HospitalInspections.org

A. Through interview and direct observation, the recently constructed 20' x 20' Chapel building area is not in compliance with applicable requirements. The following conditions exist:

1. The construction type of the Chapel building was indicated to be of Type V Ordinary construction utilizing wood frame walls and roof construction in non-compliance with Hospital requirements and NFPA 101, 18.1.6.2.

2. The building area is not provided with sprinkler protection to comply with NFPA 101, 18.1.6.2 as a Healthcare occupancy.

3. The building area is not separated from the Healthcare occupancy by 2-hour rated construction to be classified as a different occupancy/construction type. The doors to the corridor are not minimum 1 1/2-hour rated and are not provided with latching hardware. The doors to the corridor are not otherwise provided with latching hardware to comply with 18.3.6.3.2.

A. Barriers indicated to be building separations to divide different construction types are not minimum 2-hour rated to comply with 19.1.1.4 and 19.1.2.3.

1. The 2-hour barrier indicated to be between the 1972 building and the 2000 and 2007 buildings is not provided with minimum 1 1/2-hour rated door assemblies. Surveyor notes that this barrier appears to be installed as a required smoke barrier but does not meet the requirements for a 2-hour barrier to separate the different building construction types. Surveyor also notes that this corridor connection through the 1972 building between the 2000 and 2007 buildings is a required Healthcare corridor to link the ER/Radiology departments with the OR/Med-Surg patient areas. The building construction types are compliant but lack separation between them to consider the buildings of a greater construction type than the least construction type of Type II (000) Fully Sprinklered which applies to the 1972 building.

A. The third floor area formerly a corridor connection to the 1922 building (which has been razed) is now utilized as a storage room for roof top equipment supplies has wood paneling on the walls in non-compliance with 19.3.3.2. This area requires confirmation that sprinkler protection is provided.

A. Waiting areas open to the exit access corridor are not protected in accordance with the exceptions permitted under 19.3.6.1.

1. The corridor between the 2000 and 2007 building areas located in the 1972 building contains chairs at an alcove constituting a waiting area which is not provided with smoke detection or direct observation by staff to comply with 19.3.6.1 Exception No. 2 or at least smoke detection to comply with 19.3.6.1 Exception No. 7.

B. The Specialty Clinic area corridor doors are not provided with positive latching hardware to comply with 19.3.6.3.2. The area does not otherwise comply as a suite of rooms (that would not require latching hardware on individual room doors) because the pair of doors at the corridor intersection that would form the boundary of the suite are not positive latching doors. These doors are also installed in a double acting configuration where no stops are provided to seal the door against the passage of smoke as required for a corridor door of a suite. Surveyor notes that if this area is not considered a suite, the individual room doors will be considered non-compliant with 7.2.1.5.4 if latching hardware is added and the dead bolt locks are not removed because the doors will require more than one operation to release the door when both the dead bolt lock and latching hardware are in use.

A. Corridor doors are not provided with positive latching hardware to comply with 19.3.6.3.2. Locations observed include:

1. The 1st floor Resppiratory Therapy office corridor door.

2. The small storage room across from Respiratory Therapy Waiting is equipped with a pair of doors which were found with the inactive door manual flush bolts disengaged which prevented the pair from being provided with positive latching.

3. The 2nd floor old surgery suite (now used as the Environmental Services dept.) corridor door.

4. The Information Technology office/shop corridor door is equipped with a dead bolt lock only. Surveyor notes that if latching hardware is added and the dead bolt lock is not removed, the door will not comply with 7.2.1.5.4 because the door will require more than one operation to release the door when both the dead bolt lock and latching hardware are in use.

A. The wall between the 1972 building and the 2000 addition on the 1st floor was indicated to be of 2-hour rated construction but was observed to only function as a smoke barrier due to the cross corridor doors at the connecting corridor to only be 3/4-hour rated. Unsealed PVC and steel pipe penetrations at sprinkler piping located above the ceiling near the lobby door in the barrier were observed.

A. Hazardous areas are not protected in accordance with NFPA 101, 18.3.2.1, 19.3.2.1, 39.3.2.1 & 8.4.1. Locations observed include:

1. The ER Janitor room storing combustible paper products and linens and supplies is not provided with a self-closing door to comply with 19.3.2.1.

2. The center core Storage room (with two corridor doors) in the 2007 building med/surg area is not provided with self-closing 3/4-hour doors to comply with 18.3.2.1. The required 1-hour rated enclosure of this storage room above the ceiling was not confirmed.

3. The Laboratory corridor door(s) are not self-closing to comply with 18.3.2.1.

4. The 2nd floor Medical Records area corridor door and reception window are not self-closing to comply with 19.3.2.1 (or 38.3.2.1 & 8.4.1.2 if considered as a Business Occupancy floor).

