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Based on observation and interview, the facility failed to ensure that all means of egress were free from obstruction to facilitate evacuation during fire or other emergency. This was evidenced by unattended carts and chairs left in the corridors blocking egress. This could result in delayed evacuation and possible harm to residents and staff in the event of a fire or other emergency.. This affected 2 of 6 sections of the main building.

NFPA 101, Life Safety Code 2012 Edition.

19.2.3.4 Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2) Where corridor width is at least 6 ft. (1830 mm), non-continuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c) The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment


Findings:

During a tour of the facility with the Plant Operation Manager (POM) and Vice President for Campus Planning (VPCP) from 6/6/17 to 6/8/17, the hallways and corridors used as path of escape from the building were observed.

1. On 6/6/17 at 3:01 p.m., there were boxes of supplies, unattended carts with supplies on them located in the egress aisle leading to the kitchen exit door. The POM confirmed the supplies were stored in the egress aisle that led to the kitchen exit door to the outside.
2. On 6/7/17 at 3:01 p.m., there were three chairs in the corridor outside the North Rotunda Intensive Care Unit.

Based on observation and interview, the facility failed to ensure keys were provided to all staff to open a locked egress door in the event of an emergency, and failed to ensure locking of doors were allowed based on patient clinical and security needs to ensure their safety. Only a limited number of nursing staff had access to a key to open one locked egress door in the ICU patient sleeping area. The Chemical Dependency Unit smoke barrier doors were locked without clinical or security reasons. This affected 2 of 7 sections of the Main Building and could result in delay in evacuation during fire or other emergencies. The Intensive Care unit was a locked unit. There were no smoke detection system and fire sprinklers in the patient sleeping area. The Chemical Dependency unit was partially locked and had no fire sprinklers. There were battery powered, single station smoke alarms in sleeping rooms not meeting the smoke detection system requirement. This could result in delayed notification of fire and delayed evacuation and possible harm to patients and staff. This affected 2 of 7 sections of the Main Building.


National Fire Prevention Association 101, Life Safety Code, 2000 Edition

19.2.2.2.5.2* Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:
(1) Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
(2) A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
(3)*The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.1.
(4) The locks are electrical locks that fail safely so as to release upon loss of power to the device.
(5) The locks release by independent activation of each of the following:
(a) Activation of the smoke detection system required by 19.2.2.2.5.2(2)
(b) Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3)


Findings:

During a tour of the facility with the Plant Operation Manager(POM) and Vice President of Campus Planning (VPCP) from 6/6/17 to 6/8/17, the egress doors and corridors were observed.

Intensive Care Unit (ICU)
1. On 6/7/17 at 8:38 a.m., during facility tour, 2 mental health workers (MHW) were asked if they had keys to unlock the locked exit door by Room 228. The MHW Staff stated they did not have keys to open the exit door. Not all staff had keys to open the locked exit doors.
At 10:22 a.m., the ICU was observed as a locked unit. The East and West Wings sleeping compartments of the ICU were not equipped with smoke detection system and no automatic fire sprinkler system.

2. On 6/8/17 at 10:35 a.m., the North Rotunda Chemical Dependency Unit (CDU) was observed without a complete smoke detection system in the corridors. The sleeping area was not protected with fire sprinklers. On 6/8/17 at 8:30 a.m., during interview with the Vice President of Campus Planning (VPCP), he stated the Chemical Dependency Unit was an open unit and not a locked unit. He said the Facility locked the exit/entrance smoke barrier door by Administrative hallway but the facility staff had keys to open the locked door. The door would not automatically open when the fire alarm was activated. The VPCP stated the locked exit/entrance smoke barrier door was locked due to people using the egress corridor to access other parts of the building. He said there was no clinical or security needs for patient safety to lock the doors.

Based on observation, the facility failed to maintain their manual fire alarm pull station in accordance with NFPA 101, 2012 Edition. This was evidenced by a manual pull station installed 48 inches above the floor, and could not be seen from the east wing and the west wing of the Intensive Care Unit (ICU). This could delay the activation of the fire alarm in a partially sprinklered unit and cause possible harm to patients and staff in the event of a fire. This affected 2 of 3 smoke compartments in the ICU.

