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Based on observation, it was determined that the facility failed to ensure staff have direct visual supervision of patient sleeping rooms from a constantly attended location or that the rooms are provided with an automatic smoke detection system.

Findings include:

1. On 2/8/17 at 11:10 AM in the presence of Staff #1, Patient Sleeping Room #4466 was not located with direct visual supervision from a constantly attended location or provided with automatic smoke detection.

2. On 2/8/17 at 11:25 AM in the presence of Staff #1, Patient Sleeping Room #3439 was not located with direct visual supervision from a constantly attended location or provided with automatic smoke detection.

3. On 2/8/17 at 11:30 AM in the presence of Staff #1, Patient Sleeping Room #3420 was not located with direct visual supervision from a constantly attended location or provided with automatic smoke detection.

Based on document review and staff interview on 2/10/17, it was determined that the facility failed to ensure the fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire.

Findings include:

Definition:

Automatic, 2012 Life Safety Code 101:3.3.30, Capable of performing a function without the necessity of human intervention.

Reference #1: 2012 Life Safety Code 101:9.6.4.1, Where required by another section of this code, emergency forces notification shall be arranged to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.

Reference#2: 2012 Life Safety Code 101:9.6.4.2 Where fire department notification is required by another section of this code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm Signaling Code.

1) Auxiliary fire alarm system
2) Central station fire alarm system
3) Proprietary supervising station fire alarm system
4) Remote supervising station fire alarm system

1. During a review of fire alarm testing documents dated 6/16/16, the monitoring company was identified as "Self Monitored."

a. During interview, Staff #1 confirmed the fire alarm signals are not automatically transmitted.

2. Staff #1 confirmed, upon activation of the fire alarm system, the hospital operator must physically call the dispatch center to make notification of the alarm.

Based on observation, it was determined that the facility failed to ensure every patient sleeping room has an outside window or outside door.

Finding include:

1. On 2/8/17 at 2:08 PM in the presence of Staff #1, the following patient sleeping rooms lacked either a window or a door to the outside:

a. Room #2209

b. Room #2213

c. Room #2223

d. Room #2224

Based on staff interview, it was determined that the facility failed to ensure compliance with chapter 6 of the the 2012 edition of the National Fire Protection Association's Health Care Facilities Code 99.

Findings include:

Reference: National Fire Protection Association's Health Care Facilities Code 99:6.3.2.2.11.1 One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.

1. During interview, Staff #1 confirmed no battery-powered emergency lighting was provided in any of the five (5) Operating Rooms.