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Based on observation the facility failed to provide corridor doors that were positive latching. The facility also had doors that were obstructed in such a manner that they were unable to close and latch. Both conditions made the doors incapable of resisting the passage of smoke. Failure on the part of the facility to provide doors that properly latch and or allow them to close and latch puts patients, staff and visitors of the facility at risk from the effects of smoke.

Findings include:

1. On 8/10/2010 the surveyor noted that the elevator lobby doors leading the the heliport would not securely latch closed when manually released from the hold open position.

2. On 8/10/2010 the surveyor noted that the fire door leading into the espresso stand from the gift shop would not securely latch closed once an unapproved door wedge was manually removed.

3. On 8/11/2010 the surveyor noted that the door to the PACS room in the imaging department was propped open with an unapproved door wedge.

4. On 8/11/2010 the surveyor noted that the fire door(s) leading into the kitchen from the service corridor would not latch closed when manually released from the hold open position.

Based on observation the facility failed to properly mark an exit access route of travel.

Failure on the part of the facility to mark exit access routes puts patients, staff and visitors at risk should emergency exiting be required via an alternative route.

Findings include:

1. On 8/10/2010 the surveyor noted in the MRI unit that the door leading to the back exit door (reached by traversing an intervening space or room) was not marked with an exit sign.

Based on observation the facility failed to maintain smoke barriers so as to prevent the migration of smoke from one area to another.

Failure on the part of the facility to maintain smoke barriers puts patients, staff and visitors of the facility at risk from migrating smoke.

Findings include:

1. On 8/10/2010 the surveyor noted that a cable bundle that penetrated the smoke barrier in the central corridor of the facility (near junction of service corridor and that of ICU/CCU) was not properly sealed to prevent the migration of smoke.

2. On 8/11/2010 the surveyor noted penetrations that were not properly sealed in the electrical room located off the kitchen dinning area.

3. On 8/11/2010 the surveyor noted that the double doors between the Laboratory and Radiation units had gaps in excess of 1/4 inch which would permit the passage of smoke between the two compartments.

Based on observation the hospital failed to provide a self-closing door so as to maintain the proper separation of a hazardous area from other areas of the facility.

Failure to provide hazardous areas with required door assemblies puts patients, staff and visitors of the facility at risk from the affects of smoke and fire.

Findings include:

On 8/11/2010 the surveyor observed that a storage room (hazardous area) in Respiratory Therapy had a door that was not self-closing as is required.

Based on observation the facility failed to provide and maintain an effective fire alarm system in certain areas of the facility.

Failure on the part of the facility to provide and maintain its fire alarm system where required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Background:

NFPA 101 Life Safe Code 2000 Edition, Chapter 6.6.14.2 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. And, Chapter 26.3.3.5 requires that smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings include:

1. On 8/10/2010 the surveyor noted that the "Anesthesia Office" was made up to serve as a medical staff sleep room without benefit of a smoke alarm being installed as is required.

2. On 8/10/2010 the surveyor noted that a manual pull station located at the Emergency Department ambulance entrance was obscured by a supply cart. The cart was relocated at the time of the inspection.

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 8/10/2010 the surveyor noted that both the men's and woman's restrooms located on the 2nd floor of the administrative wing were not provided with sprinklers as is required.

2. On 8/10/2010 the surveyor noted that a sprinkler head in the Respiratory Therapy storage closet was obstructed by materials stored on a shelving unit that were less than 18 inches from the bottom of the sprinkler head deflector.

3. On 8/10/2010 the surveyor noted that the installed post indicator valve (PIV) was not properly maintained. More specifically, the valve was not provided with a valve wrench and locking mechanism. It was further noted that the window glass covering the indicator open close sign was broken.

4. On 8/11/2010 the surveyor noted that a sprinkler head in the back room of the CT control room was missing an escutcheon ring.

Based on observation the facility failed to provide portable fire extinguishers as required for certain locations of the facility.

Failure to provide portable fire extinguishers as required (location and manner) puts patients, staff and visitors of the facility at risk from the effects of fire.