National Fire Prevention Alarm (NFPA) 101 Life Safety Code, 2012 Edition

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an
approved existing installation, which shall be permitted to be continued in use.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

19.3.4.2.2 Manual fire alarm boxes in patient sleeping areas shall not be required at exits if located at all nurses ' control stations or other continuously attended staff location, provided that both of the following criteria are met:
(1) Such manual fire alarm boxes are visible and continuously accessible.
(2) Travel distances required by 9.6.2.5 are not exceeded.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition

17.14.4 The operable part of each manual fire alarm box shall be not less than 42 in. (1.07 m) and not more than 48 in. (1.22 m) above floor level.

17.14.5 Manual fire alarm boxes shall be installed so that they are conspicuous, unobstructed, and accessible.

17.14.6 Manual fire alarm boxes shall be located within 60 in. (1.52 m) of the exit doorway opening at each exit on each floor.

Findings:

During a tour of the facility with the Plant Operations Manager (POM) on 6/6/17 to 6/8/17, the manual pull station in the ICU was observed. There was one manual pull station for the three smoke compartments and it was located in the Nursing Station.

1. On 6/7/17 at 2:40 p.m., the manual pull box was observed on the east wall of the Nursing Station. The manual pull box was not visible from the patient sleeping areas of the east and west wing of the ICU. The manual pull station was not visible from resident room 228 and 233.

2. At 2:45 p.m., when the Mental Health Worker (MHW11) was asked where the manual pull station was located in the ICU, the MHW 11 looked around attempting to locate the manual pull station, and then sstaff stated they were not sure where it was located.

3. On 6/8/17 at 9:49 a.m., in the ICU, the manual pull station mounted on the east wall and above the desk at the Nurses Station measured approximately 67 inches from the floor to the operable handle, as measured by the POM.

Based on observation, record review and interview, the facility failed to ensure that the fire alarm notification system was maintained in reliable operating condition. This was evidenced by not hearing the fire alarm in all areas above the ambient sound of the area, and by a fire alarm chime box that failed when tested. This affected 2 of 6 sections of the Main Buildings. This could result in delay in notification of fire to staff and visitors and patients.

NFPA 101 Life Safety Code, 2012 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.3.7 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level that exits under normal conditions of occupancy.
19.3.4.2.2 Manual fire alarm boxes in patient sleeping areas shall not be required at exits if located at all nurses ' control stations or other continuously attended staff location, provided that both of the following criteria are met:
(1) Such manual fire alarm boxes are visible and continuously accessible

Findings:

During the testing of the fire alarm system with the Plant Operation Manager (POM) and the Vice President of Campus Planning (VPCP) on 6/6/17 to 6/8/17, the strobes and audio alarm boxes were tested and observed.

1. On 6/6/17 at 10:20 a.m., the fire drill records were reviewed. The fire drill conducted on 8/16 indicated the staff in the outpatient area could not hear the fire alarm.

2. On 6/7/17, at 9:39 a.m., the fire alarm chime box located in the corridor outside the Dining Room of Rotunda South failed to emit a sound when the pull station was activated.

3. At 9:43 a.m., when the smoke detector and manual pull station were tested, the alarm could not be heard above the ambient sound in the Dining room/Cafeteria. The Cafeteria and Kitchen areas were not sprinklered. The POM confirmed the alarm could not be heard above the ambient sound in the dining room/cafeteria under normal use.

4. At 9:55 a.m., the manual pull station by outpatient waiting area was blocked from ready access by chairs. A person was seated in one of the chairs next to the manual pull box, blocking the activation of the manual pull box during fire alarm testing.

5. At 10:04 a.m., the smoke detector and manual pull box were tested, and the alarm could not be heard above the ambient sound in the outpatient nurses office. The door to the Nurses office was closed. The Facility Nurse in the room at the time stated that when the door was closed, the staff could not hear the fire alarms.

