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While facility tour at the FMC campus of North Shore Hospital in the company of the administrator and plant operations director, the fifth floor of the structure marked as "Pent House" in the existing signage and life safety plans was surveyed; where the exit access corridor was observed to be marked with signage that offers only one marked exit. The second exit provided by a horizontal exit through the pharmacy suite is not marked. Exit signage must be installed to announce the existence of this second required exit provision in order to re-establish compliance of the required number of exits. In addition, signage within the pharmacy suite must be marked to announce change in direction of travel to reach the stairs at the remote corner of the suite.

Based on a review of fire drill reports and interview on 12/07/2010, it was determined that the facility was not following procedures pertaining to training and practicing fire drills. In the event of a fire, the staff may not be adequately drilled to effectively use the life safety features to protect the building occupants.

The findings include:

During the tour of the facility and staff interview it was determined that staff did not know the proper procedures in case of fire under the kitchen's exhaust hood. The staff member could not explain the proper steps to activate the fixed suppression system or the use of the back up extinguisher.

NFPA 101 (2000)
NFPA 96

The Federal Life Safety Survey at North Shore Medical Center/FMC Campus in Fort Lauderdale was conducted on December 9th and 10th, 2010. The following life safety deficiencies were noticed based on the findings of this survey:
Provide a fire alarm visual device (strobe) in the Staff Lunch Room area located in 3 East - North Corridor.
Provide a fire alarm visual device (strobe) in the Staff Bathroom adjacent to the Nurse's Station on the 3rd Floor opposite Room #362.
Provide a fire alarm visual device (strobe) in the Administration Conference Room on the 1st Floor.
Provide a fire alarm visual device (strobe) in the Nurse's Lounge at 2 North opposite Room #244.
Provide a fire alarm visual device (strobe) in the Waiting Room at 2 South.
Provide fire alarm visual devices (strobes) in the Men's and Women's Rest Rooms in the Lab. area on the 1st Floor.

Based on a review of the facility records and interview with the staff, it was determined that the facility failed to test the smoke detectors as frequently as required. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

The findings include:

There was no documentation during the 12/07/10 survey to show that the duct smoke detectors were tested for sensitivity within the last two years. Sensitivity testing is required within one year after installation and every two years thereafter. The documents dated 09/07/2010, did not include a sensitivity test for the duct detectors in the fire alarm system.

NFPA 101 (2000)
NFPA 72 (1999) (National Fire Alarm Code) 7-3.2.

Based on observations made during tour of the facility it was determined that the facility failed to ensure that the patient smoking areas were safe. Proper ashtrays are required for the safety of the patients, and a lack could cause a fire.

The findings include:

Inspection of the patient smoking areas for the Psychiatric floor on 12/08/10, revealed that the facility did not have proper ashtrays in the smokers room. During the tour with the director of maintenance cigarette butts were observed on the floor and table in the room. Staff stated the ashtray was removed because it was broken and it had not been replaced.

NFPA 101(2006) chapter 19.7.4.

Base on staff interview and documentation it was determined that the facility failed to ensure all staff members in the laboratory have been trained in fire emergency in the laboratory as required. It was determined that the facility was not following procedures pertaining to training and practicing fire drills.

The findings include:

During the Life Safety survey conducted on December 8, 2010, fire drill reports for 2009 and 2010 were reviewed with the Director of Facilities Management. It was revealed that the laboratory staff have not conducted the required quarterly fire drills. This was confirmed during staff interview by personnel in the lab.

NFPA 1010 (2006)
NFPA 99 Chapter 10.

While facility tour at the FMC campus of North Shore Hospital in the company of the administrator and plant operations director, the fifth floor of the structure marked as "Pent House" in the existing signage and life safety plans was surveyed; where the exit access corridor was observed to be marked with signage that offers only one marked exit. The second exit provided by a horizontal exit through the pharmacy suite is not marked. Exit signage must be installed to announce the existence of this second required exit provision in order to re-establish compliance of the required number of exits. In addition, signage within the pharmacy suite must be marked to announce change in direction of travel to reach the stairs at the remote corner of the suite.

Based on a review of fire drill reports and interview on 12/07/2010, it was determined that the facility was not following procedures pertaining to training and practicing fire drills. In the event of a fire, the staff may not be adequately drilled to effectively use the life safety features to protect the building occupants.

The findings include:

During the tour of the facility and staff interview it was determined that staff did not know the proper procedures in case of fire under the kitchen's exhaust hood. The staff member could not explain the proper steps to activate the fixed suppression system or the use of the back up extinguisher.

NFPA 101 (2000)
NFPA 96

The Federal Life Safety Survey at North Shore Medical Center/FMC Campus in Fort Lauderdale was conducted on December 9th and 10th, 2010. The following life safety deficiencies were noticed based on the findings of this survey:
Provide a fire alarm visual device (strobe) in the Staff Lunch Room area located in 3 East - North Corridor.
Provide a fire alarm visual device (strobe) in the Staff Bathroom adjacent to the Nurse's Station on the 3rd Floor opposite Room #362.
Provide a fire alarm visual device (strobe) in the Administration Conference Room on the 1st Floor.
Provide a fire alarm visual device (strobe) in the Nurse's Lounge at 2 North opposite Room #244.
Provide a fire alarm visual device (strobe) in the Waiting Room at 2 South.
Provide fire alarm visual devices (strobes) in the Men's and Women's Rest Rooms in the Lab. area on the 1st Floor.

Based on a review of the facility records and interview with the staff, it was determined that the facility failed to test the smoke detectors as frequently as required. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

The findings include:

There was no documentation during the 12/07/10 survey to show that the duct smoke detectors were tested for sensitivity within the last two years. Sensitivity testing is required within one year after installation and every two years thereafter. The documents dated 09/07/2010, did not include a sensitivity test for the duct detectors in the fire alarm system.

NFPA 101 (2000)
NFPA 72 (1999) (National Fire Alarm Code) 7-3.2.

Based on observations made during tour of the facility it was determined that the facility failed to ensure that the patient smoking areas were safe. Proper ashtrays are required for the safety of the patients, and a lack could cause a fire.

The findings include:

Inspection of the patient smoking areas for the Psychiatric floor on 12/08/10, revealed that the facility did not have proper ashtrays in the smokers room. During the tour with the director of maintenance cigarette butts were observed on the floor and table in the room. Staff stated the ashtray was removed because it was broken and it had not been replaced.

NFPA 101(2006) chapter 19.7.4.

Base on staff interview and documentation it was determined that the facility failed to ensure all staff members in the laboratory have been trained in fire emergency in the laboratory as required. It was determined that the facility was not following procedures pertaining to training and practicing fire drills.

The findings include:

During the Life Safety survey conducted on December 8, 2010, fire drill reports for 2009 and 2010 were reviewed with the Director of Facilities Management. It was revealed that the laboratory staff have not conducted the required quarterly fire drills. This was confirmed during staff interview by personnel in the lab.

NFPA 1010 (2006)
NFPA 99 Chapter 10.