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Based on observation, the facility failed to maintain their doors. This was evidenced by corridor doors that were not equipped to resist the passage of smoke. This affected one of three floors in the Main Hospital and could result in a delay to contain smoke or fire to a room.

NFPA 101, 2000 edition
8.3.4 Doors.
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings:

During a facility tour with staff, the corridor doors were observed.

Main Hospital:

1. On 8/6/12 at 10:47 a.m., the corridor double doors to the Storage Room (3PD68) were observed. The meeting edge of the doors had an approximately one quarter inch separation gap. The doors were not equipped with any astragal, rabbet, bevel, or gasket to help resist the potential passage of smoke.

Based on observation, the facility failed to protect the hazardous areas. This was evidenced by door to a hazardous area that was not equipped with a self-closing device. This affected 1 of 4 floors in the Main Hospital, and could result in the increased potential for the spread of fire and/or smoke to other areas of the facility.

Findings:

Main Hospital:

During a tour of the facility with Chief of engineer, the hazardous areas were observed.
On 8/6/12, at 2:25 p.m., the storage room 1CV12 in the Cafe area contained approximately a dozen of cardboard boxes and paper packaging. The room was 80 square foot in size, and the door was not equipped with a self-closing device. Any combustible storage rooms/spaces over 50 square feet, door shall be self closing.

Based on record review, the facility failed to establish required laboratory emergency procedures. This was evidenced by the facility's failure to establish an emergency procedure for extinguishing clothing fires. This affected one of three floors in the Main Hospital and could result in clothing fire injury to laboratory staff.

NFPA 99, 1999 edition
10-2.1.3 Emergency Procedures.
10-2.1.3.2 Emergency procedures shall be established for controlling chemical spills.
10-2.1.3.3 Emergency procedures shall be established for extinguishing clothing fires.

NFPA 101, 2000 edition
19.3.2.2 Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Findings:

During record review with staff, the facility's laboratory policies and procedures were reviewed.

Main Hospital:

1. On 8/7/12 at 1:30 p.m., the laboratory specific emergency policies and procedures were reviewed. There was no emergency procedure regarding the extinguishment of clothing fires in the laboratory.

Based on observation, record review, and interview, the facility failed to maintain their fire rated stairway doors. This was evidenced by two stairway doors that had conflicting fire ratings in a two hour fire rated enclosure. This affected three of three floors in the Main Hospital and could result in the spread of smoke or fire through the stairway.

NFPA 101, 2000 edition
8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 1 1/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42
Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1-hour fire resistance-rated construction, the opening protectives shall be permitted to have not less than a 20-minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test.
Exception No. 2: The requirement of 8.2.3.2.3.1(2) shall not apply where special requirements for doors in 1-hour fire resistance-rated corridor walls and 1-hour fire resistance-rated smoke barriers are specified in Chapters 18 through 21.
Exception No. 3: Existing doors having a 3/4-hour fire protection rating shall be permitted to continue to be used in vertical openings and in exit enclosures in lieu of the 1-hour rating required by 8.2.3.2.3.1(2).
(3) 1/2-hour fire barrier - 20-minute fire protection rating Exception: Twenty-minute fire protection-rated doors shall be exempt from the hose stream test of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

Findings:

During a facility tour with staff, the facility's stairway doors were observed.

Main Hospital:

1. On 8/6/12 at 10:26 a.m., the corridor door to Stairway 2 near 3 South was observed. The fire rating plate on the interior edge of the door indicated that the door had a one hour fire resistance rating.

2. On 8/6/12 at 11:04 a.m., the corridor door to Stairway 2 near 2 South was observed. The fire rating plate on the interior edge of the door indicated that the door had a 45 minute fire resistance rating.

During record review on 8/7/12, the building plans were reviewed. The building plans indicated that Stairway 2 had a two hour fire rated separation. A two hour fire rated enclosure is required to have a minimum of a 90 minute fire rated door. Support Services Staff 1 was interviewed on 8/9/12. Support Services Staff 1 indicated that he spoke with the manufacturer for the doors. Support Services Staff 1 indicated that the doors were equipped with a manufacturer fire rating tag on the top edge of the doors. The manufacturer rating tags indicated that the doors were two hour fire resistant. The facility was unable to verify which fire rating on the two stairway doors was the correct rating.

Based on observation and interview, the facility failed to maintain their emergency lights. This was evidenced by two emergency lights that failed to illuminate. This affected 2 of 5 Generators in the Main Hospital and could result in a failure of a normal lighting.

NFPA 101, 7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of section 7.8.

Findings:

Main Hospital:

On 8/6/12, During tour of the facility with Engineer 1, the emergency lights were observed.