5. The 2nd floor Bio-hazard storage room corridor door is not self-closing to comply with 19.3.2.1 (or 38.3.2.1 & 8.4.1.2 if considered as a Business Occupancy floor).

6. The 2nd floor "stilted building" is a former conference room and former connecting corridor utilized for miscellaneous storage and is not provided with sprinkler protection to comply with 19.1.6.2 to consider the building fully sprinkler protected. This building area is not separated from other buildings by 2-hour rated construction to allow it to be considered a separate building. The only exit from this area is into the 1972 building corridor which would not allow it to be considered a separate building. The pair of doors at the corridor (if considered to be the boundary of the hazardous area) are not positive latching to comply with 19.3.2.1 (or 38.3.2.1 & 8.4.1.2 if considered as a Business Occupancy floor). These doors were not otherwise confirmed to be minimum 3/4-hour rated. If the conference room door is considered to be the boundary of the hazardous area, it is not a minimum 3/4-hour rated assembly (door is hollow core and frame is wood).

7. The surgery department Central Sterile Decontamination room contained two waste receptacles constituting greater than 32 gallons which requires the area to be considered as a hazardous area per 18.7.5.5. The door to this room was not self-closing.

8. The surgery department Central Sterile clean room storage room door was not self-closing to comply with 18.3.2.1.

9. The surgery department storage room door is not self-closing to comply with 18.3.2.1. Twelve (12) 'E'-size and one (1) 'K'-size medical gas tanks were observed in this room without a minimum 5' separation from combustibles to comply with NFPA 99, 1999, 8.3.1.11.2(c)(2).

10. The surgery department Janitor room (containing combustible paper and cleaning supply storage) door is not self-closing to comply with 18.3.2.1.

11. The Rehabilitation building storage room is not enclosed with 1-hour rated construction including a 3/4-hour rated self-closing door to comply with 38.3.2.1 & 8.4.1.1.

A. The 2nd floor door of the East Stair is not positive latching to comply with 8.2.3.2.1.

A. Exit components are not in compliance with 7.2. Conditions observed include:

1. A wheeled cart was stationed at the 1st floor level of the South stair in non-compliance with 7.1.3.2.3.

2. The areaway stair from the Boiler room exterior exit is provided with only one handrail where one on each side is required under 7.2.2.4.2.

3. The ramp from the kitchen exterior exit door is provided with only one handrail where one on each side is required under 7.2.5.4.

4. Communications equipment is located at the 3rd floor level of the Stair in non-compliance with 7.1.3.2.3.

A. Exit access is not maintained in accordance with 7.1. Locking hardware was observed to be installed to prevent egress through required exit access doors in non-compliance with 7.1.9, 7.2.1.5.1, or 7.2.1.5.4. Locations and conditions observed include:

1. A hasp-type lock is provided at the exterior Boiler room exit door in addition to the latching hardware in non-compliance with 7.2.1.5.4.

2. A hasp-type lock is used on the interior boiler room door which can prevent egress from the Boiler room.

3. A hasp-type lock is provided at the dining room serving line door which can prevent egress from the serving line staff serving area in non-compliance with 7.2.1.5.1.

4. A hasp-type lock is provided at the door between the kitchen and the Dining room.

5. The 2nd floor former Clean Supply room has a dead bolt lock operable from the corridor side only in addition to a latchset in non-compliance with 7.2.1.5.4 and 7.2.1.5.1.

A. Horizontal exits are not in compliance with 19.2.2.5 and 7.2.4. Conditions observed include:

1. The building separation between the sprinklered 1972 Healthcare occupancy building and the non-sprinklered 1956 Storage occupancy building appears to be a required horizontal exit because the 1956 building will not comply as a Healthcare building and the 1972 building requires the entry into the 1956 building for the purpose of exiting. The door at this horizontal exit swings against the direction of travel from the 1972 building as allowed by 19.2.2.5.3 and 7.2.4.3.6 Exception No. 1. However, a fire alarm manual pull station is not provided within 5' of this exit door on the 1972 building side in accordance with NFPA 72, 1999, 2-8.2.2. Surveyor notes that the 1956 Storage occupancy building does not require a fire alarm system but may require the horizontal exit into the 1972 building if common path of travel distance within the 1956 building exceeds 50' allowed under NFPA 101, 2000, 42.2.5.4.

