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Based on observation, the critical access hospital failed to ensure that exit access was arranged so that exits are readily accessible at all times in accordance with section 7.1. by failing to provide a hard-packed travel surface from the building exit to the public way.

Failure to provide a hard-packed travel surface from the building exit to the public way risks inability of hospital personnel to quickly evacuate patients on gurneys or in wheelchairs or otherwise requiring assistance.

Findings include:

During a tour of the critical access hospital on 08/07/2012, it was observed that two exterior doors were signed as exits leaving the surgery recovery area and the surgery suite. Both doors exited into loose-packed large decorative stones or grass that was not level. It was not possible to exit from these doors and reach the public way without traveling over uneven turf or loose stone.

Based on record review, the critical access hospital failed to establish a complete and clear plan for emergency evacuation procedures.

Failure to establish a complete and clear plan for emergency evacuation procedures risks confusion among hospital personnel regarding the appropriate actions to take in the event of the necessity for an evacuation.

Findings include:

Review of the critical access hospital policy "Evacuation" found in the emergency management policies (no policy number or effective/reviewed dates) found that the policy did not include any description or location of fire and smoke barriers and the appropriate times to relocate from one smoke compartment in the hospital to another.

Based on maintenance record review and interview with hospital staff, the hospital failed to test smoke detectors for sensitivity [reference National Fire Protection Association (NFPA) 72 7-3.2.1].

Failure to ensure smoke detectors are tested for sensitivity in accordance with NFPA 72 requirements risks building occupant life safety due to potentially inadequate smoke detection, subsequent occupant notification and evacuation during a fire event.

Findings:

Review on 08/08/2012 of hospital maintenance records for annual servicing of the fire alarm system for 2011 and 2012 did not show evidence of smoke detector sensitivity testing one year after inital installation and testing of the system.

Maintenance staff confirmed during an interview that the smoke detectors were on a zone system, and that smoke detector sensitivity testing had not been performed in accordance with NFPA 72.

Based on observation and record review, the critical access hospital failed to maintain records and signage documenting the installation requirements and hydraulic specifications for the approved automatic sprinkler system (AASS).

Failure to maintain records and signage documenting the installation requirements and hydraulic specifications for the AASS risks improper installation and management of the AASS.

Findings include:

During a tour of the critical access hospital on 08/07/2012, it was observed that no hydraulic signage was present at the main AASS standpipes. It was not possible to determine whether the seismic bracing observed at the standpipes was acceptable because installation drawings were not available.

Based on observation, the critical access hospital failed to ensure that exit access was arranged so that exits are readily accessible at all times in accordance with section 7.1. by failing to provide a hard-packed travel surface from the building exit to the public way.

Failure to provide a hard-packed travel surface from the building exit to the public way risks inability of hospital personnel to quickly evacuate patients on gurneys or in wheelchairs or otherwise requiring assistance.

Findings include:

During a tour of the critical access hospital on 08/07/2012, it was observed that two exterior doors were signed as exits leaving the surgery recovery area and the surgery suite. Both doors exited into loose-packed large decorative stones or grass that was not level. It was not possible to exit from these doors and reach the public way without traveling over uneven turf or loose stone.

Based on record review, the critical access hospital failed to establish a complete and clear plan for emergency evacuation procedures.

Failure to establish a complete and clear plan for emergency evacuation procedures risks confusion among hospital personnel regarding the appropriate actions to take in the event of the necessity for an evacuation.

Findings include:

Review of the critical access hospital policy "Evacuation" found in the emergency management policies (no policy number or effective/reviewed dates) found that the policy did not include any description or location of fire and smoke barriers and the appropriate times to relocate from one smoke compartment in the hospital to another.

Based on maintenance record review and interview with hospital staff, the hospital failed to test smoke detectors for sensitivity [reference National Fire Protection Association (NFPA) 72 7-3.2.1].

Failure to ensure smoke detectors are tested for sensitivity in accordance with NFPA 72 requirements risks building occupant life safety due to potentially inadequate smoke detection, subsequent occupant notification and evacuation during a fire event.

Findings:

Review on 08/08/2012 of hospital maintenance records for annual servicing of the fire alarm system for 2011 and 2012 did not show evidence of smoke detector sensitivity testing one year after inital installation and testing of the system.

Maintenance staff confirmed during an interview that the smoke detectors were on a zone system, and that smoke detector sensitivity testing had not been performed in accordance with NFPA 72.

Based on observation and record review, the critical access hospital failed to maintain records and signage documenting the installation requirements and hydraulic specifications for the approved automatic sprinkler system (AASS).

Failure to maintain records and signage documenting the installation requirements and hydraulic specifications for the AASS risks improper installation and management of the AASS.

Findings include:

During a tour of the critical access hospital on 08/07/2012, it was observed that no hydraulic signage was present at the main AASS standpipes. It was not possible to determine whether the seismic bracing observed at the standpipes was acceptable because installation drawings were not available.