At 1:15 p.m., the generator room had two emergency lights (2HLF3). Both emergency lights failed to illuminated when the test button were pressed. During an interview, at 1:16 p.m., Engineer 1 stated he was not sure why the emergency lights failed to illuminate.

Based on interview, the facility failed to ensure that all staff members are familiar with the emergency plan procedures. This was evidenced by one of nine staff members who was not familiar with the location of the fire alarm pull station. This deficient affected one of three floors in the main hospital. This could result in failure to protect residents in the event of a fire.

Findings:

During fire alarm testing with staff members, staff members were interviewed.

Main Hospital:

1. On 8/9/12 at 10:30 a.m., Staff 1 was interviewed regarding what action to take in the event of a fire. Staff 1 was not able to locate the nearest fire alarm pull station.

Based on record review, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the facility's failure to conduct one of four quarterly automatic fire sprinkler system tests and inspections during the past twelve months. This affected three of three floors in the Main Hospital and could result in a malfunction of the automatic fire sprinkler system.

NFPA 25, 1998 edition
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer ' s instructions.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During record review with staff, the facility's automatic fire sprinkler system test and inspection records were reviewed.

Main Hospital:

1. On 8/7/12 at 9:29 a.m., the facility had records of three quarterly automatic fire sprinkler system tests and inspections completed during the past twelve months. The facility conducted quarterly sprinkler system tests and inspections in September 2011, January 2012, and May 2012. The facility did not complete one of four quarterly automatic fire sprinkler system tests and inspections during the past twelve months.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of 5 alcohol based hand rub dispenser over or adjacent to ignition sources. This affected two of three floors in the Main Hospital and two of four floors in the Women and Children's Center and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff, the facility's alcohol based hand rub dispensers in the facility were observed.

Main Hospital:

1. On 8/6/12 at 10:35 a.m., an alcohol based hand rub dispenser in Room 3015 was mounted on the wall approximately seven inches above a light switch. The hand rub was 62.5 percent ethyl alcohol by volume.

2. On 8/6/12 at 11:23 a.m., an alcohol based hand rub dispenser in Office 25A02 was mounted on the wall approximately six inches above a light switch. The hand rub was 62.5 percent ethyl alcohol by volume.

3. On 8/6/12 at 11:40 a.m., an alcohol based hand rub dispenser in Soiled Utility Room 2CCE13 was mounted on the wall approximately six inches above a light switch. The hand rub was 62.5 percent ethyl alcohol by volume.

4. On 8/6/12 at 11:43 a.m., an alcohol based hand rub dispenser by ICU Room 2CCE21 was mounted on the wall approximately three feet above an electrical receptacle. The hand rub was 62.5 percent ethyl alcohol by volume.

5. On 8/6/12 at 11:46 a.m., an alcohol based hand rub dispenser by ICU Room 2CCW21 was mounted on the wall approximately three feet above an electrical receptacle. The hand rub was 62.5 percent ethyl alcohol by volume.

Women and Children's Center:

6. On 8/6/12, at 10:55 a.m., an ABHR was mounted two inches next to a light source, in the EVS W3B24, on the third floor.

7. On 8/6/12, at 11 a.m., an ABHR was mounted three inches next to a light source, in the Clean utility room/med room triage B22, on the second floor.

Based on observation, the facility failed to maintain their doors. This was evidenced by corridor doors that were not equipped to resist the passage of smoke. This affected one of three floors in the Main Hospital and could result in a delay to contain smoke or fire to a room.

NFPA 101, 2000 edition
8.3.4 Doors.
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings:

During a facility tour with staff, the corridor doors were observed.

Main Hospital:

1. On 8/6/12 at 10:47 a.m., the corridor double doors to the Storage Room (3PD68) were observed. The meeting edge of the doors had an approximately one quarter inch separation gap. The doors were not equipped with any astragal, rabbet, bevel, or gasket to help resist the potential passage of smoke.

Based on observation, the facility failed to protect the hazardous areas. This was evidenced by door to a hazardous area that was not equipped with a self-closing device. This affected 1 of 4 floors in the Main Hospital, and could result in the increased potential for the spread of fire and/or smoke to other areas of the facility.

Findings:

Main Hospital:

During a tour of the facility with Chief of engineer, the hazardous areas were observed.
On 8/6/12, at 2:25 p.m., the storage room 1CV12 in the Cafe area contained approximately a dozen of cardboard boxes and paper packaging. The room was 80 square foot in size, and the door was not equipped with a self-closing device. Any combustible storage rooms/spaces over 50 square feet, door shall be self closing.

Based on record review, the facility failed to establish required laboratory emergency procedures. This was evidenced by the facility's failure to establish an emergency procedure for extinguishing clothing fires. This affected one of three floors in the Main Hospital and could result in clothing fire injury to laboratory staff.

