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Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the ceiling. This failure could result in the transfer of smoke or fire and affected 1 of 6 smoke compartments in Building E.

Findings:

During a tour of the facility with the Chief Engineer and Facility Manager on 2/12/14 and 2/13/14, the facility construction was observed.

Mammoth Hospital - Building E on 2/12/14:
At 9:56 a.m., there were eight unsealed conduits penetrating the right side of the ceiling in Imaging room E197.

Based on observation, the facility failed to maintain its corridor doors to latch and resist the passage of smoke. This was evidenced by a door that failed to latch. This failure affected patients in 1 of 6 smoke compartments in Building E.

Findings:

During a tour of the facility with the Chief Engineer and Facility Manager on 2/12/14 and 2/13/14, the doors were observed.

Mammoth Hospital - Building E on 2/12/14:
At 10:25 a.m., the door to Labor and Delivery room LD2 (E 234) failed to latch upon self closure during the testing of the fire alarm system.

Mammoth Hospital - Building E:
3. At 3:46 p.m., the facility failed to provide documentation for fire drills held during the second quarter (April, May, June 2013) AM, PM, and NOC shifts. The drill reports provided by the facility for the NOC shift fire drills documented the first quarter NOC shift fire drill was held at 6 a.m., and the third and fourth quarter NOC shift fire drills were held at 6:30 a.m. The drills were not held at unexpected times. During interview, the Chief Engineer stated there were no additional records for review.

Based on observation, document review and interview, the facility failed to maintain the fire alarm system. This was evidenced by the failure of two notification devices (chime/strobe), by failure of two smoke detection devices and by incomplete documentation of monthly testing of the fire alarm system with the central station and expired batteries for the fire alarm panel. This failure could result in the delay of notification to facility staff and the Fire Department in the event of a fire. This affected 5 of 5 smoke compartments in Building A and the Bridgeport Clinic.

NFPA 72, National Fire Alarm Code (1999) Edition
Table 7-3.2 Testing Frequencies, Item 23 - requires testing with the receiving station on a monthly basis.

Findings:

During the testing of the fire alarm system and document review with the Chief Engineer and Facility Manager on 2/12/14 and 2/13/14, the fire alarm system was observed.

Mammoth Hospital Rural Health Clinic - Bridgeport on 2/12/14:
1. At 12:30 p.m., during the facility tour a manual pull station was observed in the corridor of the clinic. During an interview, staff stated the manual pull had never been tested and did not know if the device was working or monitored. The facility failed to provide documentation for the testing of the manual pull.

Mammoth Hospital - Building A on 2/12/14:
2. At 4:01 p.m., the facility failed to provide documentation for the monthly testing or the fire alarm system with the central monitoring station. During an interview staff stated the fire alarm system is tested quarterly and provided documentation for the month of January, September and October.

Mammoth Hospital - Building A on 2/13/14:
3. At 11:22 a.m., the smoke detector in the cafeteria failed to activate an alarm when tested.

4. At 11:24 a.m., the chime and strobe device in the kitchen failed to activate during the testing of the fire alarm system.

5. At 11:26 a.m., the chime and strobe device in the Health, Information Management Systems "HIMS" office failed to activate during fire alarm testing.

6. At 11:33 a.m., the smoke detector in the "old" lobby failed to activate the fire alarm system when tested.

7. At 11:34 a.m., the smoke detector located in the corridor next to the Chemotherapy Infusion Room A 113 was tested and addressed incorrectly at the fire alarm control panel as "smoke detector Bone Density Hall."

Mammoth Hospital - Building E:
2. At 3:24 p.m., on 2/12/14, the facility failed to provide documentation for smoke detector sensitivity testing. During an interview, the Chief Engineer stated he would contact the fire alarm vendor and request the report.

3. At 8:33 a.m., on 2/13/14, the facility stated there were no additional records for review.

Based on observation, the facility failed to ensure the Automatic Sprinkler system was maintained in accordance with NFPA 25 Standards for Inspection, Testing and Maintenance of Water - Base Fire Protection Systems. This was evidenced by sprinkler escutcheon rings that had gaps, unsealed penetrations or sprinkler escutcheon rings that were missing. This failure could result in the automatic sprinkler system not functioning as designed in the event of a fire and affected 3 of 5 smoke compartments in Building A.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water- Base Fire Protection Systems, 1998 Edition
Chapter 2 Sprinkler Systems 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g. upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with the Chief Engineer and Facility Manager on 2/12/14 and 2/13/14 the sprinkler system was observed.

Mammoth Hospital - Building A on 2/12/14:
1. At 8:43 a.m., the sprinkler escutcheon ring was missing in the Environmental Storage closet located next to Dietary.

2. At 8:47 a.m., there was a 1 inch unsealed penetration next to the sprinkler escutcheon ring located in the kitchen dish washing area.

3. At 9:26 a.m., there was a 1/2 inch unsealed penetration next to the sprinkler escutcheon ring in the Environmental Storage closet located next to the doctors sleeping room.

4. At 9:36 a.m., in Respiratory Therapy 1 of 4 sprinkler escutcheon rings were missing.

5. At 9:38 a.m., the sprinkler escutcheon ring was missing in the medical surgical equipment storage room.

6. At 9:42 a.m., there was an unsealed penetration next to the sprinkler escutcheon ring in ICU room 2.

Based on observation, the facility failed to provide readily accessible fire extinguishers, as evidenced by 2 of 2 fire extinguishers that were obstructed, not visible and had expired annual tags. This failure could result in the fire extinguisher failure to suppress a fire, and could result in the potential spread of a fire. This affected 1 of 1 smoke compartments in the Bridgeport clinic.

