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Based on facility tour and staff verification it was determined this facility failed to ensure all smoke/fire barrier doors were constructed to resist the passage of smoke. This had the potential to affect all those utilizing this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 and 09/18/13 with staff members A1, B2, C3 and D4. During tour of the basement observation was made of three fire doors which had gaps greater than one eighth inch between the door leafs when in the closed position.

1) Fire rated double leafed door located in the corridor adjacent to the accounting department identified as C004.

2) Fire rated double leafed door identified as C001 next to the business office.

3) Fire rated double leafed door was located outside of the vascular lab and identified as C003.

First floor:

4) The fire rated double doors leading to the medical office building was observed with a gap greater than one-eighth inch between the door leafs when in the closed position.


These findings were verified by all staff members present during tour of this area.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing those areas of the facility. The patient census at the beginning of the survey was 23.

Findings include:

Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour of the fire rated barrier observation was made of penetrations above the ceiling tiles in the following locations:

Basement
1) Within corridor C001 facing the east fire rated wall being across from the business office, observation was made of two insulated lines not sealed around the annular space.

2) Above the ceiling tiles facing the same fire barrier located adjacent to and south of the stairs and above the double doors, observation was made of two metal sleeves having tape over the ends to cover the openings, two unsealed sleeves with wires passing through, two unsealed black water lines and three unsealed copper lines.

First floor:
3) Beginning at the same fire wall extending from the basement through the first floor and above the double doors adjacent to and south of the stairwell, observation was made of two four inch black unsealed water lines and an open end conduit with blue and white wires passing through.

4) Moving north along the same fire wall in the room just north of the vending area, observation was made of one unsealed pipe and one unsealed conduit.

5) Turning the corner heading west and within the lab waiting area identified as 1103, observation was made of one open end conduit which had tape covering the open end. Just to the west of that, there was one unsealed conduit around the annular space.

6) Within the job care waiting area identified as 1104 observation was made of a one inch open end conduit.

7) Continuing west and now within the x-ray waiting area identified as 1106, observation was made of an approximate two inch open end pipe.

8) Continuing west and now at the north/south fire rated wall being the back wall of the x-ray room identified as 1510, observation was made of two unsealed conduits around the annular space.

9) Continuing south along the north/south fire rated wall and at the double doors located between the a-ray room identified as 1504 and the intake room identified as 1501, observation was made of an unsealed area around the water line feeding the sprinkler system, a small hole drilled through the concrete block and one unsealed flex conduit.

These findings were verified by staff members during tour of this area.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 23.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the first floor two hour fire rated barrier located at the south end of the obstetrics department, observation was made of penetrations in the following locations:

1) Within room 124, facing the south wall and above the ceiling tiles, observation was made of two insulated lines not sealed around the annular space, one open end silver conduit with blue and orange wires passing through and one silver conduit not sealed around the annular space.

2) Above the ceiling tiles facing the same fire barrier located at the cross-over to the new building by the lab, observation was made of three unsealed girders where it passed through the fire barrier and an unsealed area around two silver conduits.

These findings were verified by staff members during tour of this area.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all doors in smoke/fire barriers were equipped with self-closing or automatic closing devices. This had the potential to affect all those who utilized this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour of the east/west two hour fire rated barrier separating the x-ray department from the x-ray waiting area, specifically at the entrance to the x-ray office, observation was made of a one and one-half hour fire rated door which was not equipped with a self-closing or automatic closing device. This door was observed to be left in the open position.

This finding was verified by staff members present during tour.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all hazardous areas were constructed with at least a one hour fire rated enclosure. This had the potential to affect all those who utilized this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour of the first floor hazardous room identified as 1315, observation was made of seven penetrations around and within conduits located above the ceiling tile.

This finding was verified by staff members present during tour.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all smoke detectors were mounted in areas where the normal operation of the detectors would not be affected by any air flow device. This had the potential to affect all those who utilized this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour observation was made of smoke detectors mounted or placed near air flow devices in the following locations:

Basement:
1) Within corridor C001

First floor:
2) Within the balcony area identified as corridor C103
3) Within the corridor between rooms 1410 and 1424.
4) Within the ambulance entrance area between rooms 1428 and 1402.
5) Within the emergency department waiting area identified as number 1414.

