did not have knowledge of where the smoke compartments were located and what the evacuation plan required for patient and staff movement in the event of fire.

These findings were discussed with Maintenance Staff.

Based on record review and interview, the critical access hospital failed to provide documentation that all of the hospital personnel were participants in the required one fire drill per quarter per shift.

Failure to ensure that all hospital personnel participate in the required fire drills risks unpreparedness of hospital personnel to manage a fire emergency.

Findings include:

During review of critical access hospital fire drill records on on February 15, 2011 from 8:30 am to 12:30 pm, it was found that:

1) The hospital's fire drill records did not support a finding that the hospital staff actually held the required amount of fire drills. Some fire drill records did not have Hospital in the title, but instead had ALF (the adjacent assisted living facility).


2) Interviews with hospital facilities management revealed that some fire drills originate in either the adjacent assisted living facility or adjacent long term care facility. Although hospital personnel respond to both ALF and LTC fire drills, these drills do not originate within the hospital and do not test personnel's reaction to a fire in their area.

This finding was discussed with Maintenance Staff.

Based upon observation and interview, the critical access hospital failed to ensure that the automatic sprinkler system has been installed in accordance with NFPA 13.

Failure on the part of the facility to provide an approved sprinkler system could possibly expose the hospital to risk through an inability to extinguish a fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The CS-Purchasing warehouse room had two sprinkler heads placed approximately 18' apart over the combustible storage on shelving in the center of the room. This room contained a large quantity of combustible materials. The hospital did not provide documentation that a distance of 18' between sprinkler heads in this room was approved.

2) Interview with Maintenance Staff indicated that the laundry chute did not have sprinkler protection as required.

These findings were discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to ensure that the automatic sprinkler system has been installed in accordance with NFPA 13.

Failure on the part of the facility to provide an approved sprinkler system risks injury to patients, staff and visitors through an inadequate automatic fire sprinkler system.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) Escutcheons were missing in two closets in birthing hallway.

2) The fire sprinkler riser room door did not have an identification sign indicating "Sprinkler Riser Room".

Based on record review, the critical access hospital failed to ensure that the automatic sprinkler systems were continuously maintained in reliable operating condition and were inspected as required.

Failure to perform required maintenance and inspection risks injury to patients, staff and visitors through a potentially inoperable automatic fire sprinkler system.

Findings include:

During review of automatic sprinkler system maintenance records on February 15, 2011 from 8:30 am to 12:30 pm, it was found that:

1) There was no documentation that an acceptance test was conducted on the new sprinkler system installed throughout the new and old hospital before occupancy of the new hospital building.

2. There was no documentation that quarterly inspections were conducted on sprinkler system.

These findings were discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to provide portable fire extinguishers as required.

Failure to provide portable fire extinguishers as required risks inability of hospital personnel to quickly extinguish a fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The new hospital addition acute care unit has a BC fire extinguisher rather than an ABC fire extinguisher as required.

2) A fire extinguisher in the boiler room was discharged.

These finding were discussed with the Maintenance Staff.

Based upon observation, the critical access hospital failed to provide a laundry chute with a fire door assembly having a fire protection rating of 1 hour.

Failure to provide a laundry chute with a fire door assembly having a fire protection rating of 1 hour risks injury to patients, staff and visitors through exposure of the corridor to spreading smoke and fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that the linen chute room door did not automatically close and latch.

This finding was discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to ensure that containers greater than 32 gallons located in a room protected as a hazardous area when not attended.

Failure to ensure that containers greater than 32 gallons located in a room protected as a hazardous area when not attended risks injury to patients, staff and visitors through uncontained fire in the hospital exit corridors.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that a container greater than 32 gallons in capacity was stored in the basement corridor adjacent to the elevator. The container was observed to be full of flattened cardboard and other combustibles at the time of the observation.

This finding was discussed with the Maintenance Staff.

Based on observation, the critical access hospital failed to limit the quantity of oxygen (nonflammable medical gas) stored outside of an enclosure to 300 cubic feet or less .

Failure limit the amount of oxygen cylinders stored outside an enclosure puts patients, staff and visitors at risk from the effects of smoke and fire which would be accelerated in an oxygen rich environment.

[Reference:CMS Memorandum S&C-07-10, January 12, 2007; and NFPA 99 Health Care Facilities Chapter 9.4.3, 2005 Edition. Memorandum Summary: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured".]

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that the smoke compartment on the east end of the second floor of the old building contained at least 4 H cylinders (244 cubic feet each) and 2 E cylinders (150 cubic feet each) of compressed oxygen, exceeding the quantity of oxygen permissible to be exposed to the hospital corridor.

