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Based on facility observation and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In sprinkler buildings, partitions are only required to resist the passage of smoke. In non-sprinkler buildings, walls properly extend above the ceiling. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. The following observations were of use areas open to the corridor.

1. Observation of the x-ray waiting area, located on the fist floor, revealed the area was approximately 14 feet long and six feet wide. The waiting area had two openings directly into the corridor. There was no smoke detection, sprinkler system or direct supervision of the waiting room.

2. Observation of the corridor near the PET/CT scan room revealed the area was partially sprinklered. Observation above the ceiling tiles inside the PET/CT room revealed at least three penetrations surrounding a flex conduit, a pipe and wires. Observation of a point between two pieces of gypsum revealed a penetration. Observation from outside the room, above the ceiling tiles revealed a penetration in the wall approximately one half inch in diameter.

3. Observation of the ground floor on 07/30/13 between 2:40 P.M. and 4:15 P.M. revealed the presence of the dietary area. The corridor was not provided sprinkler protection. The kitchen and serving line for staff and visitors was on one side of the corridor with the dining room entrance located on the opposite side of the corridor. Staff and visitors were served through large open areas in the walls. At the end of the same corridor was the opening where dirty items were taken for dishwashing.

Observation of the openings at the serving lines and the dish washing areas revealed the presence of one and a half hour fire rated shutters. Review of the fire shutters revealed fusible links as part of the operational component of the fire shutters. Staff #6 demonstrated that staff could raise and lower the fire shutters manually. During the days of the survey, the fire shutters were in the lowered position when the kitchen was closed. The fire shutter at the dishwashing area was observed to be in the raised position between 7:30 A.M. and 5:00 P.M.

Interview of Staff #5 and #6 regarding the mechanical operation of the fire shutters when in the raised position, revealed the shutters were not connected with the facility alarm system. Both staff verified that heat or fire would have to affect the fusible link before the fire shutters would lower, otherwise staff would have to manually lower the shutters.

4. Observation above the ceiling tiles in the partially sprinklered corridor on the ground floor between the back of the kitchen and the pharmacy revealed a large penetration. Staff #6 verified the observation and noted the large opening was the result of removal of an exhaust duct from the dietary department. The penetration was noted in a barrier wall designated to be a two hour fire rated barrier.

Observation of the other side of the corridor, at the pharmacy , revealed the barrier wall had a one hour fire resistance rating. Located in the same wall, was a window, used by pharmacy staff to pass through medications and money. The window was in a steel frame but had no wire in the glass and no noted fire rating. The window could not be opened or closed with the pass through area at the bottom of the glass. A fire shutter, similar in design and function observed in the dietary area, was above the pharmacy window.

Observation above the ceiling tiles of the one hour fire rated wall revealed a one inch penetration as well as an open area approximately four inches in diameter near the pharmacy door.

Observation above the fire rated doors located near the pharmacy revealed a penetration surrounding conduit.

The observations and findings were verified by staff present on the tour.

Based on facility observation and staff interview and verification, the facility failed to ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas were substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/31/13 at 9:20 A.M. observation of 17 patient rooms on the fire floor, revealed the doors to the rooms had significant gaps between the bottom of the doors and the floor covering. Staff #5 measured the gaps at the bottom of 10 of 17 patient rooms. The following rooms, 102 and 104, had a gap at the bottom of the door that measured one and three fourths inches. Rooms 106, ,108, 114, 115, 118 and 119 had gaps that measured one and one half inches.

Staff #5 verified the gaps at the bottom of doors were greater than the required one inch.

Based on facility observation and staff interview and verification, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Windows were to be protected by fire-rated glazing or by wired glass panels and steel frames. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. The following observations were of designated smoke barrier walls which were to form the smoke compartments on each floor of the facility.

Second floor;

1. Observation above the ceiling tiles, at the smoke barrier doors located in both the long and short halls, a penetrations surrounding a pipe sleeve for wires.

First Floor;

1. Observation above the ceiling tiles, in the ultrasound bathroom, penetrations were observed surrounding flex cable and surrounding black wires extending through the walls.