Second floor:
6) Within the infusing waiting room identified as M2201.
7) Within the coumadin clinic waiting room identified as M2301.
8) Within the respiratory waiting room identified as M2501.

This finding was verified by staff members present during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure all components of the sprinkler system were maintained in order to provide complete sprinkler coverage in the event of an emergency requiring activation of the suppression system. This had the potential to affect all those utilizing those areas of the facility. The patient census at the beginning of the survey was 23.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the first floor obstetrics department observation was made within the closet of room 124 of a sprinkler pendant which had been displaced from it's original mounted position and was observed to be withdrawn above the ceiling and offset from the pendant access opening.

This finding was verified by staff members during tour of the obstetrics department.

Based on observation during tour and staff interview it was determined this facility failed to ensure all portable fire extinguishers were mounted with the mounting bracket no greater than five feet from the floor or placed within a fire extinguisher cabinet. Additionally, this facility failed to ensure all fire extinguishers were accessible in the event of an emergency and were checked monthly. This had the potential to affect all those utilizing this area of the facility. The facility census was 10 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4.

1) During tour of the generator house and basement area, observation was made of five portable fire extinguishers which were mounted greater than five feet from the floor. These were observed in the following locations: Two were observed in the number one generator house. One was located outside the pump room, one within the boiler room and one within the housekeeping room located east of the medical records room.

2) During tour of the first floor, observation was made of one fire extinguisher located in the lab which was mounted greater than five feet from the floor. Another fire extinguisher in the lab was observed to be mounted behind a large metal framed work station.

3) Within the MRI electrical room, observation was made of a portable fire extinguisher located on the floor.

4) Within the medical surgery department and adjacent to the nurses station observation was made of a hoyer lift placed in front of a mounted portable fire extinguisher. Within a small work room behind the nurse's station observation was made of a portable fire extinguisher sitting on the top of the counter. This fire extinguisher was observed to be "borrowed" and had an inspection tag last dated for September 2009.

These findings were verified by staff members during tour of this floor.

Based on facility tour and staff verification it was determined this facility failed to ensure medical gas storage did not exceed 300 cubic feet per smoke compartment. This had the potential to affect all those utilizing those areas of the facility. The patient census at the beginning of the survey was 23.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the second floor storage room adjacent to the sleep lab observation was made within this room of 16 E-tanks of oxygen placed within two separate holding racks. This amount totaled 400 cubic feet and exceeded the limit per smoke compartment by 100 cubic feet.

This finding was verified by staff members during tour of the obstetrics department.

Based on observation during tour and staff verification it was determined this facility failed to ensure all medical gas bottles were secured when not in use. This had the potential to affect all those utilizing this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the MRI control room area observation was made of one E-tank of oxygen unsecured sitting on floor.

This finding was verified by staff members during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure all electrical wiring and equipment was in accordance with the National Fire Protection Association (NFPA) 70, specifically in regards to the use of power strips. This had the potential to affect all those utilizing this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the surgery department, specifically operating room number one, observation was made of a power strip plugged into a wall outlet. The power strip was observed to have three plugs attached into it from surgical equipment and an additional plug which attached into it from another power strip. In essence, there was one power strip "piggy backed" into the other power strip.

This finding was verified by staff members during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke/fire barrier doors were constructed to resist the passage of smoke. This had the potential to affect all those utilizing this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 and 09/18/13 with staff members A1, B2, C3 and D4. During tour of the basement observation was made of three fire doors which had gaps greater than one eighth inch between the door leafs when in the closed position.

1) Fire rated double leafed door located in the corridor adjacent to the accounting department identified as C004.

2) Fire rated double leafed door identified as C001 next to the business office.

3) Fire rated double leafed door was located outside of the vascular lab and identified as C003.