Based on observation, interview and record review, the facility failed to ensure that fire watch rounds were conducted to ensure fire safety of the occupants. The fire watch was observed not inspecting all areas and rooms to ensure fire safety, and the fire watch was not trained on fire watch procedures. This could result in delay in the facility's response to a fire causing injury to patients, staff and visitors. This affected all areas where the fire watch was assigned.

National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 Edition

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.1.1.3.2 Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building

Findings:

During a tour of the facility with Plant Operation Manager (POM) and Vice President of Campus Planning (VPCP) from 6/6/17 to 6/8/17, the Intensive Care Unit(ICU) and East Wing 2 (EW2) were observed while a fire watch round was being conducted.

1. On 6/7/2017 at 7:10 p.m., it was determined that the facility was not in compliance with the smoke detection system requirement to maintain fire safety. As an interim measure to protect their patients from fire, the CEO stated the security guards will do the fire watch rounds in the areas identified as non-compliant with the smoke detection system requirement. A fire watch was initiated by the facility when it was determined they were not in compliance with the requirement to have smoke detection system in the corridors.

2. On 6/8/17 at 9:46 a.m. the security guard was observed conducting the fire watch rounds in the East and West wing of the ICU. He was observed not going into patient rooms, and locked rooms off the corridors to inspect for a fire or fire hazard.
At 11:45 a.m. the fire watch log was requested. The fire watch log dated 6/7/17 to 6/8/17 indicated that no fire watch rounds were made between 6:30 a.m. to 12 noon on 6/8/17 for the North Rotunda.

3. At 12:15 p.m., a review of the facility fire watch policy dated 9/15 indicated the following: A trained individual assigned to an area for the purpose of protecting the occupants from fire or similar emergencies.
(g) Fire-watch personnel shall be on constant patrol for signs of fire or other unsafe life safety practices, keep a log of entries consisting of the date, time, area observed, observers initials and be assigned no more than 1 floor in affected areas of multistory buildings.
(h) Fire-watch personnel shall be relieved by other qualified standbys as needed for breaks, lunch, etc.
(j) Fire-watch personnel shall be provided with master key and/ or access cards to all areas under the fire watch.

4. At 3 p.m., the VPCP stated the security guard competency file does not address the process of doing a fire watch going and into rooms, opening bathrooms etc. The VPCP stated they do not have a procedure to describe what the expectation is and what to do when conducting a fire watch and the security guard was given the fire watch documents to fill out and does a fire watch rounds with no other instruction and training.

Based on observation, document review and interview, the facility failed to provide a complete smoke detection system in accordance with NFPA 101, 2012 Edition, and failed to maintain their existing smoke alarms to protect their patients from fire. There was no smoke detection system in the corridors of the Intensive Care Unit (ICU), East Wing 2 (EW2) and the North Rotunda. These areas had no automatic fire sprinkler systems in the patient sleeping areas. These affected 71 patients, staff and visitors located in 2 of 3 smoke compartments of the ICU, 3 of 3 smoke compartments in EW2 and the chemical dependency recovery unit. This could result in delay in notification of fire to the fire authorities and cause injury from smoke inhalation and burns.

National Fire Prevention Association (NFPA) 101, Life Safety Code 2012 Edition
19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

19.2.2.2.5.2* Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:
(1) Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
(2) A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
(3)*The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.1.
(4) The locks are electrical locks that fail safely so as to release upon loss of power to the
device.
(5) The locks release by independent activation of each of the following:
(a) Activation of the smoke detection system required by 19.2.2.2.5.2(2)
b) Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3)


19.3.4.5 Detection.
19.3.4.5.1 Corridors. An approved automatic smoke detection system in accordance with Section 9.6 shall be installed in all corridors of limited care facilities, unless otherwise permitted by one of the following:
(1) Where each patient sleeping room is protected by an approved smoke detection system, and a smoke detector is provided at smoke barriers and horizontal exits in accordance with Section 9.6, the corridor smoke detection system shall not be required on the patient sleeping room floors.
(2) Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7 shall be permitted.