NFPA 99, 1999 edition
10-2.1.3 Emergency Procedures.
10-2.1.3.2 Emergency procedures shall be established for controlling chemical spills.
10-2.1.3.3 Emergency procedures shall be established for extinguishing clothing fires.

NFPA 101, 2000 edition
19.3.2.2 Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Findings:

During record review with staff, the facility's laboratory policies and procedures were reviewed.

Main Hospital:

1. On 8/7/12 at 1:30 p.m., the laboratory specific emergency policies and procedures were reviewed. There was no emergency procedure regarding the extinguishment of clothing fires in the laboratory.

Based on observation, record review, and interview, the facility failed to maintain their fire rated stairway doors. This was evidenced by two stairway doors that had conflicting fire ratings in a two hour fire rated enclosure. This affected three of three floors in the Main Hospital and could result in the spread of smoke or fire through the stairway.

NFPA 101, 2000 edition
8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 1 1/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42
Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1-hour fire resistance-rated construction, the opening protectives shall be permitted to have not less than a 20-minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test.
Exception No. 2: The requirement of 8.2.3.2.3.1(2) shall not apply where special requirements for doors in 1-hour fire resistance-rated corridor walls and 1-hour fire resistance-rated smoke barriers are specified in Chapters 18 through 21.
Exception No. 3: Existing doors having a 3/4-hour fire protection rating shall be permitted to continue to be used in vertical openings and in exit enclosures in lieu of the 1-hour rating required by 8.2.3.2.3.1(2).
(3) 1/2-hour fire barrier - 20-minute fire protection rating Exception: Twenty-minute fire protection-rated doors shall be exempt from the hose stream test of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

Findings:

During a facility tour with staff, the facility's stairway doors were observed.

Main Hospital:

1. On 8/6/12 at 10:26 a.m., the corridor door to Stairway 2 near 3 South was observed. The fire rating plate on the interior edge of the door indicated that the door had a one hour fire resistance rating.

2. On 8/6/12 at 11:04 a.m., the corridor door to Stairway 2 near 2 South was observed. The fire rating plate on the interior edge of the door indicated that the door had a 45 minute fire resistance rating.

During record review on 8/7/12, the building plans were reviewed. The building plans indicated that Stairway 2 had a two hour fire rated separation. A two hour fire rated enclosure is required to have a minimum of a 90 minute fire rated door. Support Services Staff 1 was interviewed on 8/9/12. Support Services Staff 1 indicated that he spoke with the manufacturer for the doors. Support Services Staff 1 indicated that the doors were equipped with a manufacturer fire rating tag on the top edge of the doors. The manufacturer rating tags indicated that the doors were two hour fire resistant. The facility was unable to verify which fire rating on the two stairway doors was the correct rating.

Based on observation and interview, the facility failed to maintain their emergency lights. This was evidenced by two emergency lights that failed to illuminate. This affected 2 of 5 Generators in the Main Hospital and could result in a failure of a normal lighting.

NFPA 101, 7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of section 7.8.

Findings:

Main Hospital:

On 8/6/12, During tour of the facility with Engineer 1, the emergency lights were observed.

At 1:15 p.m., the generator room had two emergency lights (2HLF3). Both emergency lights failed to illuminated when the test button were pressed. During an interview, at 1:16 p.m., Engineer 1 stated he was not sure why the emergency lights failed to illuminate.

Based on interview, the facility failed to ensure that all staff members are familiar with the emergency plan procedures. This was evidenced by one of nine staff members who was not familiar with the location of the fire alarm pull station. This deficient affected one of three floors in the main hospital. This could result in failure to protect residents in the event of a fire.

Findings:

During fire alarm testing with staff members, staff members were interviewed.

Main Hospital:

1. On 8/9/12 at 10:30 a.m., Staff 1 was interviewed regarding what action to take in the event of a fire. Staff 1 was not able to locate the nearest fire alarm pull station.

Based on record review, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the facility's failure to conduct one of four quarterly automatic fire sprinkler system tests and inspections during the past twelve months. This affected three of three floors in the Main Hospital and could result in a malfunction of the automatic fire sprinkler system.

NFPA 25, 1998 edition
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer ' s instructions.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During record review with staff, the facility's automatic fire sprinkler system test and inspection records were reviewed.

Main Hospital:

1. On 8/7/12 at 9:29 a.m., the facility had records of three quarterly automatic fire sprinkler system tests and inspections completed during the past twelve months. The facility conducted quarterly sprinkler system tests and inspections in September 2011, January 2012, and May 2012. The facility did not complete one of four quarterly automatic fire sprinkler system tests and inspections during the past twelve months.