2. Observation above the ceiling tiles, in the former transcription room, a penetration approximately two inches in diameter where fire rated caulking had sagged.

3. Observation above the ceiling tiles, at the phone room, revealed penetrations surrounding copper pipe.

4. Observation above the ceiling tiles, on the corridor side of the wall at the pre/post operative area, two penetrations were noted. One open area surrounded a conduit and the other was an unsealed area between two pieces of gypsum board. This wall was designated a two hour fire rated barrier.

5. Observation of the barrier wall at the sterile processing room revealed a window, in a steel frame. The window did not have wire in the glass and had no indication of a fire rating. Staff present on the tour stated the window had been there since 1964. The window was used by sterile processing staff to pass through instrument packs to courier staff. Staff #5 stated a fire shutter was present on the inside of the sterile processing room but the fire shutter was not connected to the facility alarm system.

6. Observation above the ceiling tiles, at the smoke doors located near the main lab, revealed a plug of fire rated caulking had fell out of a pipe sleeve for wires.

7. Interview of Staff #5 regarding the square footage of a smoke compartment on the first floor revealed there was a smoke barrier wall not designated on the facility schematic. This barrier wall surrounded the surgical services area. Observation above the ceiling tiles of the specified barrier wall, at the corridor doors inside the surgical area, near the linen chute room, revealed an approximately three inch by four inch penetration surrounding conduit near duct work. Further observation of the wall on the exterior corridor side, near the staff lounge door, revealed a penetration surrounding conduit. Observation above the ceiling tiles, on the exterior corridor side, near the women's locker room, revealed a penetration approximately one inch wide by four inches long surrounding a conduit.

Ground Floor;

8. Observation above the ceiling tiles, from inside the clean linen room revealed two copper pipes that were cut and two large conduit extended through the wall and were unsealed.

9. Observation above the ceiling tiles, near the biomedical office revealed penetrations surrounding conduit.

Staff present on tour observed and verified the above findings.



8.

Based on facility observation and staff interview and verification, the facility failed to ensure one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option is used, the areas were to be separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. Observation of hazardous storage areas reveal the following findings.

1. Located on the second floor, within the sleep lab area, observation of the last room, next to the stairwell, revealed the room to be used for a storage area. The room was not equipped with a sprinkler system and the door to the room did not have a 3/4 hour fire rating. The room contained patient care equipment, boxes of housekeeping supplies which included toilet tissue. Staff #5 verified the room was no longer used as a patient room but was used for storage.

2. Located on the first floor, in the surgical area, observation of a housekeeping closet, revealed the sprinkler room did not have a self-closing device on the 20 minute fire rated door to the room.

3. Observation of a former medical records office, located on the first floor, revealed the room contained multiple cardboard banker boxes that contained paper financial records. The room had no sprinkler protection. Observation above the ceiling tiles revealed there was no one hour fire rated construction. The door to the room had a 20 minute fire rating.

4. Observation of two rooms, the housekeeping closet and the laundry room, housing the washer and dryer, located on the ground floor, revealed the rooms were not provided doors with self-closing devices.

5. The door to the mechanical room located on the ground floor was observed to fail to securely latch.

6. Observation of an equipment storage area on the ground floor, noted by staff as once the doctor's dining area, revealed the room was not provided with automatic sprinkler protection. Observation above the ceiling tiles revealed penetrations surrounding a copper pipe and two hot water pipes. The fire rated door to the room had no self-closing device.

Staff present on tour verified the observations and findings.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure emergency lighting of at least 1½ hour duration was provided in accordance with 7.9. with regards to monthly and yearly testing. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. During the tour, the facility was noted to have at least four battery operated emergency lights in various locations of the building.

During review of facility documentation on 07/31/13, between 8:30 A.M. and 10:30 A.M. with Staff #5, it was noted the facility tested the emergency lighting monthly. Review of the documentation revealed there was no indication the monthly test was conducted for 30 seconds per emergency light. Further review of the documentation revealed there was no indication of an annual test lasting 90 minutes.