A. Not all exterior lighting provided at exit discharges could not be confirmed to comply with 19.2.8 and 7.8 and 7.9. The lighting provided could not be confirmed to be provided by multiple fixtures or multiple lamps within the fixtures. The type of lamp could not be confirmed to be of the instant-on type such as incandescent, fluorescent, halogen or quartz at all locations. The lighting could not be confirmed to be connected to the emergency power system at all locations. Locations observed include but are not necessarily limited to the following:

1. The ER entry covered alcove area.

2. The main entry canopy/bollard lighting.

3. Circuit #74 in Panel RP in the 2007 Mechanical/electric room indicated as "SE Entry light" did not appear to be fed from emergency power source.

4. The Rehabilitation building exit discharge lighting.

5. The Boiler room exterior exit to the areaway.

A. Exit signage is not provided in accordance with 7.10. Conditions observed include:

1. Exit signs are not illuminated to comply with 7.10.5 at the following locations:

a. At the boiler exterior door.

b. At the exit from the South stair.

c. At the 3rd floor Stair.

2. The exit sign at the corridor intersection west of the Pharmacy is not fully visible when viewed from near the Lab end of the corridor.

3. An exit sign exists within the 'stilted' building areaway (as accessed from the 2nd floor) that is no longer accurate.

A. Fire drill documentation does not indicate compliance with 19.7.1.2. Observations include:

1. Fire drills were not documented for the 3rd shift (11pm to 7am) during the 2nd quarter (April through June).

2. Fire drill response documentation is not consistantly filled out. Example: It is not clear whether the indicated 'alarm' and 'drill' designations are representative of the actual conditions. 'False alarms' may be designated as a 'drill' when the alarms were activated unintentionally. The staff and building system response information (doors close/alarms heard, etc.) is not always filled out on the forms when they are utilized to meet the minimum required once-per-shift-per-quarter Fire Drill requirement.

A. Fire alarm systems are not maintained in accordance with NFPA 72. Observations include:

1. The last annual inspection and testing of the fire alarm system dated 11/19/10 indicated that ten (10)smoke detection devices failed. No indication of repair or replacement was documented. Devices noted were indicated to be:

a. Hall at Personnel
b. 2nd floor by elevator
c. Material Storage
d. At Heather's desk
e. At double doors south
f. At double doors south
g. Hall at Phone room
h. Hall at Business office
i. Business office manager
j. Records Break room

2. On the afternoon of 1/4/11 during testing of the fire alarm system, the audio/visual notification devices near patient room 112 and near the middle of the south corridor in the 2007 building did not operate.

3. On the afternoon of 1/4/11 during testing of the fire alarm system, the audio/visual notification devices and the rolling shutters on corridor windows within the 2000 building did not function as intended. Although the system was indicated to be activated from the 2000 building addition area and register with the building Fire Alarm Control Panel and audible notification devices could be heard from other adjacent building areas, the notification devices in the 2000 addition of the building did not function. Service technicians were called and were on-site investigating to make necessary repairs prior to Surveyor leaving the facility. An hourly fire watch was implemented and was to continue until the system was fully functional.

A. The building sprinkler system is not maintained in accordance with NFPA 13. Conditions observed include:

1. Numerous rooms were observed to lack complete ceiling tile installation to maintain the proper activation of the sprinkler systems. Missing ceiling tile compromises the activation of the sprinklers and/or detection systems dissipating heat/smoke into the above ceiling cavities. Locations observed include:

a. At the Electric Panel room near the main lobby. Detector was also taped-over at this location.

b. At the Cashiers office.

c. At the Sprinkler Riser room near the Ambulance entrance for ER.

d. At the 2nd floor Bio-hazard Storage room.

2. Building areas are not fully covered by sprinkler protection to meet the requirements for allowable construction type. The inspection and testing documentation by McDaniel notes that not all portions of the building are provided with sprinkler protection. Spaces lacking sprinkler protection include:

a. The 1st floor Janitor closet in the 1972 building connecting corridor link between the 2000 and 2007 buildings.

b. The 'stilted' building area conference room and old corridor.

c. The 1956 building (if NOT considered a separate building)

3. The sprinkler system inspection and testing documentation by McDaniel indicates that during the 7/28/09 inspection that "Tampers not working properly". The inspection and testing of 11/18/10 indicates "supervision operational". However, documentation of repairs or resolution of the non-working tamper switches was not readily available for review.

A. Based on direct observation, staff interview and document review, the portable fire extinguishers are not maintained in accordance with 9.7.4.1, 19.3.5.6 and NFPA 10. The following conditions were observed:

1. Portable extinguishers throughout the facility were not inspected during November 2010 as evidenced by the lack of documentation on the tags attached to the fire extinguishers.

