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Based on visual observation this facility failed to assure the smoke compartmentation of the membrane between the egress corridor and rooms was not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice has the potential to affect 7 of 7 patients and
2 of 2 smoke compartments.

Findings:

During the facility tour, between the hours of 9:30 a.m. and 3:30 p.m. the endo anti room, front receptionist lobby, wire glass panel by conference room, and the chapel were observed open to the corridor because of the following: 1. endo anti room has double doors that are not positive latching and smoke resistive 2. front receptionist lobby has a 4 inch by 5 inch opening in the glass 3. wire glass panel outside of conference room is not smoke resistive. 4. the chapel has sliding doors with no positive latch.

Interview with the maintenance supervisor revealed the facility was not aware these rooms were required to be separated from the corridor or protected by smoke detection.

Based on visual observation the facility failed to provide corridor doors that were closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room's occupants. This deficient practice has the potential to affect 7 of 7 patients.

Findings:

During facility tour, between the hours of 9:30 a.m. and 3:30 p.m. the X ray room, file room, and outpatient suite were observed with no positive latching devices provided to ensure the doors close tightly in the frames.

Based on visual observation the facility failed to provide exit signage in areas where the exits were not apparent. Exit signs provide a route for occupants to reach safety. The deficient practice has the potential to affect 7 of 7 patients.


Findings:

During the facility tour, between the hours of 9:30 a.m. and 3:30 p.m. the cross corridor doors by emergency rooms A and B and conference room were observed with no exit signs to direct occupants out of the building in a fire emergency.

Interview with the maintenance supervisor revealed the facility was unaware the exit paths were not marked.

Based on visual observation the facility failed to assure the fire rating of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the adjoining compartment. This deficient practice has the potential to affect 7 of 7 patients.
2 of 2 smoke barriers are deficient.

Findings:

During the facility tour, between the hours of 9:30 a.m. and 3:30 p.m. the 2 smoke barrier walls were observed with unsealed penetrations. Mineral wool substituted for fire rated caulk used to seal penetrations and open area between wall and roof deck. Metal beams with no fire rating. And areas with missing sections of sheet rock.

Interview with the maintenance supervisor revealed the facility was not aware the fire walls were not sealed properly.

Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice has the potential to affect 7 of 7 patients.

Findings:

During the facility tour and interview with staff, between the hours of 9:30 a.m. and 3:30 p.m. the psych unit corridor doors were observed with dead bolt locks, rendering the occupant incapable of exiting the room in a emergency situation. The outside wooden gate to the exit discharge was observed with a padlock. The doors entering the unit and the rear exit door were observed with magnetic locks which do not meet Fire Marshal requirements for special locking in health care.

Interview with the maintenance supervisor revealed he was not aware these locks were required to allow free egress from the building.

When special locking devices are permitted, one of three options is required in order to allow free egress for staff and visitors. The three options are:
1. The access code for the keypad is posted at the device, or,
2. The key to the override switch is posted at the device, or,
3. Staff carry a key to the override switch at all times

A. UNLOCKING (EMERGENCY RELEASE) shall be accomplished by the following:
1. Loss of power to any part of the system that controls locks or the emergency
releasing mechanisms; and
2. Activation of the fire alarm system; and
3. Remote release at approved, constantly attended location(s). Furnish a floor
plan showing the location of required exits, all locked doors - (existing and
new), nurses ' station(s), control station(s) and remote release location(s).
(NOTE: The remote control functions must be identified at the remote release
location(s) with permanent legible signage and responsible staff must be
trained on system control and emergency operations); and,
4. A means of manual mechanical unlocking must be provided at each door
that is not in direct view of the remote release location. Doors must be keyed
alike and keys must be carried by the staff responsible for patient evacuation
whenever the locking system is operational and in use.
(Keypads, card readers, and other electrical devices are not acceptable as means of
mechanically unlocking doors during emergency conditions.)
B. " AUTOMATIC " RE-LOCKING, after an emergency release as described above, shall
be PROHIBITED. A specific human action dedicated for re-locking doors must be
provided at the remote control location or at each lock location.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice has the potential to affect 7 of 7 patients.
3 of 4 quarters in 2013 were deficient.

Findings:

During the record review, between the hours of 9:30am and 3:30pm, fire drills were not conducted for the evening shift in the 2nd quarter, the day shift in the 3rd quarter, and the midnight shift in the 4th quarter.

Interview with maintenance supervisor revealed the facility was not aware fire drills were not being held one per quarter per shift.