Staff #5, present at the documentation review verified the testing information did not reflect testing for 30 seconds per month or an annual test of 90 minutes.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure all required smoke detectors, including those activating door hold-open devices, were approved, maintained, inspected and tested in accordance with the manufacturer's specifications.
The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. During the tour, the facility was noted to have smoke detection at various locations throughout the building.

During review of facility documentation on 07/31/13, between 8:30 A.M. and 10:30 A.M. with Staff #5, there was no documented evidence the smoke detector system had been tested in at least the past 12 months. In addition to the lack of an annual test of the smoke detection system there was no documented evidence that smoke sensitivity testing had been conducted in recent years.

Staff #5 verified there was no documented evidence that smoke detector testing had not been completed in the past year and that smoke detector sensitivity testing had been completed in recent years.

Based on facility observation and staff interview and verification, the facility failed to ensure required automatic sprinkler systems are continuously maintained in reliable operating condition The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. Observation of the following areas revealed storage placed less than 18 inches from the automatic sprinkler head.

1. Located on the ground floor, within the central storage area, a shelf containing at least 12 manuals was placed within 12 inches of the sprinkler head.

2. Observation of a storage area near operating room #2, revealed supplies placed on the top shelf of a unit. The items were placed significantly closer than 18 inches from the sprinkler head which was over the storage unit.

Staff present on tour verified the observation and findings.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure heating, ventilating, and air conditioning comply with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. During the tour, the facility was noted to have fire and smoke dampers in various locations of the building.

During review of facility documentation on 07/31/13, between 8:30 A.M. and 10:30 A.M. with Staff #5, it was noted there was no evidence of smoke or fire damper testing in recent years. Staff #5 verified the smoke and fire dampers had not been tested in more than 12 years. Staff #5 revealed a company had been contacted and arrangements were made to have the dampers tested.

Based on facility observation and staff interview and verification, the facility failed to ensure laundry chutes were provided with automatic extinguishing protection in accordance with 9.7., linen gravity chutes were to be limited access so that they could be used only by authorized personnel and the door at the chute discharge was self-closing. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. The facility was noted to have a linen gravity chute that extended from the second floor, through the first floor to the discharge room on the ground floor. The linen chute was noted to be inside a service room on each floor.

Observation inside the linen chute revealed there was no automatic sprinkler system in place. Staff #5 verified the linen chute was not provided with sprinkler protection. Staff #5 stated only the service rooms had sprinkler protection.

Observation of the service room for the linen chute located on the first floor on 07/30 at 7:37 A.M. and 07/31/13 at 12:25 P.M. and at 5:00 P.M., near the main elevator, revealed the service room door was not securely closed. The linen chute door was unlocked and accessible to unauthorized persons. Nursing staff at the nurse station, located near the linen chute service room were informed the room and chute were not secured.

On 07/30/13 at 3:15 P. M, observation of the line chute discharge room revealed the discharge door of the chute was in the closed and secured position. Staff #5 verified the linen chute discharge door was not connected to a hold open device that would allow it close in the event of fire. Staff #5 stated the chute door had to be manually open and closed.

Interview of Staff K regarding the chute discharge door revealed the facility staff have been told to keep the door closed at all times. Further interview revealed the staff check and empty the linen chute about every hour between the hours of 7:00 A.M. and 11:00 P.M. The linen chute remains closed and unchecked during the night shift. Staff K revealed that 16 bags of linen were the most ever removed from the linen chute.

Based on facility observation and staff interview and verification the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. The facility was noted to have smoke detectors throughout the building. The following smoke detectors were noted to be placed significantly closer than 36 inches to airflow devices;

1. Located on first floor at the junction of the entrance corridor and the main corridor, a smoke detector within 20 inches of the air flow device.

2. Located on first floor , in the emergency department patient treatment area, a smoke detector within 10 inches of the air flow device. Also in the emergency department in the patient exam room, a smoke detector approximately 18 inches from a air flow device.