First floor:

4) The fire rated double doors leading to the medical office building was observed with a gap greater than one-eighth inch between the door leafs when in the closed position.


These findings were verified by all staff members present during tour of this area.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing those areas of the facility. The patient census at the beginning of the survey was 23.

Findings include:

Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour of the fire rated barrier observation was made of penetrations above the ceiling tiles in the following locations:

Basement
1) Within corridor C001 facing the east fire rated wall being across from the business office, observation was made of two insulated lines not sealed around the annular space.

2) Above the ceiling tiles facing the same fire barrier located adjacent to and south of the stairs and above the double doors, observation was made of two metal sleeves having tape over the ends to cover the openings, two unsealed sleeves with wires passing through, two unsealed black water lines and three unsealed copper lines.

First floor:
3) Beginning at the same fire wall extending from the basement through the first floor and above the double doors adjacent to and south of the stairwell, observation was made of two four inch black unsealed water lines and an open end conduit with blue and white wires passing through.

4) Moving north along the same fire wall in the room just north of the vending area, observation was made of one unsealed pipe and one unsealed conduit.

5) Turning the corner heading west and within the lab waiting area identified as 1103, observation was made of one open end conduit which had tape covering the open end. Just to the west of that, there was one unsealed conduit around the annular space.

6) Within the job care waiting area identified as 1104 observation was made of a one inch open end conduit.

7) Continuing west and now within the x-ray waiting area identified as 1106, observation was made of an approximate two inch open end pipe.

8) Continuing west and now at the north/south fire rated wall being the back wall of the x-ray room identified as 1510, observation was made of two unsealed conduits around the annular space.

9) Continuing south along the north/south fire rated wall and at the double doors located between the a-ray room identified as 1504 and the intake room identified as 1501, observation was made of an unsealed area around the water line feeding the sprinkler system, a small hole drilled through the concrete block and one unsealed flex conduit.

These findings were verified by staff members during tour of this area.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 23.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the first floor two hour fire rated barrier located at the south end of the obstetrics department, observation was made of penetrations in the following locations:

1) Within room 124, facing the south wall and above the ceiling tiles, observation was made of two insulated lines not sealed around the annular space, one open end silver conduit with blue and orange wires passing through and one silver conduit not sealed around the annular space.

2) Above the ceiling tiles facing the same fire barrier located at the cross-over to the new building by the lab, observation was made of three unsealed girders where it passed through the fire barrier and an unsealed area around two silver conduits.

These findings were verified by staff members during tour of this area.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all doors in smoke/fire barriers were equipped with self-closing or automatic closing devices. This had the potential to affect all those who utilized this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour of the east/west two hour fire rated barrier separating the x-ray department from the x-ray waiting area, specifically at the entrance to the x-ray office, observation was made of a one and one-half hour fire rated door which was not equipped with a self-closing or automatic closing device. This door was observed to be left in the open position.

This finding was verified by staff members present during tour.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all hazardous areas were constructed with at least a one hour fire rated enclosure. This had the potential to affect all those who utilized this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour of the first floor hazardous room identified as 1315, observation was made of seven penetrations around and within conduits located above the ceiling tile.

This finding was verified by staff members present during tour.

Based on fire drill record review and staff interview it was determined this facility failed to ensure fire drills were held at unexpected times and conducted by activating a manual pull station device in order to sound an audible alarm for hours not between 9:00 PM and 6:00 AM. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 23.