Based on visual observation the facility failed to assure that the fire alarm system was installed to provide effective warning to all parts of the building. This deficiency could potentially affect 2 of 7 patients.

Findings:

During the facility tour and the record review, between the hours of 9:30am and 3:30pm, the admitting lounge was observed to be lacking visual and audible fire alarm notification devices.

Interview with maintenance supervisor revealed he was unaware this area was lacking fire alarm notification devices.


NFPA101:9.6.3.6.1 The general evacuation alarm signal shall operate throughout the entire building.

Based on visual observation and record review the facility failed to maintain minimum safety requirements for cooking equipment. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice has the potential to affect 7 of 7 residents.

Findings:

During the facility tour of the kitchen, between the hours of 9:30am and 3:30pm, the deep fat fryer was observed without the minimum clearance as required by NFPA 96.

NFPA96:12.1.2.4 All deep-fat fryers shall be installed with at least a 406 mm (16 in.) space between the fryer and surface flames from adjacent cooking equipment.
NFPA96:12.1.2.5 Where a steel or tempered glass baffle plate is installed at a minimum 203 mm (8 in.) in height between the fryer and surface flames of the adjacent appliance, the requirement for a 406 mm (16 in.) space shall not apply.

Interview with maintenance supervisor revealed he was not aware of this requirement.

Based on visual observation the facility failed to perform the required 6 year maintenance test on the smoke dampers. This deficient practice could cause harm to 7 of 7 patients.

Findings: During tour of the building between the hours of 9:30 a.m. and 3:30 p.m. interview with the maintenance supervisor revealed the hospital has no maintenance program in place to perform the required 6 year damper test. The smoke dampers are critical in preventing the passage of smoke from one smoke compartment to another.

Based on visual observation and record review, the facility failed to assure the emergency generator was in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 7 of 7 patients.

Findings:

During the record review, between the hours of 9:30am and 3:30pm, the battery electrolyte levels were not checked and documented monthly.

During facility tour the generator room was observed not separated from the hospital with a 2-hour fire wall. Also, the annunciator panel was not in a location that allows the staff to observe it readily.

Interview with the maintenance supervisor revealed the facility was not aware documentation was incomplete regarding the inspection/testing of the emergency generator, the annunciator panel, and the 2 hour wall.

Based on visual observation this facility failed to assure the smoke compartmentation of the membrane between the egress corridor and rooms was not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice has the potential to affect 7 of 7 patients and
2 of 2 smoke compartments.

Findings:

During the facility tour, between the hours of 9:30 a.m. and 3:30 p.m. the endo anti room, front receptionist lobby, wire glass panel by conference room, and the chapel were observed open to the corridor because of the following: 1. endo anti room has double doors that are not positive latching and smoke resistive 2. front receptionist lobby has a 4 inch by 5 inch opening in the glass 3. wire glass panel outside of conference room is not smoke resistive. 4. the chapel has sliding doors with no positive latch.

Interview with the maintenance supervisor revealed the facility was not aware these rooms were required to be separated from the corridor or protected by smoke detection.

Based on visual observation the facility failed to provide corridor doors that were closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room's occupants. This deficient practice has the potential to affect 7 of 7 patients.

Findings:

During facility tour, between the hours of 9:30 a.m. and 3:30 p.m. the X ray room, file room, and outpatient suite were observed with no positive latching devices provided to ensure the doors close tightly in the frames.

Based on visual observation the facility failed to provide exit signage in areas where the exits were not apparent. Exit signs provide a route for occupants to reach safety. The deficient practice has the potential to affect 7 of 7 patients.


Findings:

During the facility tour, between the hours of 9:30 a.m. and 3:30 p.m. the cross corridor doors by emergency rooms A and B and conference room were observed with no exit signs to direct occupants out of the building in a fire emergency.

Interview with the maintenance supervisor revealed the facility was unaware the exit paths were not marked.

Based on visual observation the facility failed to assure the fire rating of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the adjoining compartment. This deficient practice has the potential to affect 7 of 7 patients.
2 of 2 smoke barriers are deficient.

Findings:

During the facility tour, between the hours of 9:30 a.m. and 3:30 p.m. the 2 smoke barrier walls were observed with unsealed penetrations. Mineral wool substituted for fire rated caulk used to seal penetrations and open area between wall and roof deck. Metal beams with no fire rating. And areas with missing sections of sheet rock.

Interview with the maintenance supervisor revealed the facility was not aware the fire walls were not sealed properly.

Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice has the potential to affect 7 of 7 patients.

