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Based on observation, it was determined the facility failed to maintain a clear and unobstructed corridor.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.2.3.4 "Any required aisle, corridor, or ramp shall not be less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met: (a) The fixed furniture is securely attached to the floor or to the wall. (b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830mm), except as permitted by 19.2.3.4(2). (c) The fixed furniture is located only on one side of the corridor. (d) The fixed furniture is grouped such that each grouping is not does not exceed an area of 50 ft* (4.6 m*). (e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by by a distance of at least 10 ft (3050 mm). (f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.

Findings include:

On December 5, 2017, the surveyor, accompanied by the Director of Plant Services, observed in the OR area between OR #4 and the OB Wing, had portable storage racks, stationary storage racks, a stationary bike, and ladders in the corridor and by the emergency exits. None of the equipment stated above were secured to the floor or the wall.

During the exit conference on December 6, 2017, the above findings were again acknowledged by the Chief Executive Officer, Director of Plant Services, Director of Nursing, and key members of hospital staff.

Blocked exits and unsecured equipment in the corridors could cause harm to the patients and staff in the event of an emergency.

Based on observation, it was determined the facilty had ABHR dispensers above electrical outlets and light switches.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.6. " Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (4) Dispensers shall be separated from each other by horizontal spacing of not less than 48 in. (1220 mm). (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within 1 in. (25 mm) horizontal distance from each side of the ignition source. (b) to the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source. (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source."

Findings include:

On December 5-6, 2017, the surveyor, accompanied by the Director of Plant Services,observed the following ABHR dispensers above an ignition source:

1. Security office, above a light switch.
2. OB room #7 above an outlet/nightlight.
3. ICU room #6 above an outlet/nightlight.

During the exit conference on December 6, 2017, the above findings were again acknowledged by the Chief Executive Officer, Director of Plant Services, Director of Nursing, and key members of hospital staff.

Having ABHR dispensers mounted or placed in the wrong locations could cause harm to patients or staff in the event of a fire.

Based on record review, it was determined that the facility failed to have the five (5) year internal inspection of the automatic sprinkler piping.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.1.1.1.3. General "The provisions of Chapter 4, General, shall apply." Chapter 4, Section 4.6.12.3, "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed." Section 4.6.12.4, "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. NFPA 13, "Installation of Sprinkler Systems." Chapter 26, Section 26.1, General, "A sprinkler system installed in accordance with this standard shall be properly inspected, tested and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed." NFPA 25, Chapter 14, Section 14.2 "Internal Inspection of Piping" "Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and be removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material."

Findings Include:

On December 5, 2017, the surveyor accompanied by Director of Plant Services, reviewed the automatic sprinkler inspection, testing, and maintenance documentation. No documentation was found for the five (5) year internal inspection of piping.

During the exit conference on December 6, 2017, the above findings were again acknowledged by the Chief Executive Officer, Director of Plant Services, Director of Nursing, and key members of hospital staff.

Failing to conduct the 5 year internal inspection of sprinkler piping could allow build-up of foreign material which will affect the operation of the automatic sprinklers and may cause harm to patients and staff

Based on observation, it was determined the facility failed to fill penetrations in the smoke barriers in the facility.

NFPA 101 Life Safety Code 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

On December 5, 2017, the surveyor, accompanied by the Director of Plant Services observed unsealed penetrations in the smoke barriers in the following locations:

1. By Regulatory Compliance, an unsealed conduit, and two (2) penetrations.
2. By Compliance, one (1) penetration.

During the exit conference on December 6, 2017, the above findings were again acknowledged by the Chief Executive Officer, Director of Plant Services, Director of Nursing, and key members of hospital staff.

Failing to seal the penetrations, holes and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients i time of a fire.

Based on record review and interview with the Director of Plant Services, it was determined that there was no fire drill documentation for the second (2nd) quarter of 2016, both shifts.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.2.2 written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Emergency phone call to the fire department
4. Response to alarms
5. Isolation of fire
6. Evacuation of immediate area
7. Evacuation of smoke compartment
8. Preparation of floors and building for evacuation
9. Extinguishment of fire.

Findings include:

On December 5, 2017, the surveyor in conjunction with the Director of Plant Services reviewed the fire drills. There was no evidence that any fire drills had occurred for the second (2nd) quarter of 2016, both shifts.

During the exit conference on December 6, 2017, the above findings were again acknowledged by the Chief Executive Officer, Director of Plant Services, Director of Nursing, and key members of hospital staff.

Failing to conducted the fire drills in accordance with the life safety code to familiarize staff with conditions under an actual fire can result in harm to patients and staff during a an actual fire or emergency situation.

Based on observation, it was determined the facility allowed the use of multiple outlet adapters, power strips, and extension cords and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, "2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On December 5-6, 2017, the surveyor, accompanied by the Director of Plant Services, observed the following strips in the facility and not directly plugged in to the receptacle wall outlets.

1. In the Security office, a refrigerator plugged into a power strip.
2. In PACU, daisy chain of two power strips.
3. The catch tank pump used an extension cord.

During the exit conference on December 6, 2017, the above findings were again acknowledged by the Chief Executive Officer, Director of Plant Services, Director of Nursing, and key members of hospital staff.

The use of multiple outlet adapters could create an overload of the electrical system, and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on observation, it was determined the facility failed to secure a compressed helium cylinder.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

On December 6, 2017, the surveyor, accompanied by the Director of Plant Services observed a compressed helium cylinder not secured in a proper stand or cart in the MRI equipment room.

During the exit conference on December 6, 2017, the above findings were again acknowledged by the Chief Executive Officer, Director of Plant Services, Director of Nursing, and key members of hospital staff.

Failing to secure compressed medical gas cylinders could cause harm to the patients and staff.