References:

NFPA 418 Standard for Heliports, 1995 and subsequent editions

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition, Chapter 1-6.3.

Findings include:

1. On 8/10/2010 the surveyor noted that a portable fire extinguisher was not provided for the Heliport takeoff and landing area located on the roof of the ED/Admin wing. Required extinguisher rating is provided in NFPA 418 Standard for Heliports, 1995 and subsequent editions.

2. On 8/10/2010 the surveyor noted that a portable fire extinguisher located in the Respiratory Therapy unit was not readily accessible as it was being blocked by a scale that had been placed in front of it.

Based on observation the facility failed to protect the kitchen facilities so as to minimize the potential for fire.

Failure on the part of the facility to minimize the potential for fire puts patients, staff and visitors at risk from the effects of smoke and fire.

Findings include:

1. On 8/11/2010 the surveyor observed that the hood filters located at the service preparation area (retail) had an excessive build-up of grease.

Based on observation the facility failed to keep unacceptable portable space heating devices out of none patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/10/2010 the surveyor noted a portable space heating device in the office of the assistant manager for human resources. The unit was of a type that would when energized heat the element to a temperature in excess of 212 degrees F. Subsequent to this observation it was noted that portable space heating devices were being removed from the facility.

Based on observation and interview 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.

References:

NFPA 101 Life Safety Code Chapters 19.2.2.2.4 and 7.2.1.6.2, 2000 Edition; and

NFPA Fire and Life Safety in Health Care Facilities Chapter 16 Egress Components states in part: "The Life Safety Code has no provisions for locks, such as magnetic locks, that release upon activation of the fire alarm system. If the device is not a delayed egress lock, an access control lock, or a lock as permitted for clinical needs (see next subsection), it is not permitted by the Life Safety Code...."

Findings include:

1. On 8/10/2010 the surveyor noted that a set of double doors in the egress pathway leading into the area of the Emergency Department were held in a locked state. The facility's Director of Plant Services indicated that the doors would unlock upon activation of the fire alarm system.

2. On 8/10/2010 the surveyor noted two separate impediments to egress in the Med/Surg. unit.

a. Patient lift equipment was being stored in the corridor; and

b. A Comfort Cleaning Personal Towel unit was placed in such a location that the corridor width was reduced causing an impediment to egress.

Based on observation the facility failed to properly store oxygen cylinders (nonflammable medical gas). Failure on the part of the facility to properly store oxygen cylinders puts patients, staff and visitors at risk from the effects of smoke and fire which would be accelerated in an oxygen rich environment.

References:

CMS Memorandum S&C-07-10, January 12, 2007; and NFPA 99 Health Care Facilities Chapter 9.4.3, 2005 Edition. Memorandum summary states: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured."

NFPA 99 Health Care Facilities Chapter 8-3.1.11 Storage Requirements, 1999 Edition

Findings include:

1. On 8/10/2010 the surveyor noted that twenty-two (22) E sized cylinders (Approximately 528 cubic feet) of nonflammable medical gas (oxygen) were being stored in an unrated enclosure located in the Respiratory Therapy unit. The door of the enclosure lacked a self closing device; and the cylinders were stored within 5 feet of combustibles. It was not determined if the space could be secured against unauthorized entry.

2. On 8/10/2010 the surveyor noted that precautionary signage was not provided on the door of the Respiratory Therapy storage room containing oxygen E cylinders. And, such signage was not found on the door housing medical gases located off the loading dock area.

Based on observation the facility failed to maintain electrical equipment as is required by code.

Failure to maintain electrical equipment in proper working order puts patients and staff at risk should the needed electrical equipment need to be energized.

Findings include:

1. On 8/10/2010 the surveyor observed a member of the State Fire Marshall's Office push the battery test button of the emergency lighting fixture serving Operating Room (OR) #1. The test of the fixture indicated that the batteries supplying power had failed.

2. On 8/10/2010 the surveyor observed that power strips were connected in series (one plugged into the other) in both the Pharmacy Office and the back room area of the CT control room.

