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Based on observation and interview, the facility failed to provide a minimum one half hour fire resistance rating between smoke compartments in accordance with 19.3.7.5 affecting all hospital staff, visitors and a census of 14 inpatients.

Findings included:

1. Observation on 02/17/11 at 9:40 AM showed five unsealed holes up to two inches in diameter where flex conduit and video cable penetrated the walls of a second floor electrical room (for cable television and telemetry electronics) next to Pharmacy.

2. Observation on 02/18/11 from 9:00 AM through 11:00 AM showed the following:

-Five unsealed holes up to six inches high by three inches wide in an electrical room on first floor, where the Area Control and Fire Alarm panels were located.
-Seven unsealed holes above a fire door in the corridor outside of the cafeteria, where various communication wires and electrical conduit penetrated a two hour wall between dissimilar structures.
-Five holes up to three inches wide by six inches high around penetrating cables above the doors in a firewall outside of Purchasing.
-Three holes around penetrating cables above a smoke door in the Pharmacy corridor.
-Three holes, up to one inch diameter, above the entrance to a second floor surgery clinic (outside of room 236), where cables and flex conduit penetrated the firewall.

During an interview on 02/18/07 at 11:50 A.M. the Director of Plant Operations documented the penetrations and stated they would seal the holes. He said in the future, his people would visually inspect work done by outside contractors to ensure they left no unknown damages to the walls or ceiling while gaining access to wiring or plumbing.

Based on observations and interview, the facility failed to ensure a minimum 20-minute fire protection rating in four of 12 smoke barriers (a wall constructed to resist the passage of smoke) on the first floor in accordance with 19.3.7.5 of the Life Safety Code requirements, potentially affecting staff, visitors and a census of 14 inpatients.

Findings included:

1. Observations on 02/17/11 at 11:00 AM showed a one-quarter inch space between the meeting edges of a pair of self-closing doors in the main corridor, outside of the laboratory. The doors did not have astragals (a molding attached to one leaf of a double door that creates a smoke tight barrier) to prevent the spread of smoke from one compartment to another.

2. Observations on 02/18/11 at 9:30 AM showed a one-quarter inch space between the meeting edges of a pair of self-closing doors in the corridor outside of surgery.

During an interview on 02/18/07 at 11:50 A.M. the Director of Plant Operations documented the excessive space between the doors. He stated that he planned to check all double doors and seals throughout the facility to assure smoke tight construction, and install astragals of non-combustible material on all doors with excessive spaces between meeting edges.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 14 inpatients.

Findings included:

1. Observation on 02/17/11 at 1:50 PM showed 23 "H" size cylinders of compressed gases stored in a locked room on first floor which was properly ventilated and protected by a firewall sealed to the roof deck and automatic sprinkler. None of the 23 cylinders of compressed gases were individually stabilized or supported by racks nor chained in manner to protect one from falling into the wall or another tank, potentially setting off a catastrophic chain of events that could propel one or more unsecured cylinders through the concrete block walls. Eleven of the 23 cylinders stood against the wall opposite from the entrance and were chained as a group, against the wall. Four bundles of four "H" cylinders each were connected with appropriate fittings to the facility's medical gas distribution system and standing, without racks, fasteners or collar protection, in the center of the room. Each bundle had a chain around it, but the cylinders were not individually racked or restrained to sufficiently protect them from being tipped over during change out or to protect them during movement of other cylinders within the confines of the room. The cylinders were all filled with Nitrous Oxide or Nitrogen compressed gases. (Highly compressed gasses are liquefied vapors that rapidly expand when oxidized or exposed to ambient air, causing a pressurized escape of the contents through any valve or opening. If the valve or control is knocked off or damaged, it could cause a rapid, uncontrolled release of pressure, which essentially turns the heavy metal cylinder into an unguided torpedo.)

2. Observation on 02/17/11 at 2:10 PM showed three "E" size cylinders of compressed gases (each container marked "DLCO") stored in an unlocked office used by visiting contractor for biomedical calibration of hospital equipment. The cylinders were not in a rack, equipped with a protective collar or secured in a safe manner to prevent the cylinders from tipping over and a valve knocked off or damaged.

3. During interviews on 02/17/11, the Director of Plant Operations stated that the compressed gas cylinders could be individually restrained by changing the configuration or constructing simple racks to prevent the cylinders from tipping over. He said he would also ensure the biomed gases and medical gas cylinders stored in the facility were secured.

Based on interview and record review, the facility failed to ensure their 800 kW diesel generator is exercised annually in accordance with NFPA 99, 7.13.6 and 8.4.2.3, under a full load that exceeds the amount of power currently needed by the hospital in the event of a power failure. This deficient practice potentially affects all hospital operations to include staff, visitors, outpatient clinic, and inpatient census of 14 inpatients.

Findings included:

1. During initial tour and of the building on 2/17/11 at 2:55 PM, and subsequent interviews with the Director of Plant Operations, (DPO) showed two generators located outside of the facility. The DPO stated that the new generator was a lot more powerful and exceeded the current power demands of the facility. He said both generators are exercised weekly and internally load tested monthly, using facility-based loads. He showed documentation the large generator is an 800 kW and said the current load testing capability of the facility systems does not exceed 30 percent of the larger (800 kW) generator's nameplate rating. He said the new generator was added since the last expansion and was specified with additional power capability to offset future power demands as the facility expands to remain competitive.

Based on record review and interview the facility failed to establish a written procedure for the institution of a fire watch in accordance with 9.6.1.9 that calls for notification to the appropriate authority and provides coverage to all unprotected areas until the required automatic sprinkler system has been returned to service. This deficient practice potentially affects all outpatients, staff, visitors and census of 14 inpatients.

Findings included:

1. Review of the facility's disaster handbook titled "Emergency Operation Plan" on 02/17/11 at 3:30 PM showed no watch policy or procedure for staffing and rounding through the affected areas in a fire related event, or systemic failure disabled the facility's automatic sprinklers for more than four hours.

During an interview on 02/18/10 at 1:00 PM, the Director of Plant Operations stated the facility does not have a formal written plan for a fire watch. He said the process they currently use, though rare, is to utilize maintenance staff (Maintenance also acts as grounds and building security) to perform this duty, which allows patient care staff to continue their duties without being disturbed or sidetracked. He said he would compose a policy and add it to his Emergency Operation Plan.

Based on record review and interview the facility failed to establish a written procedure for the institution of a fire watch in accordance with 9.6.1.9 that calls for notification to the appropriate authority and provides coverage to all unprotected areas until the fire alarm system has been returned to service. This deficient practice potentially affects all outpatients, staff, visitors and census of 14 inpatients.

Findings included:

1. Review of the facility's disaster handbook titled "Emergency Operation Plan" on 02/17/11 at 3:30 PM showed no written watch policy or procedure for staffing and rounding through the affected areas in the unlikely event an electrical or systemic failure disabled the facility's fire alarm for more than four hours.

During an interview on 02/18/10 at 1:00 PM, the Director of Plant Operations stated the facility does not have a formal written plan for a fire watch. He said the process they currently use, though rare, is to utilize maintenance staff (Maintenance also acts as grounds and building security) to perform this duty, which allows patient care staff to continue their duties without being disturbed or sidetracked. He said he would compose a policy and add it to his Emergency Operations Plan.