HospitalInspections.org

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that patient's doors protecting corridors at the Medicine ward I and II, patient's rooms #112, #217, #218 and #224 on the first floor do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested on 6/29/11 from 10:30 am till 12:15 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that the following patient's rooms do not have the capability of latching when the doors are in the closed position, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire:
a. Patient's rooms #112, #217, #218 and #224 (all room doors shall be verified for compliance).

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that smoke barrier are constructed to resist fire for a minimum of one half hour as evidenced by penetrations through the smoke barrier on the first floor and smoke barrier doors on the first floor lacked vision panels and positive latching which is not in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

Findings include:

1. During the life safety observational tour of the facility with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm, the space between the acoustic ceiling and the floor slab above was verified to ensure the integrity of the smoke barrier located near patient's room #110. Above the smoke barrier doors an opening was found where tubing was passed through the wall of the smoke barrier and these smoke barrier doors lack positive latching. The space shall be filled with an approved sealant that is an intumescent products. Smoke barriers must be constructed to resist fire for a minimum of one half hour and penetrations are not allowed to ensure that it can resist fire and smoke and positive latching will protect the smoke compartments from explosion or changes in pressure that can blow the doors open.

2. During the observational tour of the facility with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 6/30/11 from 9:00 am till 3:00 pm, it was found that the smoke barrier doors (one located near the nursing station and the other located near patient's room #215) of the Medicine II ward did not have vision panels and the smoke barrier doors near patient's room #215 lacked positive latching.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that the closet door located in the staircase near the administration office and all housekeeping closets can resist the passage of smoke in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 8.3.4.1 as evidenced by louvers on these doors.

Findings include:

1. A closet located in the staircase near the administration office on the ground floor was observed on 6/28/11 at 1:25 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) with a louver that open into the staircase. In the event of a fire in this closet, this door would not resist the passage of smoke into the staircase.

2. All housekeeping closets (emergency room and hospital) were observed from 6/28/11 through 7/1/11 from 8:45 am till 3:15 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and were found with louvres. In the event of a fire in these closets, these doors would not resist the passage of smoke into the area outside of these doors.

Based on tests to doors, observations made during survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that exit components (stairway doors) do not provide protection against fire or smoke from other parts of the building due to the lack of the doors' ability to close completely at the ground floor as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.1.1 and 19.3.2.1.

Findings include:

During the tour for life safety from fire, exit components (stair enclosures) were inspected and found that the enclosure (door) on the ground floor of the internal staircase near the administration office did not completely close (lacked positive latching) as observed on 6/28/11 at 1:30 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12). This fire door can be opened with a minimum force and can permit fire and toxic gases to enter this means of egress.

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided at the triage, financing department and all medications rooms, some emergency lamps did not illuminate when tested and no evidence was found that the facility is testing the emergency lamps on a monthly and annual basis as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm in the following areas:
a. At the triage area of the emergency room.
b. In the financing department on the ground floor.
c. At all medication preparation rooms (wards, Intensive Care Unit, etc).
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

2. The emergency battery operated lamps (EBOL) in the following areas were tested with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and did not illuminate as observed from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm:
a. The EBOL in the minor surgery room.
b. In the hallway near the financing department on the ground floor.
c. In the X-ray department.
d. In the hallway in front of patient's room #117.

3. Documentation about tests to emergency lighting reviewed on 7/1/11 at 11:00 am with the facility's Director of Institutional Services (employee #12) provided evidence that the facility is not documenting the duration of the monthly tests which should be for thirty seconds, nor are they documenting the annual tests which should be for 90 minutes.

Based on observations made during the survey for life safety from fire with the facility's Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that nursing wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 7/1/11 at 10:10 am with the facility's Director of Institutional Services (employee #12) that nursing ward personnel have a plan or assignment with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off and other tasks to perform. All personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation, lack of exit fire drills and the facility failed to perform at least 4 fire drills per shift during the past 12 months which is not in accordance with the requirements of the LSC 2000 section 19.7.1.2 and section 5.5.