NFPA 72 , National Fire Alarm and Signaling
14.2.1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this Code and conform to the shall satisfy the requirements of this Code and equipment manufacturer's published instructions.

Findings:

During a tour of the facility with the Plant Operation Manager(POM) and Vice President of Campus Planning(VPCP) from 6/6/17 to 6/8/17, the smoke detectors and smoke alarms in patient rooms and corridors were observed and maintenance records were reviewed. The East Wing 2(EW2), Intensive Care Unit (ICU) and the North Rotunda (NR) were not sprinklered in the patient sleeping areas, and were not equipped with smoke detection system in the corridors. The ICU was a locked unit.

Main Building:

1. On 6/6/17 at 10:15 a.m., the maintenance log was reviewed and indicated the battery operated smoke alarms in the patient sleeping rooms of the North Rotunda and the East Wing 2 were inspected and tested quarterly, and not weekly. The smoke alarms were inspected and tested on 6/17, 3/17, 12/16 and 9/16 for 17 smoke alarms in the East Wing 2, and 9 smoke alarms in the North Rotunda. At 10:16 a.m., during an interview with the Plant Operations Manager, he stated they tested the smoke alarms quarterly because they were unable to obtain manufacturer's maintenance instructions for those types of smoke alarms.

2. At 10:30 a.m., during a tour of the facility, the Intensive Care East and West units were observed. There was no smoke detection system observed in the corridors of the Intensive Care unit East and West wings. There were no fire sprinklers in the patient sleeping areas and no smoke detection system in the patient sleeping rooms. This area was a locked unit. The length of the corridor was approximately 80 feet.

3. On 6/7/17 at 9:25 a.m., in the North Rotunda (Chemical Dependency Recovery Unit) of the Main Building, the battery operated smoke alarm in Room 132 failed to activate when tested by the POM. At 9:29 a.m., the battery operated smoke alarm in Room 150 failed to activate when tested by POM.

4. At 9:29 a.m., during an interview with the POM, he stated he was unsure of who the manufacturer was and the age of the battery-powered smoke alarms or the installation dates, and could not determine the information needed because he was unable to remove any of the smoke alarms. The smoke alarms were screwed into the walls of the patient rooms.

5. At 9:30 a.m., in the North Rotunda, chemical dependency unit, there was no smoke detection system observed in the corridors. There were no smoke detection devices at the nurse station and locked rooms off the corridor. This unit was not sprinklered in the patient area corridors and the sleeping rooms.

6. At 12:35 p.m., the gift shop next to the main lobby was not equipped with a smoke detection device. The gift shop was approximately 276 square feet. The gift shop had combustible items for sale and stored boxes of supplies on a top shelf.

7. At 12:40 p.m., in the East Wing 2, the cover for the hard-wired smoke detector by Room 526 was loose from the smoke detector base.

8. At 2:30 p.m., the nurse's station and the corridors on the 2nd floor of the non-sprinklered East Wing 2 were not equipped with a smoke detection system.

9. At 2:39 p.m., in East Wing 2, the open receptionist area with public/patient seating in the corridor was not sprinklered, and was not equipped with a smoke detection system.

Based on observation, the facility failed to maintain their automatic sprinkler system in reliable operating condition. This was evidenced by incomplete documentation of maintenance, inspection and testing of the automatic fire sprinkler system. This affected 3 of 3 floors of the Child & Adolescent Program (CAP) building, and 3 of 6 sections of the main building. This could result in reduced effectiveness of the sprinkler system and cause injury to residents from fire.

National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 Edition

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 2011 Edition

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer


5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested.

13.3.2.1 All valves shall be inspected weekly.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification


13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.3.3.2* Post indicator valves shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve.

13.3.3.3 Post indicator and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming.

Findings:

During a tour of the facility with the Plant Operation Manager from 6/6/17 to 6/8/17, the sprinkler system was observed and maintenance record reviewed.