NFPA 10, Standard for Portable Fire Extinguishers (1998) Edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

NFPA 10, Standard for Portable Fire Extinguishers (1998) Edition
4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection


Findings:

During a tour of the facility with the Education Coordinator and facility staff on 2/12/14, the fire extinguishers were observed.

Mammoth Hospital Rural Health Clinic - Bridgeport:
1. At 12:38 p.m., the fire extinguisher located across from Lab, had an annual tag with the date stamp of 12/18/2012. The fire extinguisher was recessed into the wall and was not visible, there was no sign above the location of the fire extinguisher.

2. At 12:43 p.m., the fire extinguisher located across from exam room three was visually obstructed by a cart and there was no sign above the fire extinguisher. The annual tag was also expired (12/18/2012).

Based on observation, document review and interview, the facility failed to maintain the hood exhaust system above the cooking area. This was evidenced by failure to have the Hood fire extinguishing system and exhaust systems serviced at least semi annually. This affected 1 of 5 smoke compartments in Building A.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition
8-2 Inspection. An inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made a least every 6 months by properly trained and qualified persons.
8-3 Cleaning.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenance shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authoring having jurisdiction in accordance with table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking:
Frequency
Systems serving solid fuel cooking operations Monthly

Systems serving high-volume cooking operations Quarterly

System serving moderate-volume cooking operations Semiannually

System serving low-Volume cooking such as
churches, day camps, seasonal businesses, or
senior centers. Annually

Findings:

During a tour of the facility with the facility Chief Engineer and Facility Manager on 2/12/14 and 2/13/14, the kitchen fire suppression system and exhaust hood was observed and documents reviewed.

Mammoth Hospital - Building A on 2/12/14:
1. At 8:43 a.m., the cooking area fire suppression system had a tag that was stamped 1/15/14 and the hood exhaust above the stove had a sticker that was stamped 10/2013.

2. At 8:42 a.m., on 2/13/14, during an interview, staff stated the hood exhaust system and the fire suppression system was not serviced semi-annually. During an interview, staff stated the kitchen cooking area was not used frequently and would request a continuous waiver for annual service for the cleaning of the exhaust hood and fire suppression system above the cooking area.

Based on observation and interview, the facility failed to prohibit the use of portable heating devices, as evidence by a heating devices in a room. This failure could in crease the risk of a potential fire and affected 1 of 2 floors in the out patient Physical Therapy Building.

Findings:

During a tour of the facility with the Chief Engineer and Facility Manager on 2/13/14, the facility rooms and care areas were observed.

Out Patient Physical Therapy Building Third Floor:
At 12:16 p.m., a portable heater was observed in the Pediatrics play room. Staff acknowledged the device and removed the heater immediately. There were no patients at the time of survey.

Based on observation, interview and document review, the facility failed to maintain the emergency generator as evidenced by no complete documentation for the 30 minute monthly load test. This had the potential for generator failure and affected 5 of 5 smoke compartments in Building A and building E.

NFPA 110 Standard for Emergency and Standby Power Systems (1999) Edition
6-4 Operational Inspection and Testing.
6-4.2 Generators sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperatures conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of the day for required testing shall be decided by the owner, based on facility operations.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.7 The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

Findings:

During document review and interview with the Chief Engineer and Facility Manager on 2/12/14 and 2/13/14, the generator logs were reviewed.

Mammoth Hospital - Building A on 2/12/14:
1. At 4:13 p.m., the generator logs provided by the facility for Building A generator did not have documentation for the monthly 30 minute load test in January 2014, and February 2013 or 2014. During an interview staff stated there were no additional records for review and acknowledged the missing documentation.

Mammoth Hospital - Building E on 2/12/14:
3. At 10:01 a.m., there was a refrigerator within 12 inches of electrical panel LXM, in the Imaging office room E 213.

Based on document review and interview, the facility failed to ensure that a policy was adopted to protect their patients during fire sprinkler system outage for more than 4 hours in a 24 hour period. This could leave their patients unprotected from fire during the outage of the sprinkler system. this affected 5 of 5 smoke compartments in Building A.

Findings:

During document review with the Chief Engineer on 2/12/14, the Policy and Procedure manual was reviewed.

Mammoth Hospital - Building A:

At 4:12 p.m. the facility failed to provide a written fire watch policy in the event the sprinkler system is out of service for more than 4 hours. During interview, the Chief Engineer and Education Coordinator stated they could not find a written fire watch policy for the outage of the automatic sprinkler system.

Based on document review and interview, the facility failed to ensure that a policy was adopted to protect their patients during fire alarm system outage for more than 4 hours in a 24 hour period. This could leave their patients unprotected from fire during the outage of the fire alarm system. This affected 5 of 5 smoke compartments in Building A.

Findings:

During document review with the Chief Engineer on 2/12/14, the Policy and Procedure manual was reviewed.

Mammoth Hospital - Building A:

At 4:13 p.m. the facility failed to provide a written fire watch policy in the event the fire alarm system is out of service for more than 4 hours. During interview, the Chief Engineer and Education Coordinator stated they could not find a written fire watch policy for the outage of the fire alarm system.