Findings include:

1. Written documents about conducted fire drills for the facility were reviewed with the facility's Director of Institutional Services (employee #12) on 7/1/11 at 9:20 am and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

2. Written documents about conducted fire drills for the hospital were reviewed on 7/1/11 at 10:25 am with the facility's Director of Institutional Services (employee #12) and it was found that the facility failed to perform at least four fire drills annually for each shift. The facility has three shifts and provided evidence that only one fire drill was performed during the past twelve months for the 11:00 pm till 7:00 am shifts and only one fire drill was performed for the 3:00 pm till 11:00 pm shift. The facility failed to comply with this regulation due to the lack of at least four fire drills during the 11:00 pm till 7:00 am and 3:00 pm till 11:00 pm shifts.

3. Written evidence reviewed of fire drills on 7/1/11 at 10:30 am with the facility's Director of Institutional Services (employee #12) failed to provide evidence that the facility is performing fire exit drills for the proper protection of patients; drills for the purpose of relocating patients to an area of safety.

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that smoke detectors are available at all required areas, housekeeping closets, biohazardous trash closets, fire alarm documentation about sensitivity tests was not found and strobe lights are needed in public bathrooms as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm:
a. In the general storage area that measures 32 feet by 16 feet there is only one smoke detector and another one is needed.
b. In the general storage area where the refrigerator and coffee maker are located.
c. In the general storage area where there are three separate rooms.
d. In the financing department.
e. All housekeeping closets located throughout the hospital.
f. In the room used to place extra medical records at the ground floor.
g. In the Respiratory therapy department (found with two type E oxygen cylinders).
h. In the storage room of the Intensive Care Unit (a coffee maker and refrigerator were found).
i. In the machine room of the elevator (this elevator is used to bring up and take down the food tray cart from the ground floor).
j. In the biohazardous storage closet near the nursery hallway.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 7/1/11 at 10:05 am with the facility's Director of Institutional Services (employee #12), however no evidence was found of the following:
a. Smoke detector sensitivity tests and readings.

3. Patient's and visitor's public bathrooms (both male and female) were visited from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and provided evidence that they do not have strobe lights to alert deaf persons using these bathrooms in the event that the fire alarm is activated.

4. The smoke detector located in in the CT scan room was observed on 6/28/11 at 11:40 am within three feet of the air conditioner vent. Air blown in air conditioner vents can affect the effectiveness of the smoke detector to detect smoke in the event of a fire.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility is not performing visual inspections, sensing chamber tests or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 7/1/11 at 9:30 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response which includes the smoke detectors in the air conditioner system (twice a year).

c. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

d. Location of pull-down stations and tests (monthly).

e. Visible (strobe lights) and audible signal tests (monthly).

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that the automatic sprinkler system is continuously maintained in reliable operating condition and are inspected and tested periodically as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings include:

1. Review of documentation and observations of the sprinkler system on 7/1/11 from 9:30 am till 10:00 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and the following was determined:
a. No evidence was found of the control valve identification with a sign indicating the system or portion of the system it controls.
b. No evidence was found of the weekly valve inspection (hose valves, pressure-regulating valves and valves that isolate backflow prevention devices).
c. No evidence was found of the fire department connection inspection on a quarterly basis to verify visibility and accessibility, coupling and swivels not damaged and rotate smoothly.
d. No evidence was found of tests performed on the sprinkler system (such as weekly no-flow tests and annual flow condition test of the fire pump).

2. The sprinkler head in the Intensive Care Unit storage area was observed on 6/29/11 at 11:00 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) within two inches from the wall above the door. In order for this sprinkler head to be effective in this room it should be centrally located or the sprinkler head should be the type that sprays water in a particular direction (this room has a coffee maker and a refrigerator located at the back wall at the furthest point from the sprinkler head).

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that portable fire extinguisher are maintained related to updated inspections, are visible and accessible at all required areas as states in the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. During observations made of the hospital with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 6/30/11 from 9:00 am till 3:00 pm, the following was determined related to fire extinguishers:
a. Fire extinguishers located in the general storage area, in the pantry and in front of the I.V storage room all on the ground floor were found without the facility's monthly inspection for April and May of 2011.