3. Located on first floor in the cashier hallway, a smoke detector within 20 inches of the air flow device.

4. Located on first floor in the ICU corridor, a smoke detector within 14 inches of the air flow device.

Staff #5 and #6 , present at the observations, verified the findings.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure generators were exercised under load for 30 minutes per month in accordance with NFPA 99. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. During the tour, the facility was noted to have three emergency generators for emergency power. One generator was natural gas and two were diesel powered generators.

During review of facility documentation on 07/31/13, between 8:30 A.M. and 10:30 A.M. with Staff #5, the monthly load testing for the two diesel generators was reviewed. Both generators were noted to not reach 30 percent of the nameplate rating during the exercise each month.

Review of annual preventative maintenance of the generators revealed there was no evidence that a load bank test had been conducted. Staff #5 verified the two diesel generators did not reach the 30 percent nameplate rating each month with the load test and that a load bank test had not been completed in at least the past 12 months.

Based on review of agency policy and procedure and staff interview and verification, the facility failed to ensure that where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, an approved fire watch system was provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/31/13, between 8:30 A.M. and 10:30 A.M. facility documentation was reviewed with Staff #5. The documentation review included the facility life safety management plan from fire. Staff #5 verified the policy and procedure was to be implemented in event the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period.

Review of the policy and procedure revealed it did not address implementation of a fire watch procedure specifically when the automatic sprinkler system would be out of service for more than four hours in a 24-hour period.

Staff #5 verified the procedure was not addressed in the document.

Based on review of agency policy and procedure and staff interview and verification, the facility failed to ensure that where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, an approved fire watch was provided for all parties left unprotected by the shutdown until the fire alarm system was returned to service. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/31/13, between 8:30 A.M. and 10:30 A.M. facility documentation was reviewed with Staff #5. The documentation review included the facility life safety management plan from fire. Staff #5 verified the policy and procedure was to be implemented in event the fire alarm system was out of service for more than 4 hours in a 24-hour period.

Review of the policy and procedure revealed it did not address implementation of a fire watch procedure specifically when the fire alarm system would be out of service for four in more hours in a 24-hour period.

Staff #5 verified the procedure was not addressed in the document.

Based on facility observation and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In sprinkler buildings, partitions are only required to resist the passage of smoke. In non-sprinkler buildings, walls properly extend above the ceiling. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. The following observations were of use areas open to the corridor.

1. Observation of the x-ray waiting area, located on the fist floor, revealed the area was approximately 14 feet long and six feet wide. The waiting area had two openings directly into the corridor. There was no smoke detection, sprinkler system or direct supervision of the waiting room.

2. Observation of the corridor near the PET/CT scan room revealed the area was partially sprinklered. Observation above the ceiling tiles inside the PET/CT room revealed at least three penetrations surrounding a flex conduit, a pipe and wires. Observation of a point between two pieces of gypsum revealed a penetration. Observation from outside the room, above the ceiling tiles revealed a penetration in the wall approximately one half inch in diameter.

3. Observation of the ground floor on 07/30/13 between 2:40 P.M. and 4:15 P.M. revealed the presence of the dietary area. The corridor was not provided sprinkler protection. The kitchen and serving line for staff and visitors was on one side of the corridor with the dining room entrance located on the opposite side of the corridor. Staff and visitors were served through large open areas in the walls. At the end of the same corridor was the opening where dirty items were taken for dishwashing.

Observation of the openings at the serving lines and the dish washing areas revealed the presence of one and a half hour fire rated shutters. Review of the fire shutters revealed fusible links as part of the operational component of the fire shutters. Staff #6 demonstrated that staff could raise and lower the fire shutters manually. During the days of the survey, the fire shutters were in the lowered position when the kitchen was closed. The fire shutter at the dishwashing area was observed to be in the raised position between 7:30 A.M. and 5:00 P.M.

Interview of Staff #5 and #6 regarding the mechanical operation of the fire shutters when in the raised position, revealed the shutters were not connected with the facility alarm system. Both staff verified that heat or fire would have to affect the fusible link before the fire shutters would lower, otherwise staff would have to manually lower the shutters.

4. Observation above the ceiling tiles in the partially sprinklered corridor on the ground floor between the back of the kitchen and the pharmacy revealed a large penetration. Staff #6 verified the observation and noted the large opening was the result of removal of an exhaust duct from the dietary department. The penetration was noted in a barrier wall designated to be a two hour fire rated barrier.