2. Portable extinguishers located in certain areas have not been documented as being inspected for multiple months. Examples include but are not limited to:

a. Fire extinguisher at main entry corridor not inspected since 10/18/10.

b. Fire extinguishers at 1972 building air handler room and boiler room areas are only tagged as inspected during months 8, 9, 10, and 12.

c. The Ansul system for the kitchen exhaust hood is tagged with a 2010 annual inspection tag with only a 12/29/10 monthly inspection indicated. Monthly inspection of the system is not indicated on this tag.

A. Inspection and maintenance records for the kitchen hood Ansul extinguishing system indicates on the 12/29/10 inspection that the system was not tied to the building fire alarm system. The 6/24/10 inspection indicated that the system was tied to the building fire alarm system. Confirmation that the system is connected to the fire alarm system as required was not documented.

A. Medical gas systems are not maintained in accordance with NFPA 99 and NFPA 50.

1. The bulk oxygen tank location is located less than 10' from parked vehicles in non-compliance with NFPA 50, 1996, 2-2.12.

2. The Medical Air manifold room is accessed from the exterior and has an adjoining room utilized for a condensate return pump. The door to this room which separates the pump room from the manifold room was observed in the open position and was not self-closing to comply with NFPA 99, 1999, 4-3.1.1.2.

3. The Medical Air manifold room contained 3 tanks which were not secured to comply with NFPA 99, 1999, 4-3.5.2.1.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. Building facilities/supplies/equipment are not maintained to ensure safety and quality for building occupants in accordance with CFR482.41(c)(2). Conditions observed include but are not necessarily limited to:

1. Stained ceiling tile was observed randomly throughout the facility. Staff indicated issues with condensation from ductwork and piping systems or leaks. The potential for mold growth exists. Various methods of remediation have been employed which compromise other life safety features including:

a. A 'residential' box fan was observed to be installed above the ceiling near the 2-hour barrier cross corridor doors adjacent the Doctors Lounge. Its installation, wiring methods and controls were not verified to be in compliance with NFPA 70 and 90A regarding electrical and mechanical installations. The fan was indicated to be installed to circulate above ceiling air to prevent condensation.

b. A catch basin under an open ceiling tile under an insulated duct was observed in the Pharmacy. The open ceiling tile compromises the sprinkler system by allowing heat/smoke to dissipate into the above ceiling cavity which can delay activation of the sprinkler system during a fire event. It was indicated that a leak from the roof top air handler above was the suspected problem.

2. The roof top unit for the Emergency Room area is installed with a plumbing vent and an exhaust fan outlet adjacent (within 10') of the fresh air intake in non-compliance with accepted standard practice and recommendations of ASHRAE HVA/C Applications Chapter 7 regarding Hospitals. Surveyor notes that ASHRAE recommends that "These intakes should be located as far as is practical (on a directionally different exposures whenever possible) but not less than 25 ft from exhaust outlets of combustion equipment stacks, ventilation exhaust outlets from the hospital or adjoining buildings, medical-surgical vacuum systems, plumbing vent stacks, or from areas that may collect vehicular exhaust and other noxious fumes."

A. The emergency generator system is not maintained in accordance with NFPA 99 and 110. Conditions observed include:

1. Two exterior mounted generators are not provided with battery heaters to maintain battery temperature above 50 degrees F as required by NFPA 110, 1999, 3-3.1.

2. The emergency generators are indicated to be excercised weekly and run under load monthly. However documentation failed to indicate required information consistantly for the past 12 months. Observations include:

a. The rated capacity of the generators was not determined and the surveyor was unable to determine if the minimum 30% of nameplate rating loads were being applied to comply with NFPA 110, 1999, 6-4.2. Annual load bank testing was not otherwise indicated to have been performed.

b. Monthly documentation for applied loads were recorded only for months 9, 10, 11, & 12 during the last year.

c. Weekly inspections did not include the checking of the battery electrolyte levels and specific gravity to comply with NFPA 110, 1999, 6-3.6. Conductance testing was not otherwise provided for maintenance-free batteries.

A. Electrical installations are not in compliance with NFPA 70. Conditions observed include:

1. The electric panel "PP" in the Electric room near the main lobby lacks a panel directory to comply with NFPA 70, 1999, 384-13.

2. Electric panels lack full enclosure with blanks, spare breakers, or other protection to comply with NFPA 70, 1999, 370-18 and 370-25.

a. At the "LL" & "LP-1" panels in the Electric room near the main lobby.

b. At an above ceiling pull-box located in the 1972 building connecting corridor between the 2000 and 2007 buildings.

c. At the Main Switchboard located in the Boiler room.

B. Critical Care red emergency power receptacles are not labeled as to the electrical panel and circuit number from which they are fed to comply with NFPA 70,1999, 517-19(a) within the Emergency Department.