2. Fire extinguishers were observed throughout the hospital from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and the following was found:
a. Two fire extinguishers were found in the OPD hallway mounted next to pull stations and which did not allow the pull stations to be easily distinguished.
b. The fire extinguisher located in the hallway near the emergency room was located behind a column and could not be seen from the other side of the column down the hallway.
c. The facility has fire hose cabinets located throughout the facility and they also have fire extinguishers in them (such as in Medicine II ward). However, the notification of these fire extinguishers in these fire hose cabinets is a flat sign that sticks on the wall and is not visible from different areas of the hallway.

Based on observations made during for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility has central air conditioner units with air handling systems in the corridor that uses return air to cool the facility and the system does not have dampers to prevent the re-circulation of smoke into the corridor in the event of a fire and is not in compliance with the Code requirements of NFPA-90-A and the 2000 edition of the Life Safety Code of the NFPA Section 9.2.

Findings include:

1. During the observational tour throughout the facility from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that the main corridors where patients receive treatment and services are used as a plenum. The air conditioner machine room doors were observed with louvres at the base of the doors which allows air movement. Air is blown into the corridor and returned into these air conditioner machine rooms to recirculate the cool air into the corridors. These air conditioner machine rooms were found with smoke detectors to automatically shut down the fan. However, no evidence was provided that the facility has smoke dampers in their air conditioner vent system to ensure that when smoke is detected by the smoke detectors and it turns off the air conditioner, smoke does not continue to travel through the vent system. The smoke dampers will ensure that smoke and toxic gases do not spread via the air conditioner ventilation system.

a. The janitor's room located near patient's room #110 was visited on 6/29/11 at 10:30 am
with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that this room also contains the air conditioner machinery used to return cool air to the corridors. The janitor's closet and the air conditioner machine return room can not share the same space especially due to the chemicals used to clean the hospital.

b. The air conditioner machine room located in front of the nursing station of the Medicine I ward was visited on 6/29/11 at 10:50 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that this room is used by personnel to leave personal items, to eat and has a garbage container. These items can not share space in this room dedicated to return air through the facility.

Based on observations during the survey for Life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, propane gas tanks do not have seismic shut off devices, oxygen storage, fire hose cabinets are painted in white, paint stored in a closet on the ground floor, facility is using mult-outlet adapter, uneven step at the emergency room, diesel storage #1 does not have a gauge to measure diesel level and the facility is not using fire rated garbage containers.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. In the CT scan room (a type H oxygen cylinder).
b. A type H oxygen cylinder was found in the pre-anesthesia area.
c. Two type E oxygen cylinders were found in the respiratory therapy department.
d. One type H oxygen cylinder in operating suite #3.

2. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) on 7/1/11 from 9:00 am till 3:00 pm and the following was determined:
a. No evidence was found of standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

3. The facility has two areas with propane gas tanks (a total of two tanks at each location) located at the back and side of the hospital as observed on 6/28/11 at 11:30 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and provided evidence that they are not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required.

4. Some fire hose cabinets (such as the one at Medicine II ward) were found during the observational tour of the entire facility from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) painted white. The walls are painted a light color and the fire hose cabinet is not clearly distinguished from down the hall.

5. A small closet located in the hallway near the general storage area on the ground floor was visited on 6/28/11 at 9:30 am and was found with three gallons of paint. Products and materials that are flammable can not be stored in a closet that is not meant for this purpose.

6. The general storage area on the ground floor was visited on 6/28/11 at 9:40 am and was found with a regular receptacle that had an adapter which converted two outlets into six. The six outlet were used for a coffee maker, refrigerator and to charge I.V pump machines. Multi-outlet adapters are not recommended due to the potential for them to over heat.

7. During the observational tour of the emergency room on 6/28/11 at 2:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) it was found that there are several steps before the door to enter the waiting room of the emergency room. The first of these steps was measured for the riser height and was found to be 10 inches (in height) and the risers of the other steps were all measured at 6 and a half inches in height from one riser to the other. According with NFPA 101 Life Safety Code Handbook from 2006 section 7.2.2.3.6 "Dimensional Uniformity", "The tolerance between the largest and the smallest riser or between the largest and smallest tread shall not exceed 3/8 of an inch.