Observation of the other side of the corridor, at the pharmacy , revealed the barrier wall had a one hour fire resistance rating. Located in the same wall, was a window, used by pharmacy staff to pass through medications and money. The window was in a steel frame but had no wire in the glass and no noted fire rating. The window could not be opened or closed with the pass through area at the bottom of the glass. A fire shutter, similar in design and function observed in the dietary area, was above the pharmacy window.

Observation above the ceiling tiles of the one hour fire rated wall revealed a one inch penetration as well as an open area approximately four inches in diameter near the pharmacy door.

Observation above the fire rated doors located near the pharmacy revealed a penetration surrounding conduit.

The observations and findings were verified by staff present on the tour.

Based on facility observation and staff interview and verification, the facility failed to ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas were substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/31/13 at 9:20 A.M. observation of 17 patient rooms on the fire floor, revealed the doors to the rooms had significant gaps between the bottom of the doors and the floor covering. Staff #5 measured the gaps at the bottom of 10 of 17 patient rooms. The following rooms, 102 and 104, had a gap at the bottom of the door that measured one and three fourths inches. Rooms 106, ,108, 114, 115, 118 and 119 had gaps that measured one and one half inches.

Staff #5 verified the gaps at the bottom of doors were greater than the required one inch.

Based on facility observation and staff interview and verification, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Windows were to be protected by fire-rated glazing or by wired glass panels and steel frames. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. The following observations were of designated smoke barrier walls which were to form the smoke compartments on each floor of the facility.

Second floor;

1. Observation above the ceiling tiles, at the smoke barrier doors located in both the long and short halls, a penetrations surrounding a pipe sleeve for wires.

First Floor;

1. Observation above the ceiling tiles, in the ultrasound bathroom, penetrations were observed surrounding flex cable and surrounding black wires extending through the walls.

2. Observation above the ceiling tiles, in the former transcription room, a penetration approximately two inches in diameter where fire rated caulking had sagged.

3. Observation above the ceiling tiles, at the phone room, revealed penetrations surrounding copper pipe.

4. Observation above the ceiling tiles, on the corridor side of the wall at the pre/post operative area, two penetrations were noted. One open area surrounded a conduit and the other was an unsealed area between two pieces of gypsum board. This wall was designated a two hour fire rated barrier.

5. Observation of the barrier wall at the sterile processing room revealed a window, in a steel frame. The window did not have wire in the glass and had no indication of a fire rating. Staff present on the tour stated the window had been there since 1964. The window was used by sterile processing staff to pass through instrument packs to courier staff. Staff #5 stated a fire shutter was present on the inside of the sterile processing room but the fire shutter was not connected to the facility alarm system.

6. Observation above the ceiling tiles, at the smoke doors located near the main lab, revealed a plug of fire rated caulking had fell out of a pipe sleeve for wires.

7. Interview of Staff #5 regarding the square footage of a smoke compartment on the first floor revealed there was a smoke barrier wall not designated on the facility schematic. This barrier wall surrounded the surgical services area. Observation above the ceiling tiles of the specified barrier wall, at the corridor doors inside the surgical area, near the linen chute room, revealed an approximately three inch by four inch penetration surrounding conduit near duct work. Further observation of the wall on the exterior corridor side, near the staff lounge door, revealed a penetration surrounding conduit. Observation above the ceiling tiles, on the exterior corridor side, near the women's locker room, revealed a penetration approximately one inch wide by four inches long surrounding a conduit.

Ground Floor;

8. Observation above the ceiling tiles, from inside the clean linen room revealed two copper pipes that were cut and two large conduit extended through the wall and were unsealed.

9. Observation above the ceiling tiles, near the biomedical office revealed penetrations surrounding conduit.

Staff present on tour observed and verified the above findings.



8.

Based on facility observation and staff interview and verification, the facility failed to ensure one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option is used, the areas were to be separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. Observation of hazardous storage areas reveal the following findings.