A. Through interview and direct observation, the recently constructed 20' x 20' Chapel building area is not in compliance with applicable requirements. The following conditions exist:

1. The construction type of the Chapel building was indicated to be of Type V Ordinary construction utilizing wood frame walls and roof construction in non-compliance with Hospital requirements and NFPA 101, 18.1.6.2.

2. The building area is not provided with sprinkler protection to comply with NFPA 101, 18.1.6.2 as a Healthcare occupancy.

3. The building area is not separated from the Healthcare occupancy by 2-hour rated construction to be classified as a different occupancy/construction type. The doors to the corridor are not minimum 1 1/2-hour rated and are not provided with latching hardware. The doors to the corridor are not otherwise provided with latching hardware to comply with 18.3.6.3.2.

A. Barriers indicated to be building separations to divide different construction types are not minimum 2-hour rated to comply with 19.1.1.4 and 19.1.2.3.

1. The 2-hour barrier indicated to be between the 1972 building and the 2000 and 2007 buildings is not provided with minimum 1 1/2-hour rated door assemblies. Surveyor notes that this barrier appears to be installed as a required smoke barrier but does not meet the requirements for a 2-hour barrier to separate the different building construction types. Surveyor also notes that this corridor connection through the 1972 building between the 2000 and 2007 buildings is a required Healthcare corridor to link the ER/Radiology departments with the OR/Med-Surg patient areas. The building construction types are compliant but lack separation between them to consider the buildings of a greater construction type than the least construction type of Type II (000) Fully Sprinklered which applies to the 1972 building.

A. The third floor area formerly a corridor connection to the 1922 building (which has been razed) is now utilized as a storage room for roof top equipment supplies has wood paneling on the walls in non-compliance with 19.3.3.2. This area requires confirmation that sprinkler protection is provided.

A. Waiting areas open to the exit access corridor are not protected in accordance with the exceptions permitted under 19.3.6.1.

1. The corridor between the 2000 and 2007 building areas located in the 1972 building contains chairs at an alcove constituting a waiting area which is not provided with smoke detection or direct observation by staff to comply with 19.3.6.1 Exception No. 2 or at least smoke detection to comply with 19.3.6.1 Exception No. 7.

B. The Specialty Clinic area corridor doors are not provided with positive latching hardware to comply with 19.3.6.3.2. The area does not otherwise comply as a suite of rooms (that would not require latching hardware on individual room doors) because the pair of doors at the corridor intersection that would form the boundary of the suite are not positive latching doors. These doors are also installed in a double acting configuration where no stops are provided to seal the door against the passage of smoke as required for a corridor door of a suite. Surveyor notes that if this area is not considered a suite, the individual room doors will be considered non-compliant with 7.2.1.5.4 if latching hardware is added and the dead bolt locks are not removed because the doors will require more than one operation to release the door when both the dead bolt lock and latching hardware are in use.

A. Corridor doors are not provided with positive latching hardware to comply with 19.3.6.3.2. Locations observed include:

1. The 1st floor Resppiratory Therapy office corridor door.

2. The small storage room across from Respiratory Therapy Waiting is equipped with a pair of doors which were found with the inactive door manual flush bolts disengaged which prevented the pair from being provided with positive latching.

3. The 2nd floor old surgery suite (now used as the Environmental Services dept.) corridor door.

4. The Information Technology office/shop corridor door is equipped with a dead bolt lock only. Surveyor notes that if latching hardware is added and the dead bolt lock is not removed, the door will not comply with 7.2.1.5.4 because the door will require more than one operation to release the door when both the dead bolt lock and latching hardware are in use.

A. The wall between the 1972 building and the 2000 addition on the 1st floor was indicated to be of 2-hour rated construction but was observed to only function as a smoke barrier due to the cross corridor doors at the connecting corridor to only be 3/4-hour rated. Unsealed PVC and steel pipe penetrations at sprinkler piping located above the ceiling near the lobby door in the barrier were observed.

A. Hazardous areas are not protected in accordance with NFPA 101, 18.3.2.1, 19.3.2.1, 39.3.2.1 & 8.4.1. Locations observed include:

1. The ER Janitor room storing combustible paper products and linens and supplies is not provided with a self-closing door to comply with 19.3.2.1.

2. The center core Storage room (with two corridor doors) in the 2007 building med/surg area is not provided with self-closing 3/4-hour doors to comply with 18.3.2.1. The required 1-hour rated enclosure of this storage room above the ceiling was not confirmed.

3. The Laboratory corridor door(s) are not self-closing to comply with 18.3.2.1.

4. The 2nd floor Medical Records area corridor door and reception window are not self-closing to comply with 19.3.2.1 (or 38.3.2.1 & 8.4.1.2 if considered as a Business Occupancy floor).