Based on observation the facility failed to provide corridor doors that were positive latching. The facility also had doors that were obstructed in such a manner that they were unable to close and latch. Both conditions made the doors incapable of resisting the passage of smoke. Failure on the part of the facility to provide doors that properly latch and or allow them to close and latch puts patients, staff and visitors of the facility at risk from the effects of smoke.

Findings include:

1. On 8/10/2010 the surveyor noted that the elevator lobby doors leading the the heliport would not securely latch closed when manually released from the hold open position.

2. On 8/10/2010 the surveyor noted that the fire door leading into the espresso stand from the gift shop would not securely latch closed once an unapproved door wedge was manually removed.

3. On 8/11/2010 the surveyor noted that the door to the PACS room in the imaging department was propped open with an unapproved door wedge.

4. On 8/11/2010 the surveyor noted that the fire door(s) leading into the kitchen from the service corridor would not latch closed when manually released from the hold open position.

Based on observation the facility failed to properly mark an exit access route of travel.

Failure on the part of the facility to mark exit access routes puts patients, staff and visitors at risk should emergency exiting be required via an alternative route.

Findings include:

1. On 8/10/2010 the surveyor noted in the MRI unit that the door leading to the back exit door (reached by traversing an intervening space or room) was not marked with an exit sign.

Based on observation the facility failed to maintain smoke barriers so as to prevent the migration of smoke from one area to another.

Failure on the part of the facility to maintain smoke barriers puts patients, staff and visitors of the facility at risk from migrating smoke.

Findings include:

1. On 8/10/2010 the surveyor noted that a cable bundle that penetrated the smoke barrier in the central corridor of the facility (near junction of service corridor and that of ICU/CCU) was not properly sealed to prevent the migration of smoke.

2. On 8/11/2010 the surveyor noted penetrations that were not properly sealed in the electrical room located off the kitchen dinning area.

3. On 8/11/2010 the surveyor noted that the double doors between the Laboratory and Radiation units had gaps in excess of 1/4 inch which would permit the passage of smoke between the two compartments.

Based on observation the hospital failed to provide a self-closing door so as to maintain the proper separation of a hazardous area from other areas of the facility.

Failure to provide hazardous areas with required door assemblies puts patients, staff and visitors of the facility at risk from the affects of smoke and fire.

Findings include:

On 8/11/2010 the surveyor observed that a storage room (hazardous area) in Respiratory Therapy had a door that was not self-closing as is required.

Based on observation the facility failed to provide and maintain an effective fire alarm system in certain areas of the facility.

Failure on the part of the facility to provide and maintain its fire alarm system where required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Background:

NFPA 101 Life Safe Code 2000 Edition, Chapter 6.6.14.2 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. And, Chapter 26.3.3.5 requires that smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings include:

1. On 8/10/2010 the surveyor noted that the "Anesthesia Office" was made up to serve as a medical staff sleep room without benefit of a smoke alarm being installed as is required.

2. On 8/10/2010 the surveyor noted that a manual pull station located at the Emergency Department ambulance entrance was obscured by a supply cart. The cart was relocated at the time of the inspection.

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 8/10/2010 the surveyor noted that both the men's and woman's restrooms located on the 2nd floor of the administrative wing were not provided with sprinklers as is required.

2. On 8/10/2010 the surveyor noted that a sprinkler head in the Respiratory Therapy storage closet was obstructed by materials stored on a shelving unit that were less than 18 inches from the bottom of the sprinkler head deflector.

3. On 8/10/2010 the surveyor noted that the installed post indicator valve (PIV) was not properly maintained. More specifically, the valve was not provided with a valve wrench and locking mechanism. It was further noted that the window glass covering the indicator open close sign was broken.

4. On 8/11/2010 the surveyor noted that a sprinkler head in the back room of the CT control room was missing an escutcheon ring.

Based on observation the facility failed to provide portable fire extinguishers as required for certain locations of the facility.

Failure to provide portable fire extinguishers as required (location and manner) puts patients, staff and visitors of the facility at risk from the effects of fire.