8. The diesel storage tank for electrical generator #1 located in front of the emergency room was visited with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) on 6/30/11 at 11:40 am and provided evidence that they use a large wooden ruler to measure the amount of diesel in this tank. The tank does not have a gauge to automatically measure the amount of diesel left in the tank. The method of placing the ruler into the tank increases the chance of impurities entering the tank, miscalculations of the amount of diesel left in the tank and in the event of an emergency and the generators are running for a few days, the ruler can not be used to measure the diesel left in the tank. An automatic measuring gauge is useful and may also emit a signal when the tank reaches a critically low level which allows time to fill the tank before the tank is empty.

9. Regular garbage containers located at offices and work areas were verified from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm and provided evidence that they are not made of fire rated material and tested as such. Rubber or plastic garbage containers that are not made of fire rated material can emit toxic fumes if they catch on fire.

Based on the review of written documents during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that personnel perform the monthly 30 minute load test of the electrical generators and monthly transfer switch tests as required by the NFPA 99, section 3.4.4.1.

Findings include:

1. The facility lacks written evidence that the electrical generators are tested under load condition for 30 minutes on a monthly basis as reviewed on 7/1/11 at 10:00 am with the facility's Physical Plant Manager (employee #18). The facility has two large electrical generators however documentation reviewed could not support that the generators ran with load for 30 minutes.

2. The facility lacks written evidence that the electrical generators' transfer switches are tested on a monthly basis as reviewed on 7/1/11 at 10:15 am with the facility's Physical Plant Manager (employee #18).

3. During observations of the generator used to power the pumps of the sprinkler system on 6/30/11 at 9:00 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that the battery terminal had what appeared to be corrosion (a built up white crust) and no evidence was found of the periodic maintenance performed on these batteries.

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 7/1/11 at 11:00 am about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that patient's doors protecting corridors at the Medicine ward I and II, patient's rooms #112, #217, #218 and #224 on the first floor do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested on 6/29/11 from 10:30 am till 12:15 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that the following patient's rooms do not have the capability of latching when the doors are in the closed position, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire:
a. Patient's rooms #112, #217, #218 and #224 (all room doors shall be verified for compliance).

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that smoke barrier are constructed to resist fire for a minimum of one half hour as evidenced by penetrations through the smoke barrier on the first floor and smoke barrier doors on the first floor lacked vision panels and positive latching which is not in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

Findings include:

1. During the life safety observational tour of the facility with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm, the space between the acoustic ceiling and the floor slab above was verified to ensure the integrity of the smoke barrier located near patient's room #110. Above the smoke barrier doors an opening was found where tubing was passed through the wall of the smoke barrier and these smoke barrier doors lack positive latching. The space shall be filled with an approved sealant that is an intumescent products. Smoke barriers must be constructed to resist fire for a minimum of one half hour and penetrations are not allowed to ensure that it can resist fire and smoke and positive latching will protect the smoke compartments from explosion or changes in pressure that can blow the doors open.

2. During the observational tour of the facility with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 6/30/11 from 9:00 am till 3:00 pm, it was found that the smoke barrier doors (one located near the nursing station and the other located near patient's room #215) of the Medicine II ward did not have vision panels and the smoke barrier doors near patient's room #215 lacked positive latching.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that the closet door located in the staircase near the administration office and all housekeeping closets can resist the passage of smoke in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 8.3.4.1 as evidenced by louvers on these doors.

Findings include:

1. A closet located in the staircase near the administration office on the ground floor was observed on 6/28/11 at 1:25 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) with a louver that open into the staircase. In the event of a fire in this closet, this door would not resist the passage of smoke into the staircase.

2. All housekeeping closets (emergency room and hospital) were observed from 6/28/11 through 7/1/11 from 8:45 am till 3:15 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and were found with louvres. In the event of a fire in these closets, these doors would not resist the passage of smoke into the area outside of these doors.