1. Located on the second floor, within the sleep lab area, observation of the last room, next to the stairwell, revealed the room to be used for a storage area. The room was not equipped with a sprinkler system and the door to the room did not have a 3/4 hour fire rating. The room contained patient care equipment, boxes of housekeeping supplies which included toilet tissue. Staff #5 verified the room was no longer used as a patient room but was used for storage.

2. Located on the first floor, in the surgical area, observation of a housekeeping closet, revealed the sprinkler room did not have a self-closing device on the 20 minute fire rated door to the room.

3. Observation of a former medical records office, located on the first floor, revealed the room contained multiple cardboard banker boxes that contained paper financial records. The room had no sprinkler protection. Observation above the ceiling tiles revealed there was no one hour fire rated construction. The door to the room had a 20 minute fire rating.

4. Observation of two rooms, the housekeeping closet and the laundry room, housing the washer and dryer, located on the ground floor, revealed the rooms were not provided doors with self-closing devices.

5. The door to the mechanical room located on the ground floor was observed to fail to securely latch.

6. Observation of an equipment storage area on the ground floor, noted by staff as once the doctor's dining area, revealed the room was not provided with automatic sprinkler protection. Observation above the ceiling tiles revealed penetrations surrounding a copper pipe and two hot water pipes. The fire rated door to the room had no self-closing device.

Staff present on tour verified the observations and findings.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure emergency lighting of at least 1½ hour duration was provided in accordance with 7.9. with regards to monthly and yearly testing. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. During the tour, the facility was noted to have at least four battery operated emergency lights in various locations of the building.

During review of facility documentation on 07/31/13, between 8:30 A.M. and 10:30 A.M. with Staff #5, it was noted the facility tested the emergency lighting monthly. Review of the documentation revealed there was no indication the monthly test was conducted for 30 seconds per emergency light. Further review of the documentation revealed there was no indication of an annual test lasting 90 minutes.

Staff #5, present at the documentation review verified the testing information did not reflect testing for 30 seconds per month or an annual test of 90 minutes.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure all required smoke detectors, including those activating door hold-open devices, were approved, maintained, inspected and tested in accordance with the manufacturer's specifications.
The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. During the tour, the facility was noted to have smoke detection at various locations throughout the building.

During review of facility documentation on 07/31/13, between 8:30 A.M. and 10:30 A.M. with Staff #5, there was no documented evidence the smoke detector system had been tested in at least the past 12 months. In addition to the lack of an annual test of the smoke detection system there was no documented evidence that smoke sensitivity testing had been conducted in recent years.

Staff #5 verified there was no documented evidence that smoke detector testing had not been completed in the past year and that smoke detector sensitivity testing had been completed in recent years.

Based on facility observation and staff interview and verification, the facility failed to ensure required automatic sprinkler systems are continuously maintained in reliable operating condition The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. Observation of the following areas revealed storage placed less than 18 inches from the automatic sprinkler head.

1. Located on the ground floor, within the central storage area, a shelf containing at least 12 manuals was placed within 12 inches of the sprinkler head.

2. Observation of a storage area near operating room #2, revealed supplies placed on the top shelf of a unit. The items were placed significantly closer than 18 inches from the sprinkler head which was over the storage unit.

Staff present on tour verified the observation and findings.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure heating, ventilating, and air conditioning comply with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. During the tour, the facility was noted to have fire and smoke dampers in various locations of the building.

During review of facility documentation on 07/31/13, between 8:30 A.M. and 10:30 A.M. with Staff #5, it was noted there was no evidence of smoke or fire damper testing in recent years. Staff #5 verified the smoke and fire dampers had not been tested in more than 12 years. Staff #5 revealed a company had been contacted and arrangements were made to have the dampers tested.

Based on facility observation and staff interview and verification, the facility failed to ensure laundry chutes were provided with automatic extinguishing protection in accordance with 9.7., linen gravity chutes were to be limited access so that they could be used only by authorized personnel and the door at the chute discharge was self-closing. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. The facility was noted to have a linen gravity chute that extended from the second floor, through the first floor to the discharge room on the ground floor. The linen chute was noted to be inside a service room on each floor.