5. The 2nd floor Bio-hazard storage room corridor door is not self-closing to comply with 19.3.2.1 (or 38.3.2.1 & 8.4.1.2 if considered as a Business Occupancy floor).

6. The 2nd floor "stilted building" is a former conference room and former connecting corridor utilized for miscellaneous storage and is not provided with sprinkler protection to comply with 19.1.6.2 to consider the building fully sprinkler protected. This building area is not separated from other buildings by 2-hour rated construction to allow it to be considered a separate building. The only exit from this area is into the 1972 building corridor which would not allow it to be considered a separate building. The pair of doors at the corridor (if considered to be the boundary of the hazardous area) are not positive latching to comply with 19.3.2.1 (or 38.3.2.1 & 8.4.1.2 if considered as a Business Occupancy floor). These doors were not otherwise confirmed to be minimum 3/4-hour rated. If the conference room door is considered to be the boundary of the hazardous area, it is not a minimum 3/4-hour rated assembly (door is hollow core and frame is wood).

7. The surgery department Central Sterile Decontamination room contained two waste receptacles constituting greater than 32 gallons which requires the area to be considered as a hazardous area per 18.7.5.5. The door to this room was not self-closing.

8. The surgery department Central Sterile clean room storage room door was not self-closing to comply with 18.3.2.1.

9. The surgery department storage room door is not self-closing to comply with 18.3.2.1. Twelve (12) 'E'-size and one (1) 'K'-size medical gas tanks were observed in this room without a minimum 5' separation from combustibles to comply with NFPA 99, 1999, 8.3.1.11.2(c)(2).

10. The surgery department Janitor room (containing combustible paper and cleaning supply storage) door is not self-closing to comply with 18.3.2.1.

11. The Rehabilitation building storage room is not enclosed with 1-hour rated construction including a 3/4-hour rated self-closing door to comply with 38.3.2.1 & 8.4.1.1.

A. The 2nd floor door of the East Stair is not positive latching to comply with 8.2.3.2.1.

A. Exit components are not in compliance with 7.2. Conditions observed include:

1. A wheeled cart was stationed at the 1st floor level of the South stair in non-compliance with 7.1.3.2.3.

2. The areaway stair from the Boiler room exterior exit is provided with only one handrail where one on each side is required under 7.2.2.4.2.

3. The ramp from the kitchen exterior exit door is provided with only one handrail where one on each side is required under 7.2.5.4.

4. Communications equipment is located at the 3rd floor level of the Stair in non-compliance with 7.1.3.2.3.

A. Exit access is not maintained in accordance with 7.1. Locking hardware was observed to be installed to prevent egress through required exit access doors in non-compliance with 7.1.9, 7.2.1.5.1, or 7.2.1.5.4. Locations and conditions observed include:

1. A hasp-type lock is provided at the exterior Boiler room exit door in addition to the latching hardware in non-compliance with 7.2.1.5.4.

2. A hasp-type lock is used on the interior boiler room door which can prevent egress from the Boiler room.

3. A hasp-type lock is provided at the dining room serving line door which can prevent egress from the serving line staff serving area in non-compliance with 7.2.1.5.1.

4. A hasp-type lock is provided at the door between the kitchen and the Dining room.

5. The 2nd floor former Clean Supply room has a dead bolt lock operable from the corridor side only in addition to a latchset in non-compliance with 7.2.1.5.4 and 7.2.1.5.1.

A. Horizontal exits are not in compliance with 19.2.2.5 and 7.2.4. Conditions observed include:

1. The building separation between the sprinklered 1972 Healthcare occupancy building and the non-sprinklered 1956 Storage occupancy building appears to be a required horizontal exit because the 1956 building will not comply as a Healthcare building and the 1972 building requires the entry into the 1956 building for the purpose of exiting. The door at this horizontal exit swings against the direction of travel from the 1972 building as allowed by 19.2.2.5.3 and 7.2.4.3.6 Exception No. 1. However, a fire alarm manual pull station is not provided within 5' of this exit door on the 1972 building side in accordance with NFPA 72, 1999, 2-8.2.2. Surveyor notes that the 1956 Storage occupancy building does not require a fire alarm system but may require the horizontal exit into the 1972 building if common path of travel distance within the 1956 building exceeds 50' allowed under NFPA 101, 2000, 42.2.5.4.