Findings:

During the facility tour and interview with staff, between the hours of 9:30 a.m. and 3:30 p.m. the psych unit corridor doors were observed with dead bolt locks, rendering the occupant incapable of exiting the room in a emergency situation. The outside wooden gate to the exit discharge was observed with a padlock. The doors entering the unit and the rear exit door were observed with magnetic locks which do not meet Fire Marshal requirements for special locking in health care.

Interview with the maintenance supervisor revealed he was not aware these locks were required to allow free egress from the building.

When special locking devices are permitted, one of three options is required in order to allow free egress for staff and visitors. The three options are:
1. The access code for the keypad is posted at the device, or,
2. The key to the override switch is posted at the device, or,
3. Staff carry a key to the override switch at all times

A. UNLOCKING (EMERGENCY RELEASE) shall be accomplished by the following:
1. Loss of power to any part of the system that controls locks or the emergency
releasing mechanisms; and
2. Activation of the fire alarm system; and
3. Remote release at approved, constantly attended location(s). Furnish a floor
plan showing the location of required exits, all locked doors - (existing and
new), nurses ' station(s), control station(s) and remote release location(s).
(NOTE: The remote control functions must be identified at the remote release
location(s) with permanent legible signage and responsible staff must be
trained on system control and emergency operations); and,
4. A means of manual mechanical unlocking must be provided at each door
that is not in direct view of the remote release location. Doors must be keyed
alike and keys must be carried by the staff responsible for patient evacuation
whenever the locking system is operational and in use.
(Keypads, card readers, and other electrical devices are not acceptable as means of
mechanically unlocking doors during emergency conditions.)
B. " AUTOMATIC " RE-LOCKING, after an emergency release as described above, shall
be PROHIBITED. A specific human action dedicated for re-locking doors must be
provided at the remote control location or at each lock location.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice has the potential to affect 7 of 7 patients.
3 of 4 quarters in 2013 were deficient.

Findings:

During the record review, between the hours of 9:30am and 3:30pm, fire drills were not conducted for the evening shift in the 2nd quarter, the day shift in the 3rd quarter, and the midnight shift in the 4th quarter.

Interview with maintenance supervisor revealed the facility was not aware fire drills were not being held one per quarter per shift.

Based on visual observation the facility failed to assure that the fire alarm system was installed to provide effective warning to all parts of the building. This deficiency could potentially affect 2 of 7 patients.

Findings:

During the facility tour and the record review, between the hours of 9:30am and 3:30pm, the admitting lounge was observed to be lacking visual and audible fire alarm notification devices.

Interview with maintenance supervisor revealed he was unaware this area was lacking fire alarm notification devices.


NFPA101:9.6.3.6.1 The general evacuation alarm signal shall operate throughout the entire building.

Based on visual observation and record review the facility failed to maintain minimum safety requirements for cooking equipment. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice has the potential to affect 7 of 7 residents.

Findings:

During the facility tour of the kitchen, between the hours of 9:30am and 3:30pm, the deep fat fryer was observed without the minimum clearance as required by NFPA 96.

NFPA96:12.1.2.4 All deep-fat fryers shall be installed with at least a 406 mm (16 in.) space between the fryer and surface flames from adjacent cooking equipment.
NFPA96:12.1.2.5 Where a steel or tempered glass baffle plate is installed at a minimum 203 mm (8 in.) in height between the fryer and surface flames of the adjacent appliance, the requirement for a 406 mm (16 in.) space shall not apply.

Interview with maintenance supervisor revealed he was not aware of this requirement.

Based on visual observation the facility failed to perform the required 6 year maintenance test on the smoke dampers. This deficient practice could cause harm to 7 of 7 patients.

Findings: During tour of the building between the hours of 9:30 a.m. and 3:30 p.m. interview with the maintenance supervisor revealed the hospital has no maintenance program in place to perform the required 6 year damper test. The smoke dampers are critical in preventing the passage of smoke from one smoke compartment to another.

Based on visual observation and record review, the facility failed to assure the emergency generator was in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 7 of 7 patients.

Findings:

During the record review, between the hours of 9:30am and 3:30pm, the battery electrolyte levels were not checked and documented monthly.

During facility tour the generator room was observed not separated from the hospital with a 2-hour fire wall. Also, the annunciator panel was not in a location that allows the staff to observe it readily.

Interview with the maintenance supervisor revealed the facility was not aware documentation was incomplete regarding the inspection/testing of the emergency generator, the annunciator panel, and the 2 hour wall.