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Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 11/30/2010 the surveyor noted penetrations of the ceiling in the "Old Decontamination Room" and the IT "Server Room" (Room 404).

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 11/30/2010 the surveyor noted that a set of double smoke doors located near the OB unit "alarmed door" had an excessive gap (> 1/8 inch to approximately 1/2 inch) between the doors that would allow for the passage of smoke.

Based on observation the facility failed to provide illumination of the means of egress as is required by Section 7.8 of the Life Safety Code; NFPA 101, 2000 edition.

Failure on the part of the facility to provide egress illumination puts patients, staff and visitors of the facility at risk in the event an emergency egress is required.

Findings include:

1. On 11/30/2010 the surveyor noted that when the test button was employed on the emergency lighting fixture located near Room 136 (Outpatient Infusion) the lights failed to be energized and be illuminated.

This finding was acknowledged by staff and the Deputy State Fire Marshal who initiated the test.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 11/30/2010 while touring the facility the surveyor noted that a branch of upright sprinkler heads located in the boiler room were improperly installed in a downward orientation.

2. On 11/30/201 while touring the facility the surveyor noted that sprinklers of differing response rates were installed in the "Old Surgery" area of the facility. One quick response sprinkler and three standard response sprinklers were installed in the same smoke compartment which could in the event of fire create a skipping effect.

3. On 11/30/2010 while touring the facility the surveyor noted that escutcheons were missing for sprinklers in Room 211 (PT Office) and in the men's restroom of the PT unit.

Based on observation and interview the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers that were being inspected as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Reference:
NFPA 101, Life Safety Code, 2000 edition; Section 38.3.5 states: "Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1".

NFPA 101, Life Safety Code, 2000 edition; Section 9.7.4.1 states: "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers".

Findings include:

1. On 11/30/2010 the surveyor noted that a portable fire extinguisher (K class) had not received annual servicing as indicated by the service tag. Staff acknowledged this finding at the time of the survey.

Based on observation the facility failed to maintain a designated means of egress free of impediments to full instant use in the case of fire or other emergency.

Failure on the part of the facility to keep a means of egress free of impediments puts patients, staff and visitors of the facility at risk in the event of fire or other emergency.

Findings include:

1. On 11/30/2010 the surveyor noted that a linen cart was placed adjacent to a set of fire doors located in a designated exit access way (near sleep lab). The linen carts placement was such that it caused an impediment to egress by blocking one of the two doors.

Based on observation the facility failed to install an alcohol based hand rub (ABHR) dispenser in an appropriate manner.

Failure to install ABHR dispensers appropriately puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

1. On 11/30/2010 the surveyor observed an ABHR dispenser which was installed over an ignition source (light switch) in the clean utility closet (Room 151).

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 11/30/2010 the surveyor noted penetrations of the ceiling in the "Old Decontamination Room" and the IT "Server Room" (Room 404).

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 11/30/2010 the surveyor noted that a set of double smoke doors located near the OB unit "alarmed door" had an excessive gap (> 1/8 inch to approximately 1/2 inch) between the doors that would allow for the passage of smoke.

Based on observation the facility failed to provide illumination of the means of egress as is required by Section 7.8 of the Life Safety Code; NFPA 101, 2000 edition.

Failure on the part of the facility to provide egress illumination puts patients, staff and visitors of the facility at risk in the event an emergency egress is required.

Findings include:

1. On 11/30/2010 the surveyor noted that when the test button was employed on the emergency lighting fixture located near Room 136 (Outpatient Infusion) the lights failed to be energized and be illuminated.

This finding was acknowledged by staff and the Deputy State Fire Marshal who initiated the test.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 11/30/2010 while touring the facility the surveyor noted that a branch of upright sprinkler heads located in the boiler room were improperly installed in a downward orientation.

2. On 11/30/201 while touring the facility the surveyor noted that sprinklers of differing response rates were installed in the "Old Surgery" area of the facility. One quick response sprinkler and three standard response sprinklers were installed in the same smoke compartment which could in the event of fire create a skipping effect.

3. On 11/30/2010 while touring the facility the surveyor noted that escutcheons were missing for sprinklers in Room 211 (PT Office) and in the men's restroom of the PT unit.

Based on observation and interview the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers that were being inspected as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Reference:
NFPA 101, Life Safety Code, 2000 edition; Section 38.3.5 states: "Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1".

NFPA 101, Life Safety Code, 2000 edition; Section 9.7.4.1 states: "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers".

Findings include:

1. On 11/30/2010 the surveyor noted that a portable fire extinguisher (K class) had not received annual servicing as indicated by the service tag. Staff acknowledged this finding at the time of the survey.

Based on observation the facility failed to maintain a designated means of egress free of impediments to full instant use in the case of fire or other emergency.

Failure on the part of the facility to keep a means of egress free of impediments puts patients, staff and visitors of the facility at risk in the event of fire or other emergency.

Findings include:

1. On 11/30/2010 the surveyor noted that a linen cart was placed adjacent to a set of fire doors located in a designated exit access way (near sleep lab). The linen carts placement was such that it caused an impediment to egress by blocking one of the two doors.