A. Not all exterior lighting provided at exit discharges could not be confirmed to comply with 19.2.8 and 7.8 and 7.9. The lighting provided could not be confirmed to be provided by multiple fixtures or multiple lamps within the fixtures. The type of lamp could not be confirmed to be of the instant-on type such as incandescent, fluorescent, halogen or quartz at all locations. The lighting could not be confirmed to be connected to the emergency power system at all locations. Locations observed include but are not necessarily limited to the following:

1. The ER entry covered alcove area.

2. The main entry canopy/bollard lighting.

3. Circuit #74 in Panel RP in the 2007 Mechanical/electric room indicated as "SE Entry light" did not appear to be fed from emergency power source.

4. The Rehabilitation building exit discharge lighting.

5. The Boiler room exterior exit to the areaway.

A. Exit signage is not provided in accordance with 7.10. Conditions observed include:

1. Exit signs are not illuminated to comply with 7.10.5 at the following locations:

a. At the boiler exterior door.

b. At the exit from the South stair.

c. At the 3rd floor Stair.

2. The exit sign at the corridor intersection west of the Pharmacy is not fully visible when viewed from near the Lab end of the corridor.

3. An exit sign exists within the 'stilted' building areaway (as accessed from the 2nd floor) that is no longer accurate.

A. Fire drill documentation does not indicate compliance with 19.7.1.2. Observations include:

1. Fire drills were not documented for the 3rd shift (11pm to 7am) during the 2nd quarter (April through June).

2. Fire drill response documentation is not consistantly filled out. Example: It is not clear whether the indicated 'alarm' and 'drill' designations are representative of the actual conditions. 'False alarms' may be designated as a 'drill' when the alarms were activated unintentionally. The staff and building system response information (doors close/alarms heard, etc.) is not always filled out on the forms when they are utilized to meet the minimum required once-per-shift-per-quarter Fire Drill requirement.

A. Fire alarm systems are not maintained in accordance with NFPA 72. Observations include:

1. The last annual inspection and testing of the fire alarm system dated 11/19/10 indicated that ten (10)smoke detection devices failed. No indication of repair or replacement was documented. Devices noted were indicated to be:

a. Hall at Personnel
b. 2nd floor by elevator
c. Material Storage
d. At Heather's desk
e. At double doors south
f. At double doors south
g. Hall at Phone room
h. Hall at Business office
i. Business office manager
j. Records Break room

2. On the afternoon of 1/4/11 during testing of the fire alarm system, the audio/visual notification devices near patient room 112 and near the middle of the south corridor in the 2007 building did not operate.

3. On the afternoon of 1/4/11 during testing of the fire alarm system, the audio/visual notification devices and the rolling shutters on corridor windows within the 2000 building did not function as intended. Although the system was indicated to be activated from the 2000 building addition area and register with the building Fire Alarm Control Panel and audible notification devices could be heard from other adjacent building areas, the notification devices in the 2000 addition of the building did not function. Service technicians were called and were on-site investigating to make necessary repairs prior to Surveyor leaving the facility. An hourly fire watch was implemented and was to continue until the system was fully functional.

A. The building sprinkler system is not maintained in accordance with NFPA 13. Conditions observed include:

1. Numerous rooms were observed to lack complete ceiling tile installation to maintain the proper activation of the sprinkler systems. Missing ceiling tile compromises the activation of the sprinklers and/or detection systems dissipating heat/smoke into the above ceiling cavities. Locations observed include:

a. At the Electric Panel room near the main lobby. Detector was also taped-over at this location.

b. At the Cashiers office.

c. At the Sprinkler Riser room near the Ambulance entrance for ER.

d. At the 2nd floor Bio-hazard Storage room.

2. Building areas are not fully covered by sprinkler protection to meet the requirements for allowable construction type. The inspection and testing documentation by McDaniel notes that not all portions of the building are provided with sprinkler protection. Spaces lacking sprinkler protection include:

a. The 1st floor Janitor closet in the 1972 building connecting corridor link between the 2000 and 2007 buildings.

b. The 'stilted' building area conference room and old corridor.

c. The 1956 building (if NOT considered a separate building)

3. The sprinkler system inspection and testing documentation by McDaniel indicates that during the 7/28/09 inspection that "Tampers not working properly". The inspection and testing of 11/18/10 indicates "supervision operational". However, documentation of repairs or resolution of the non-working tamper switches was not readily available for review.

A. Based on direct observation, staff interview and document review, the portable fire extinguishers are not maintained in accordance with 9.7.4.1, 19.3.5.6 and NFPA 10. The following conditions were observed:

1. Portable extinguishers throughout the facility were not inspected during November 2010 as evidenced by the lack of documentation on the tags attached to the fire extinguishers.