Findings include:

Fire drill record review took place on 09/16/13. During review observation was made of two second shift drills conducted on 03/26/13 at 3:15 PM and 06/21/13 at 3:05 PM which had notations in the comments section indicating a "silent alarm" was initiated due to patients in surgery and OB. Review was made of four third shift drills conducted with a "silent alarm" during times later than 6:00 AM. These dates and times are as follows: 03/08/13 at 6:50 AM, 07/31/13 at 6:30 AM, 09/28/12 at 6:30 AM and 12/06/12 at 6:45 AM.
Additionally, all six fire drills listed above were observed to be conducted within a 20 minute time frame from each other in respect to the afternoon shift and the early morning shift. This was verified with staff A1 during interview on 09/16/13 at approximately 11:50 AM.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all smoke detectors were mounted in areas where the normal operation of the detectors would not be affected by any air flow device. This had the potential to affect all those who utilized this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour observation was made of smoke detectors mounted or placed near air flow devices in the following locations:

Basement:
1) Within corridor C001

First floor:
2) Within the balcony area identified as corridor C103
3) Within the corridor between rooms 1410 and 1424.
4) Within the ambulance entrance area between rooms 1428 and 1402.
5) Within the emergency department waiting area identified as number 1414.

Second floor:
6) Within the infusing waiting room identified as M2201.
7) Within the coumadin clinic waiting room identified as M2301.
8) Within the respiratory waiting room identified as M2501.

This finding was verified by staff members present during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure all components of the sprinkler system were maintained in order to provide complete sprinkler coverage in the event of an emergency requiring activation of the suppression system. This had the potential to affect all those utilizing those areas of the facility. The patient census at the beginning of the survey was 23.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the first floor obstetrics department observation was made within the closet of room 124 of a sprinkler pendant which had been displaced from it's original mounted position and was observed to be withdrawn above the ceiling and offset from the pendant access opening.

This finding was verified by staff members during tour of the obstetrics department.

Based on observation during tour and staff interview it was determined this facility failed to ensure all portable fire extinguishers were mounted with the mounting bracket no greater than five feet from the floor or placed within a fire extinguisher cabinet. Additionally, this facility failed to ensure all fire extinguishers were accessible in the event of an emergency and were checked monthly. This had the potential to affect all those utilizing this area of the facility. The facility census was 10 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4.

1) During tour of the generator house and basement area, observation was made of five portable fire extinguishers which were mounted greater than five feet from the floor. These were observed in the following locations: Two were observed in the number one generator house. One was located outside the pump room, one within the boiler room and one within the housekeeping room located east of the medical records room.

2) During tour of the first floor, observation was made of one fire extinguisher located in the lab which was mounted greater than five feet from the floor. Another fire extinguisher in the lab was observed to be mounted behind a large metal framed work station.

3) Within the MRI electrical room, observation was made of a portable fire extinguisher located on the floor.

4) Within the medical surgery department and adjacent to the nurses station observation was made of a hoyer lift placed in front of a mounted portable fire extinguisher. Within a small work room behind the nurse's station observation was made of a portable fire extinguisher sitting on the top of the counter. This fire extinguisher was observed to be "borrowed" and had an inspection tag last dated for September 2009.

These findings were verified by staff members during tour of this floor.

Based on facility tour and staff verification it was determined this facility failed to ensure medical gas storage did not exceed 300 cubic feet per smoke compartment. This had the potential to affect all those utilizing those areas of the facility. The patient census at the beginning of the survey was 23.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the second floor storage room adjacent to the sleep lab observation was made within this room of 16 E-tanks of oxygen placed within two separate holding racks. This amount totaled 400 cubic feet and exceeded the limit per smoke compartment by 100 cubic feet.

This finding was verified by staff members during tour of the obstetrics department.

Based on observation during tour and staff verification it was determined this facility failed to ensure all medical gas bottles were secured when not in use. This had the potential to affect all those utilizing this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the MRI control room area observation was made of one E-tank of oxygen unsecured sitting on floor.

This finding was verified by staff members during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure all electrical wiring and equipment was in accordance with the National Fire Protection Association (NFPA) 70, specifically in regards to the use of power strips. This had the potential to affect all those utilizing this area of the facility. The patient census was 23 at the beginning of the survey.

Findings include:

Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the surgery department, specifically operating room number one, observation was made of a power strip plugged into a wall outlet. The power strip was observed to have three plugs attached into it from surgical equipment and an additional plug which attached into it from another power strip. In essence, there was one power strip "piggy backed" into the other power strip.

This finding was verified by staff members during tour.