References:

NFPA 418 Standard for Heliports, 1995 and subsequent editions

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition, Chapter 1-6.3.

Findings include:

1. On 8/10/2010 the surveyor noted that a portable fire extinguisher was not provided for the Heliport takeoff and landing area located on the roof of the ED/Admin wing. Required extinguisher rating is provided in NFPA 418 Standard for Heliports, 1995 and subsequent editions.

2. On 8/10/2010 the surveyor noted that a portable fire extinguisher located in the Respiratory Therapy unit was not readily accessible as it was being blocked by a scale that had been placed in front of it.

Based on observation the facility failed to protect the kitchen facilities so as to minimize the potential for fire.

Failure on the part of the facility to minimize the potential for fire puts patients, staff and visitors at risk from the effects of smoke and fire.

Findings include:

1. On 8/11/2010 the surveyor observed that the hood filters located at the service preparation area (retail) had an excessive build-up of grease.

Based on observation the facility failed to keep unacceptable portable space heating devices out of none patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/10/2010 the surveyor noted a portable space heating device in the office of the assistant manager for human resources. The unit was of a type that would when energized heat the element to a temperature in excess of 212 degrees F. Subsequent to this observation it was noted that portable space heating devices were being removed from the facility.

Based on observation and interview 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.

References:

NFPA 101 Life Safety Code Chapters 19.2.2.2.4 and 7.2.1.6.2, 2000 Edition; and

NFPA Fire and Life Safety in Health Care Facilities Chapter 16 Egress Components states in part: "The Life Safety Code has no provisions for locks, such as magnetic locks, that release upon activation of the fire alarm system. If the device is not a delayed egress lock, an access control lock, or a lock as permitted for clinical needs (see next subsection), it is not permitted by the Life Safety Code...."

Findings include:

1. On 8/10/2010 the surveyor noted that a set of double doors in the egress pathway leading into the area of the Emergency Department were held in a locked state. The facility's Director of Plant Services indicated that the doors would unlock upon activation of the fire alarm system.

2. On 8/10/2010 the surveyor noted two separate impediments to egress in the Med/Surg. unit.

a. Patient lift equipment was being stored in the corridor; and

b. A Comfort Cleaning Personal Towel unit was placed in such a location that the corridor width was reduced causing an impediment to egress.

Based on observation the facility failed to properly store oxygen cylinders (nonflammable medical gas). Failure on the part of the facility to properly store oxygen cylinders puts patients, staff and visitors at risk from the effects of smoke and fire which would be accelerated in an oxygen rich environment.

References:

CMS Memorandum S&C-07-10, January 12, 2007; and NFPA 99 Health Care Facilities Chapter 9.4.3, 2005 Edition. Memorandum summary states: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured."

NFPA 99 Health Care Facilities Chapter 8-3.1.11 Storage Requirements, 1999 Edition

Findings include:

1. On 8/10/2010 the surveyor noted that twenty-two (22) E sized cylinders (Approximately 528 cubic feet) of nonflammable medical gas (oxygen) were being stored in an unrated enclosure located in the Respiratory Therapy unit. The door of the enclosure lacked a self closing device; and the cylinders were stored within 5 feet of combustibles. It was not determined if the space could be secured against unauthorized entry.

2. On 8/10/2010 the surveyor noted that precautionary signage was not provided on the door of the Respiratory Therapy storage room containing oxygen E cylinders. And, such signage was not found on the door housing medical gases located off the loading dock area.

Based on observation the facility failed to maintain electrical equipment as is required by code.

Failure to maintain electrical equipment in proper working order puts patients and staff at risk should the needed electrical equipment need to be energized.

Findings include:

1. On 8/10/2010 the surveyor observed a member of the State Fire Marshall's Office push the battery test button of the emergency lighting fixture serving Operating Room (OR) #1. The test of the fixture indicated that the batteries supplying power had failed.

2. On 8/10/2010 the surveyor observed that power strips were connected in series (one plugged into the other) in both the Pharmacy Office and the back room area of the CT control room.