Based on tests to doors, observations made during survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that exit components (stairway doors) do not provide protection against fire or smoke from other parts of the building due to the lack of the doors' ability to close completely at the ground floor as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.1.1 and 19.3.2.1.

Findings include:

During the tour for life safety from fire, exit components (stair enclosures) were inspected and found that the enclosure (door) on the ground floor of the internal staircase near the administration office did not completely close (lacked positive latching) as observed on 6/28/11 at 1:30 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12). This fire door can be opened with a minimum force and can permit fire and toxic gases to enter this means of egress.

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided at the triage, financing department and all medications rooms, some emergency lamps did not illuminate when tested and no evidence was found that the facility is testing the emergency lamps on a monthly and annual basis as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm in the following areas:
a. At the triage area of the emergency room.
b. In the financing department on the ground floor.
c. At all medication preparation rooms (wards, Intensive Care Unit, etc).
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

2. The emergency battery operated lamps (EBOL) in the following areas were tested with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and did not illuminate as observed from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm:
a. The EBOL in the minor surgery room.
b. In the hallway near the financing department on the ground floor.
c. In the X-ray department.
d. In the hallway in front of patient's room #117.

3. Documentation about tests to emergency lighting reviewed on 7/1/11 at 11:00 am with the facility's Director of Institutional Services (employee #12) provided evidence that the facility is not documenting the duration of the monthly tests which should be for thirty seconds, nor are they documenting the annual tests which should be for 90 minutes.

Based on observations made during the survey for life safety from fire with the facility's Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that nursing wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 7/1/11 at 10:10 am with the facility's Director of Institutional Services (employee #12) that nursing ward personnel have a plan or assignment with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off and other tasks to perform. All personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation, lack of exit fire drills and the facility failed to perform at least 4 fire drills per shift during the past 12 months which is not in accordance with the requirements of the LSC 2000 section 19.7.1.2 and section 5.5.

Findings include:

1. Written documents about conducted fire drills for the facility were reviewed with the facility's Director of Institutional Services (employee #12) on 7/1/11 at 9:20 am and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

2. Written documents about conducted fire drills for the hospital were reviewed on 7/1/11 at 10:25 am with the facility's Director of Institutional Services (employee #12) and it was found that the facility failed to perform at least four fire drills annually for each shift. The facility has three shifts and provided evidence that only one fire drill was performed during the past twelve months for the 11:00 pm till 7:00 am shifts and only one fire drill was performed for the 3:00 pm till 11:00 pm shift. The facility failed to comply with this regulation due to the lack of at least four fire drills during the 11:00 pm till 7:00 am and 3:00 pm till 11:00 pm shifts.

3. Written evidence reviewed of fire drills on 7/1/11 at 10:30 am with the facility's Director of Institutional Services (employee #12) failed to provide evidence that the facility is performing fire exit drills for the proper protection of patients; drills for the purpose of relocating patients to an area of safety.

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that smoke detectors are available at all required areas, housekeeping closets, biohazardous trash closets, fire alarm documentation about sensitivity tests was not found and strobe lights are needed in public bathrooms as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm:
a. In the general storage area that measures 32 feet by 16 feet there is only one smoke detector and another one is needed.
b. In the general storage area where the refrigerator and coffee maker are located.
c. In the general storage area where there are three separate rooms.
d. In the financing department.
e. All housekeeping closets located throughout the hospital.
f. In the room used to place extra medical records at the ground floor.
g. In the Respiratory therapy department (found with two type E oxygen cylinders).
h. In the storage room of the Intensive Care Unit (a coffee maker and refrigerator were found).
i. In the machine room of the elevator (this elevator is used to bring up and take down the food tray cart from the ground floor).
j. In the biohazardous storage closet near the nursery hallway.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 7/1/11 at 10:05 am with the facility's Director of Institutional Services (employee #12), however no evidence was found of the following:
a. Smoke detector sensitivity tests and readings.

3. Patient's and visitor's public bathrooms (both male and female) were visited from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and provided evidence that they do not have strobe lights to alert deaf persons using these bathrooms in the event that the fire alarm is activated.