Observation inside the linen chute revealed there was no automatic sprinkler system in place. Staff #5 verified the linen chute was not provided with sprinkler protection. Staff #5 stated only the service rooms had sprinkler protection.

Observation of the service room for the linen chute located on the first floor on 07/30 at 7:37 A.M. and 07/31/13 at 12:25 P.M. and at 5:00 P.M., near the main elevator, revealed the service room door was not securely closed. The linen chute door was unlocked and accessible to unauthorized persons. Nursing staff at the nurse station, located near the linen chute service room were informed the room and chute were not secured.

On 07/30/13 at 3:15 P. M, observation of the line chute discharge room revealed the discharge door of the chute was in the closed and secured position. Staff #5 verified the linen chute discharge door was not connected to a hold open device that would allow it close in the event of fire. Staff #5 stated the chute door had to be manually open and closed.

Interview of Staff K regarding the chute discharge door revealed the facility staff have been told to keep the door closed at all times. Further interview revealed the staff check and empty the linen chute about every hour between the hours of 7:00 A.M. and 11:00 P.M. The linen chute remains closed and unchecked during the night shift. Staff K revealed that 16 bags of linen were the most ever removed from the linen chute.

Based on facility observation and staff interview and verification the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. The facility was noted to have smoke detectors throughout the building. The following smoke detectors were noted to be placed significantly closer than 36 inches to airflow devices;

1. Located on first floor at the junction of the entrance corridor and the main corridor, a smoke detector within 20 inches of the air flow device.

2. Located on first floor , in the emergency department patient treatment area, a smoke detector within 10 inches of the air flow device. Also in the emergency department in the patient exam room, a smoke detector approximately 18 inches from a air flow device.

3. Located on first floor in the cashier hallway, a smoke detector within 20 inches of the air flow device.

4. Located on first floor in the ICU corridor, a smoke detector within 14 inches of the air flow device.

Staff #5 and #6 , present at the observations, verified the findings.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure generators were exercised under load for 30 minutes per month in accordance with NFPA 99. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/29 between 1:20 P.M. and 4:00 P.M. and 07/30/13 between 8:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff #5 and #6. During the tour, the facility was noted to have three emergency generators for emergency power. One generator was natural gas and two were diesel powered generators.

During review of facility documentation on 07/31/13, between 8:30 A.M. and 10:30 A.M. with Staff #5, the monthly load testing for the two diesel generators was reviewed. Both generators were noted to not reach 30 percent of the nameplate rating during the exercise each month.

Review of annual preventative maintenance of the generators revealed there was no evidence that a load bank test had been conducted. Staff #5 verified the two diesel generators did not reach the 30 percent nameplate rating each month with the load test and that a load bank test had not been completed in at least the past 12 months.

Based on review of agency policy and procedure and staff interview and verification, the facility failed to ensure that where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, an approved fire watch system was provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/31/13, between 8:30 A.M. and 10:30 A.M. facility documentation was reviewed with Staff #5. The documentation review included the facility life safety management plan from fire. Staff #5 verified the policy and procedure was to be implemented in event the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period.

Review of the policy and procedure revealed it did not address implementation of a fire watch procedure specifically when the automatic sprinkler system would be out of service for more than four hours in a 24-hour period.

Staff #5 verified the procedure was not addressed in the document.

Based on review of agency policy and procedure and staff interview and verification, the facility failed to ensure that where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, an approved fire watch was provided for all parties left unprotected by the shutdown until the fire alarm system was returned to service. The facility had a census of 16 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings included:

On 07/31/13, between 8:30 A.M. and 10:30 A.M. facility documentation was reviewed with Staff #5. The documentation review included the facility life safety management plan from fire. Staff #5 verified the policy and procedure was to be implemented in event the fire alarm system was out of service for more than 4 hours in a 24-hour period.

Review of the policy and procedure revealed it did not address implementation of a fire watch procedure specifically when the fire alarm system would be out of service for four in more hours in a 24-hour period.

Staff #5 verified the procedure was not addressed in the document.