This finding was discussed with Maintenance Staff.

Based upon observation and interview, the critical access hospital failed to provide installation of LPG tanks in accordance with NFPA 58.

Failure to install tanks of flammable liquids in accordance with NFPA 58 exposes the hospital to an explosion hazard and risks injury to patients, staff and visitors through exposure to an accelerated fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) A tank of propane estimated by hospital facilities management to be approximately 250 gallons in capacity was placed immediately adjacent to a 3-story wall of single-pane glass comprising one wall of the old building west exit stairwell.

2) Signs indicating "No Smoking within 25 feet" were not visible in the vicinity of the propane tank.

3) Hospital personnel were observed smoking within approximately 15 feet of the propane tank.

4) There were no signs identifying the contents of the three propane tanks in the vicinity of the new generator.

5) There were no signs indicating "flammable" or such warning signs as required by NFPA 58.

These findings were discussed with Maintenance Staff.

Based on record review and interview, the critical access hospital failed to provide documentation that the hospital generators were run under load monthly.

Failure to run hospital generators under load monthly risks failure of the generators during a power outage.

Findings include:

Review of critical access hospital documentation on February 15, 2011 from 8:30 am to 12:30 pm, found that the new generator serving the new hospital building had been run under load in May, 2010 and June, 2010. No further monthly runs under load were documented. Hospital facilities management confirmed that additional runs under load were not documented and may not have occurred.

This finding was discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99, 3.4.2.2.2.

Failure to provide accurate branches on generators exposes the hospital to non-operational systems in the event of a power outage.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, the hospital essential electrical system emergency power distribution branches were followed from the automatic transfer switches to the end-user panels. It was found that:

The automatic transfer switch labeled "X" (Life Safety branch) led to panel BX2A. This panel had an inventory that included the following functions that are not approved for the Life Safety branch:

Exterior lighting
Communications room receptacles
HVAC controls
Water softener

The automatic transfer switch labeled "Y" (Critical branch) led to panel BY2A. This panel had an inventory that included the following functions that are not approved for the Critical branch:

Security panel
CCTV panel
CCTV power
Exterior canopy lights
Trap primers
Fuel oil pump
Equipment (DWCP 1 and 2)

This finding was discussed with Maintenance Staff.

Based upon observation, the critical access hospital failed to
maintain emergency lighting in the operating room, and electrical wiring in the boiler room as required by code.

Failure to maintain emergency lighting in the operating room risks injury to patients in the event that the hospital emergency generator fails to operate properly during a power outage. Failure to maintain electrical wiring in the boiler room risks injury to staff through shock or fire.

Findings include:

During a tour of the critical access hospital on February 14, 2011 from 12:00 pm to 4:30 pm, it was observed that:

1) The battery-powered 90-minute emergency light in the operating room failed to illuminate when the test button was pushed. Hospital facilities management stated that there was no maintenance program to test the lights for 90 minutes to ensure their proper operation.

2) Several areas of exposed electrical wiring were observed in the hospital boiler room.

These findings were discussed with the Maintenance Staff.

Based on record review and interview, the critical access hospital failed to provide a written plan for actions to implement a fire watch in the event the automatic sprinkler system were to be out of service for more than 4 hours in a 24 hour period.

Failure to provide an action plan to implement a fire watch risks injury to patients, staff and visitors in the event that a fire occurs but the automatic sprinkler system was not available to extinguish the fire.

Findings include:

During review of policies and procedures on February 15, 2011 from 8:30 am to 12:30 pm, it was found that the critical access hospital did not have a policy in place for a fire watch in the event the automatic sprinkler system were to be out of service for greater than 4 hours in a 24 hour period. Hospital facilities management confirmed the finding.

This finding was discussed with Maintenance Staff.

Based on record review and interview, the critical access hospital failed to provide a written plan for actions to implement a fire watch in the event the fire alarm system were to be out of service for more than 4 hours in a 24 hour period.

Failure to provide an action plan to implement a fire watch risks injury to patients, staff and visitors in the event that a fire occurs but the fire alarm system was not available to notify occupants of the fire.

Findings include:

During review of policies and procedures on February 15, 2011 from 8:30 am to 12:30 pm, it was found that the critical access hospital did not have a policy in place for a fire watch in the event the fire alarm system were to be out of service for greater than 4 hours in a 24 hour period. Hospital facilities management confirmed the finding.

This finding was discussed with Maintenance Staff.