1. On 6/7/17 in the Main and CAP Buildings, at 9:30 a.m., the automatic sprinkler maintenance record indicated sprinkler system was tested and inspected quarterly. The records failed to indicate the sprinkler system components were inspected monthly. During interview with the Plant Operation Manager, he stated he was unaware of the new code requirements for the sprinkler system.

2. On 6/7/17 in Main Building, at 10:39 a.m., there were corroded sprinkler heads in the day room of the Intensive Care Unit.

3. On 6/8/17 in the CAP Building, at 12:07 p.m., the post indicating valve located on the sidewalk by the CAP building failed to send an alarm to the fire alarm panel when tested by Plant Operations Manager.

4. At 9:07 a.m., there was red paint on sprinkler head in the electrical room on the 3rd floor.

5. At 9:10 a.m., there were corroded sprinkler heads on 3rd floor staircase landing.

Based on observation, the facility failed to ensure that the fire extinguishers were accessible. This was evidenced by trash can obstructing access to a fire extinguisher. This could cuase a delay in extinguishing a fire and cause harm to patients and staff, in the event of a fire. This affected the Electroconvulsive therapy (ECT) room.

National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, in- stalled, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition

6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in
the event of fire.

6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During the facility tour with the Plant Operation Manager (POM) from 6/6/17 to 6/8/17, the fire extinguishers were observed.

On 6/8/17 at 12:29 p.m., a trash can was observed blocking access to the fire extinguisher in the Main Building ECT room. The Plant Operation Manager confirmed the finding.

Based on record review and interview, the facility failed to ensure that their staff was familiar with their fire safety plan, and failed to conduct their fire drills according to their plan. This was evidenced by records showing that fire drills were conducted at similar times during the overnight and evening shifts, by staff not familiar with their fire response procedures, and by incomplete fire drill records for participating departments/unit. The failure to conduct the fire drills at un-expected times and varying conditions could result in staff not being familiar with how to respond to a fire during meal time, bedtime, shift change and other conditions that arise during a shift. This affected 6 of 6 sections of the Main Building and 3 of 3 floors of the Child & Adolescent Program building (CAP). This could result in a delay in staff response, in the event of a fire.

NFPA 101 Life Safety Code, 2012 Edition

4.7.3 Orderly Evacuation. When conducting drills, emphasis shall be placed on orderly evacuation rather than on speed.

4.7.4* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

4.8.2.1* Emergency plans shall include the following:
(1) Procedures for reporting of emergencies
(2) Occupant and staff response to emergencies
(3)*Evacuation procedures appropriate to the building, its occupancy, emergencies, and hazards (see Section 4.3)
(4) Appropriateness of the use of elevators
(5) Design and conduct of fire drills
(6) Type and coverage of building fire protection systems
(7) Other items required by the authority having jurisdiction

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures devices.

19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective re- response of health care personnel.

19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon
Staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

Findings:

During document review with the Plant Operation Manager and Vice President of Campus Planning from 6/6/17 to 6/8/17, the fire drills records were reviewed. There was a space in the fire drill report where each department or unit could provide overall response to the fire/drill for comments, suggestion, recommendation improvements.

1. The Facility's fire safety plan and emergency Response plan dated 2/17 was reviewed and indicated the following: Unannounced fire drills will be held quarterly for each shift ... (3) Fire drills will be scheduled to take place on each shift at varying times of shift, days of the week and month throughout the year so as to provide opportunity to evaluate staff actions at varying times.
Alarm:
Activate the nearest fire pull station and yell "Code Red to alert other staff. Dial "50" on any hospital phone- this activates the overhead paging system... Then dial 9-911 to give the 911 dispatcher the specific location type and the extent of the fire.

On 6/6/17 in the Main Building and CAP Building

2. The Vice President of Campus Planning (VPCP) during an interview at 10:10 a.m stated he does not oversee how the fire drills were conducted.
The VPCP job description dated 7/21/14 was reviewed and indicated the following: Key accountabilities/responsibilities: (4) Ensures organizational compliance with legislation and regulations as they impact assigned area.