4. The smoke detector located in in the CT scan room was observed on 6/28/11 at 11:40 am within three feet of the air conditioner vent. Air blown in air conditioner vents can affect the effectiveness of the smoke detector to detect smoke in the event of a fire.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility is not performing visual inspections, sensing chamber tests or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 7/1/11 at 9:30 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response which includes the smoke detectors in the air conditioner system (twice a year).

c. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

d. Location of pull-down stations and tests (monthly).

e. Visible (strobe lights) and audible signal tests (monthly).

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that the automatic sprinkler system is continuously maintained in reliable operating condition and are inspected and tested periodically as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings include:

1. Review of documentation and observations of the sprinkler system on 7/1/11 from 9:30 am till 10:00 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and the following was determined:
a. No evidence was found of the control valve identification with a sign indicating the system or portion of the system it controls.
b. No evidence was found of the weekly valve inspection (hose valves, pressure-regulating valves and valves that isolate backflow prevention devices).
c. No evidence was found of the fire department connection inspection on a quarterly basis to verify visibility and accessibility, coupling and swivels not damaged and rotate smoothly.
d. No evidence was found of tests performed on the sprinkler system (such as weekly no-flow tests and annual flow condition test of the fire pump).

2. The sprinkler head in the Intensive Care Unit storage area was observed on 6/29/11 at 11:00 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) within two inches from the wall above the door. In order for this sprinkler head to be effective in this room it should be centrally located or the sprinkler head should be the type that sprays water in a particular direction (this room has a coffee maker and a refrigerator located at the back wall at the furthest point from the sprinkler head).

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that portable fire extinguisher are maintained related to updated inspections, are visible and accessible at all required areas as states in the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. During observations made of the hospital with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) from 6/28/11 through 6/30/11 from 9:00 am till 3:00 pm, the following was determined related to fire extinguishers:
a. Fire extinguishers located in the general storage area, in the pantry and in front of the I.V storage room all on the ground floor were found without the facility's monthly inspection for April and May of 2011.

2. Fire extinguishers were observed throughout the hospital from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and the following was found:
a. Two fire extinguishers were found in the OPD hallway mounted next to pull stations and which did not allow the pull stations to be easily distinguished.
b. The fire extinguisher located in the hallway near the emergency room was located behind a column and could not be seen from the other side of the column down the hallway.
c. The facility has fire hose cabinets located throughout the facility and they also have fire extinguishers in them (such as in Medicine II ward). However, the notification of these fire extinguishers in these fire hose cabinets is a flat sign that sticks on the wall and is not visible from different areas of the hallway.

Based on observations made during for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility has central air conditioner units with air handling systems in the corridor that uses return air to cool the facility and the system does not have dampers to prevent the re-circulation of smoke into the corridor in the event of a fire and is not in compliance with the Code requirements of NFPA-90-A and the 2000 edition of the Life Safety Code of the NFPA Section 9.2.

Findings include:

1. During the observational tour throughout the facility from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that the main corridors where patients receive treatment and services are used as a plenum. The air conditioner machine room doors were observed with louvres at the base of the doors which allows air movement. Air is blown into the corridor and returned into these air conditioner machine rooms to recirculate the cool air into the corridors. These air conditioner machine rooms were found with smoke detectors to automatically shut down the fan. However, no evidence was provided that the facility has smoke dampers in their air conditioner vent system to ensure that when smoke is detected by the smoke detectors and it turns off the air conditioner, smoke does not continue to travel through the vent system. The smoke dampers will ensure that smoke and toxic gases do not spread via the air conditioner ventilation system.

a. The janitor's room located near patient's room #110 was visited on 6/29/11 at 10:30 am
with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that this room also contains the air conditioner machinery used to return cool air to the corridors. The janitor's closet and the air conditioner machine return room can not share the same space especially due to the chemicals used to clean the hospital.

b. The air conditioner machine room located in front of the nursing station of the Medicine I ward was visited on 6/29/11 at 10:50 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that this room is used by personnel to leave personal items, to eat and has a garbage container. These items can not share space in this room dedicated to return air through the facility.