2. Portable extinguishers located in certain areas have not been documented as being inspected for multiple months. Examples include but are not limited to:

a. Fire extinguisher at main entry corridor not inspected since 10/18/10.

b. Fire extinguishers at 1972 building air handler room and boiler room areas are only tagged as inspected during months 8, 9, 10, and 12.

c. The Ansul system for the kitchen exhaust hood is tagged with a 2010 annual inspection tag with only a 12/29/10 monthly inspection indicated. Monthly inspection of the system is not indicated on this tag.

A. Inspection and maintenance records for the kitchen hood Ansul extinguishing system indicates on the 12/29/10 inspection that the system was not tied to the building fire alarm system. The 6/24/10 inspection indicated that the system was tied to the building fire alarm system. Confirmation that the system is connected to the fire alarm system as required was not documented.

A. Medical gas systems are not maintained in accordance with NFPA 99 and NFPA 50.

1. The bulk oxygen tank location is located less than 10' from parked vehicles in non-compliance with NFPA 50, 1996, 2-2.12.

2. The Medical Air manifold room is accessed from the exterior and has an adjoining room utilized for a condensate return pump. The door to this room which separates the pump room from the manifold room was observed in the open position and was not self-closing to comply with NFPA 99, 1999, 4-3.1.1.2.

3. The Medical Air manifold room contained 3 tanks which were not secured to comply with NFPA 99, 1999, 4-3.5.2.1.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. Building facilities/supplies/equipment are not maintained to ensure safety and quality for building occupants in accordance with CFR482.41(c)(2). Conditions observed include but are not necessarily limited to:

1. Stained ceiling tile was observed randomly throughout the facility. Staff indicated issues with condensation from ductwork and piping systems or leaks. The potential for mold growth exists. Various methods of remediation have been employed which compromise other life safety features including:

a. A 'residential' box fan was observed to be installed above the ceiling near the 2-hour barrier cross corridor doors adjacent the Doctors Lounge. Its installation, wiring methods and controls were not verified to be in compliance with NFPA 70 and 90A regarding electrical and mechanical installations. The fan was indicated to be installed to circulate above ceiling air to prevent condensation.

b. A catch basin under an open ceiling tile under an insulated duct was observed in the Pharmacy. The open ceiling tile compromises the sprinkler system by allowing heat/smoke to dissipate into the above ceiling cavity which can delay activation of the sprinkler system during a fire event. It was indicated that a leak from the roof top air handler above was the suspected problem.

2. The roof top unit for the Emergency Room area is installed with a plumbing vent and an exhaust fan outlet adjacent (within 10') of the fresh air intake in non-compliance with accepted standard practice and recommendations of ASHRAE HVA/C Applications Chapter 7 regarding Hospitals. Surveyor notes that ASHRAE recommends that "These intakes should be located as far as is practical (on a directionally different exposures whenever possible) but not less than 25 ft from exhaust outlets of combustion equipment stacks, ventilation exhaust outlets from the hospital or adjoining buildings, medical-surgical vacuum systems, plumbing vent stacks, or from areas that may collect vehicular exhaust and other noxious fumes."

A. The emergency generator system is not maintained in accordance with NFPA 99 and 110. Conditions observed include:

1. Two exterior mounted generators are not provided with battery heaters to maintain battery temperature above 50 degrees F as required by NFPA 110, 1999, 3-3.1.

2. The emergency generators are indicated to be excercised weekly and run under load monthly. However documentation failed to indicate required information consistantly for the past 12 months. Observations include:

a. The rated capacity of the generators was not determined and the surveyor was unable to determine if the minimum 30% of nameplate rating loads were being applied to comply with NFPA 110, 1999, 6-4.2. Annual load bank testing was not otherwise indicated to have been performed.

b. Monthly documentation for applied loads were recorded only for months 9, 10, 11, & 12 during the last year.

c. Weekly inspections did not include the checking of the battery electrolyte levels and specific gravity to comply with NFPA 110, 1999, 6-3.6. Conductance testing was not otherwise provided for maintenance-free batteries.

A. Electrical installations are not in compliance with NFPA 70. Conditions observed include:

1. The electric panel "PP" in the Electric room near the main lobby lacks a panel directory to comply with NFPA 70, 1999, 384-13.

2. Electric panels lack full enclosure with blanks, spare breakers, or other protection to comply with NFPA 70, 1999, 370-18 and 370-25.

a. At the "LL" & "LP-1" panels in the Electric room near the main lobby.

b. At an above ceiling pull-box located in the 1972 building connecting corridor between the 2000 and 2007 buildings.

c. At the Main Switchboard located in the Boiler room.

B. Critical Care red emergency power receptacles are not labeled as to the electrical panel and circuit number from which they are fed to comply with NFPA 70,1999, 517-19(a) within the Emergency Department.