2. The Plant Operation Manager stated at 10:20 a.m., that he and his staff conducted the fire drills monthly for the hospital. He stated the fire drill scenarios started in one unit and other unit participates on the basis of that scenario. The employees working hours were: Morning Shift was 7 a.m., to 3 p.m., Afternoon shift was 3:00 p.m., to 11 p.m., and overnight shift was 11 p.m., to 7 a.m.
Upon review of the fire drill records, the following information and comments was read. There was no verification of 911 being notified, no simulated relocation of patients and no documentation of evaluation of the drill for the participating departments. The Fire drills records dated 12/16 for East Wing 2 indicated no simulated call or confirmation of 911 was done. On the 12/16 fire drill, East Wing 1 staff did not respond to drill due to shortage in staffing. On 2/28/17 East Wing 2 staff did not clear the corridor due to "no staff available and drill was over quickly". On 4/12/17, the CAP building participating form was blank. On 1/17 business office participating form was blank. On 8/25/16, the kitchen participating form was blank. On 8/26/16, the outpatient area could not hear the alarms. On 5/19/16 , the East Wing 2 participating form was blank.

3. At 10:20 a.m., the Plant Operation Manager acknowledged that all the unit that participated in the fire drills did not complete or filled out correctly the fire drill forms such as, writing the evaluation of the fire drills and notification of 911.

4. At 10:40 a.m. the four overnight fire drills conducted within the last 12 months indicated the drill was conducted within 1 hour time period. All four afternoon fire drills were conducted within 1/2 hour time period for the last 12 months. The fire drills were not conducted at varying time and conditions.

5. Dietary Aide 62 was interviewed on 6/6/17 at 3:07 p.m. of her role if there was a fire. She stated in the event of a fire she would pull the suppression system and call 911. Dietary Aide 62 stated that was all she would do. Dietary Aide 62 was unfamiliar with the requirements of containment of the fire by closing off doors and evacuating the area.

6. Dietary Aide 63 was interviewed on 6/6/17 at 3:14 p.m. She stated she was unfamiliar with the different type fire extinguisher in the Kitchen and their usage.
They have ABC and K type fire extinguishers in the Kitchen.

On 6/7/17 in Main Building and CAP Building

7. During interview with the Mental Health Worker 64 at 8:38 a.m., she stated she would make an overhead paging call by dialing 50, and let them know the location of the fire and she would get the fire extinguisher. She stated she would aim all over the fire and outside the fire. The State Authority Having Jurisdiction stated the proper way to extinguish a fire using a fire extinguisher was to aim the nozzle at the base of the fire and not all over the fire as stated by Mental health Worker # 64.

8. During interview with Licensed Nurse 67 at 8:40 a.m., he was not familiar with evacuation of a smoke compartment or evacuate to a safe area within the building.
The Facility fire safety plan indicated all occupants were to evacuate from the immediate fire area first; then to the next smoke/fire compartment or designated safe area.

9. During interview with Housekeeping Staff 68 at 8:43 a.m., she stated she would call code 950 if she discovers a fire and she would use the acronym R.A.C.E. When asked to explain what actions are taken for each letter of R.A.C.E, Housekeeper Staff 68 failed to explain facility's fire procedure actions for each letter of R.A.C.E.
Facility fire/emergency procedures indicated to activate the nearest fire pull station and yell "Code Red to alert other staff. Dial "50" on any hospital phone- this activates the overhead paging system

10. During interview with the Private Box Exchange Operator (PBXO) 70 at 10:45 a.m., she stated she is a volunteer and had no training on any of the facility fire/emergency procedures.

11. During interview with PBXO 69 at 10:46 a.m., he stated he would announce on overhead paging the location of the fire from the information passed to him from the staff, and respond to calls from the monitoring company and the fire department. He stated he would not call the fire department because they would call him.

Their Facility fire/ emergency procedures indicated staff to dial 9-911 to give the 911 dispatcher the specific location type and extent of the fire.