Based on observations during the survey for Life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, propane gas tanks do not have seismic shut off devices, oxygen storage, fire hose cabinets are painted in white, paint stored in a closet on the ground floor, facility is using mult-outlet adapter, uneven step at the emergency room, diesel storage #1 does not have a gauge to measure diesel level and the facility is not using fire rated garbage containers.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. In the CT scan room (a type H oxygen cylinder).
b. A type H oxygen cylinder was found in the pre-anesthesia area.
c. Two type E oxygen cylinders were found in the respiratory therapy department.
d. One type H oxygen cylinder in operating suite #3.

2. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) on 7/1/11 from 9:00 am till 3:00 pm and the following was determined:
a. No evidence was found of standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

3. The facility has two areas with propane gas tanks (a total of two tanks at each location) located at the back and side of the hospital as observed on 6/28/11 at 11:30 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) and provided evidence that they are not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required.

4. Some fire hose cabinets (such as the one at Medicine II ward) were found during the observational tour of the entire facility from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) painted white. The walls are painted a light color and the fire hose cabinet is not clearly distinguished from down the hall.

5. A small closet located in the hallway near the general storage area on the ground floor was visited on 6/28/11 at 9:30 am and was found with three gallons of paint. Products and materials that are flammable can not be stored in a closet that is not meant for this purpose.

6. The general storage area on the ground floor was visited on 6/28/11 at 9:40 am and was found with a regular receptacle that had an adapter which converted two outlets into six. The six outlet were used for a coffee maker, refrigerator and to charge I.V pump machines. Multi-outlet adapters are not recommended due to the potential for them to over heat.

7. During the observational tour of the emergency room on 6/28/11 at 2:00 pm with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) it was found that there are several steps before the door to enter the waiting room of the emergency room. The first of these steps was measured for the riser height and was found to be 10 inches (in height) and the risers of the other steps were all measured at 6 and a half inches in height from one riser to the other. According with NFPA 101 Life Safety Code Handbook from 2006 section 7.2.2.3.6 "Dimensional Uniformity", "The tolerance between the largest and the smallest riser or between the largest and smallest tread shall not exceed 3/8 of an inch.

8. The diesel storage tank for electrical generator #1 located in front of the emergency room was visited with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12) on 6/30/11 at 11:40 am and provided evidence that they use a large wooden ruler to measure the amount of diesel in this tank. The tank does not have a gauge to automatically measure the amount of diesel left in the tank. The method of placing the ruler into the tank increases the chance of impurities entering the tank, miscalculations of the amount of diesel left in the tank and in the event of an emergency and the generators are running for a few days, the ruler can not be used to measure the diesel left in the tank. An automatic measuring gauge is useful and may also emit a signal when the tank reaches a critically low level which allows time to fill the tank before the tank is empty.

9. Regular garbage containers located at offices and work areas were verified from 6/28/11 through 7/1/11 from 9:00 am till 3:00 pm and provided evidence that they are not made of fire rated material and tested as such. Rubber or plastic garbage containers that are not made of fire rated material can emit toxic fumes if they catch on fire.

Based on the review of written documents during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to ensure that personnel perform the monthly 30 minute load test of the electrical generators and monthly transfer switch tests as required by the NFPA 99, section 3.4.4.1.

Findings include:

1. The facility lacks written evidence that the electrical generators are tested under load condition for 30 minutes on a monthly basis as reviewed on 7/1/11 at 10:00 am with the facility's Physical Plant Manager (employee #18). The facility has two large electrical generators however documentation reviewed could not support that the generators ran with load for 30 minutes.

2. The facility lacks written evidence that the electrical generators' transfer switches are tested on a monthly basis as reviewed on 7/1/11 at 10:15 am with the facility's Physical Plant Manager (employee #18).

3. During observations of the generator used to power the pumps of the sprinkler system on 6/30/11 at 9:00 am with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was found that the battery terminal had what appeared to be corrosion (a built up white crust) and no evidence was found of the periodic maintenance performed on these batteries.

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Physical Plant Manager (employee #18) and Director of Institutional Services (employee #12), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 7/1/11 at 11:00 am about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.