Based on observation, the facility failed to maintain ready access to their medical gas master alarm. This was evidenced by a chair and equipment blocking ready access to the piped medical gas master alarm. This could result in staff unaware of mal-functioning medical piped-in gas system and result in possible harm to patients in the event of a medical emergency requiring medical gas. This affected 1 of 6 sections of main building.


NFPA 101 Life Safety Code 2012 Edition
4.6.1.3 Where it is evident that a reasonable degree of safety is provided, any requirement shall be permitted to be modified, if in the judgement of the authority having jurisdiction, its application would be hazardous under normal occupancy conditions.

Findings:

During tour of the facility with the Plant Operation Manager from 6/6/17 to 6/8/17, the piped-in medical gas alarm panel was observed.

On 6/8/17 at 12:16 p.m., there was a chair and vital sign machine stored in front of the piped medical gas master alarm panel in the Main Building.

Based on interview and record review, the facility failed to ensure the generator remote alarm annunciator was located in an area where it was monitored continuously. This was evidenced by the generator remote alarm annunciator located in the maintenance shop that was not continuously monitored by operating personnel. This could result in delay notification of a generator failure and possible harm to patients and staffs in the event of a power outage. This affected 6 of 6 sections of the main building and 3 of 3 floors of the Child and Adolescent Program building (CAP).

Findings;


During tour of the facility with Plant Operation Manager from 6/6/17 to 6/8/17, the generator remote alarm annunciator was observed .

On 6/8/17 in CAP Building, at 12:10 p.m., the generator remote alarm annunciator located in the maintenance repair shop was observed. During interview with the Plant Operation Manager, he stated staff were in and out of the shop daily, and maintenance staff work schedule hours were 7:00 a.m., to 10:00 p.m. There were no staff monitoring the remote alarm annunciator from 10:00 p.m., to 7:00 a.m.

Based on interview and record review, the facility failed to maintain their emergency generator in a reliable operating condition. This was evidenced by failure to provide documents to show complete maintenance and service of 2 of 2 diesel generators. This could result in generator failure and possible harm to patients and staff in the event of a power outage. This affected 6 of 6 sections of the Main Building and 3 of 3 floors of the Child and Adolescent Program building (CAP).

NFPA 99 Health Care Facilities Code, 2012 Edition
6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power System Chapter 8.



NFPA 110, Standard for Emergency and Standby Power System, 2010 Edition.

8.3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
8.3.2 A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
8.3.5* Transfer switches shall be subjected to a maintenance and testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

8.4.6.1 The monthly test of a transfer switch shall consist of electrically operating the transfer
switch from the standard position to the alternate position and then a return to the standard
position.


Findings:

During a tour of the facility with Plant Operation Manager and Vice President of Campus Planning from 6/6/17 to 6/8/17, the generator maintenance record was reviewed.


On 6/8/17 in Main and CAP Building

At 9:38 a.m., the maintenance record for the diesel generators failed to indicate a monthly battery electrolyte specific gravity test and maintenance of the automatic transfer switches was conducted. During interview with Maintenance Mechanic 74, he stated he does inspect the automatic transfer switch weekly, and tested it monthly, but does not document his inspections.

Based on observation and interview, facility failed to maintain electrical safety. This was evidenced by medical equipment plugged into a non-compliant power-strip in a patient care vicinity. This affected Electroconvulsive therapy (ECT) room. This could potentially cause a fire and harm to patients and staff, in the event of a fire.

Findings:

During tour of the facility with the Plant Operations Manager from 6/6/17 to 6/8/17, the patient care electrical equipment was observed.

On 6/8/17 in the Main Building, at 2:46 p.m., the ECT and vital sign machines were plugged into one United Laboratories (UL) 1363 multi-plug power strip, and not into special purpose UL 1363A or UL 60601-1 in the ECT room. During interview with the Plant Operations Manager, he stated he was unaware of the different type of power strips used for patient care equipment in the patient care vicinity. Plant Operation Manager confirmed the power strip was a UL 1363.