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Based on observation and interview, the facility failed to ensure doors protecting corridor openings resisted the passage of smoke. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.

Findings:

On 04/21/14 at 1:50 P.M. a tour was conducted with Staff A1 of the third floor.

1. Observation of the ostomy nurse office revealed a pencil size hole above the door handle which would allow the passage of smoke from the room out into the hall.

On 04/21/14 at 1:50 P.M. in an interview, Staff A1 confirmed the observation.

2. Observation of the door on the staff only bathroom, located near patient room B353 also revealed a pencil sized hole above the handle that would allow the passage of smoke from the room into the hall.

Based on observation and interview, the facility failed to maintain the stated fire and/or smoke rating to each of its fire and/or smoke barriers. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.

Findings:

On 04/21/14 at 1:50 P.M. a tour was conducted with Staff A1 of the third floor, which contained three patient sleeping areas.

1. At 2:40 P.M. observation of the 30 minute smoke barrier above the drop down ceiling of the south wall in the room adjacent to patient room B351 revealed a single one inch open conduit.

On 04/21/14 at 2:40 P.M. in an interview, Staff A1 confirmed the observation.

2. At 3:02 P.M. observation of the 30 minute smoke barrier above the drop down ceiling near nursing station 305 revealed a two inch unsealed conduit with yellow wires passing through.

On 04/21/14 at 3:02 P.M. in an interview, Staff A1 confirmed the observation.

3. At 3:50 P.M. observation above the drop down ceiling of the two hour rated wall between room B350G and a storage space revealed an annular space around a one inch metal conduit.

On 04/21/14 at 3:50 P.M. in an interview, Staff A1 confirmed the observation.

On 04/22/14 at 8:45 A.M. a tour of the second floor was begun with Staff A1.

4. On 04/22/14 at 8:48 A.M. observation above the drop down ceiling of the 30 minute barrier between emergency department treatment area 9 and room 2c-236 revealed a one inch conduit with an annular space within a two inch conduit.

On 04/22/14 at 8:48 A.M. in an interview, Staff A1 confirmed the observation..

5. On 04/22/14 at 8:55 A.M. observation above the drop down ceiling of the 30 minute smoke barrier in emergency department treatment area 10 revealed a one inch conduit with an annular space within a two inch conduit.

On 04/22/14 at 8:55 A.M. in an interview, Staff A1 confirmed the observation.

6. On 04/22/14 at 9:22 A.M. observation above the drop down ceiling of the 30 minute smoke barrier over double doors 2ed200 in corridor 2-2 that connects the cardio suite to the corridor outside the radiology suite revealed red, pink, white, and yellow cables with an unsealed annular space.

On 04/22/14 at 9:22 A.M. in an interview, Staff A1 confirmed the observation.

7. On 04/22/14 at 9:22 A.M. observation above the drop down ceiling of the 30 minute smoke barrier near housekeeping closet 2c205 revealed a one inch penetration with a grey wire passing through.

On 04/22/14 at 9:22 A.M. in an interview, Staff A1 confirmed the observation.

8. On 04/22/14 at 9:35 A.M. observation above the drop down ceiling of the 30 minute smoke barrier at the 90 degree corner in the corridor leading out of the emergency department suite revealed an approximate five foot long by one foot wide opening near a large heating, ventilation and cooling shaft.

On 04/22/14 at 9:35 A.M. in an interview, Staff A1 confirmed the observation.

9. On 04/22/14 at 9:42 A.M. observation above the drop down ceiling of the 30 minute smoke barrier in the emergency department manager's office, unsealed green and white wires were observed passing through a one inch hole.

On 04/22/14 at 9:42 A.M. in an interview, Staff A1 confirmed the observation.

10. On 04/22/14 at 10:10 A.M. observation above the drop down ceiling of the 2 hour rated barrier near door MAFD87 and near stair four revealed a one inch unsealed opening around a grey conduit.

On 04/22/14 at 10:10 A.M. in an interview, Staff A1 confirmed the observation.

11. On 04/22/14 at 10:21 A.M. observation above the drop down ceiling of the 2 hour rated barrier near door MAFD92 revealed open areas around yellow, white, and blue data cables.

On 04/22/14 at 10:21 A.M. in an interview, Staff A1 confirmed the observation.

12. On 04/22/14 at 10:28 A.M. observation above the drop down ceiling of the 2 hour rated barrier 90 degrees near door MAFD 92 revealed a two inch unsealed conduit with yellow, red, and blue wires.

On 04/22/14 at 10:28 A.M. in an interview, Staff A1 confirmed the observation.

13. On 04/22/14 at 2:20 P.M. observation above the drop down ceiling of the 30 minute smoke barrier over the double doors in the corridor and 90 degrees to room 2-292 revealed three copper conduits with unsealed annular spaces.

On 04/22/14 at 2:20 P.M. in an interview, Staff A1 confirmed the observation.

14. On 04/22/14 at 3:01 P.M. observation above the drop down ceiling of the 30 minute smoke barrier over door 2A408 (cath laboratory staffing office) revealed a one inch conduit with two grey and three green wires passing through an open hole, and a six inch pipe labeled "storm drain" and without an end cap.

On 04/22/14 at 3:01 P.M. in an interview, Staff A1 confirmed the observation.

15. On 04/22/14 at 3:25 P.M. observation above the drop down ceiling of the 30 minute smoke barrier near door MASD17 (nursing administration conference room) revealed an orange wire with an unsealed annular space.

On 04/22/14 at 3:25 P.M. in an interview, Staff A1 confirmed the observation.

16. On 04/22/14 at 4:10 P.M. doors (MASD21) in a 30 minute smoke barrier to the surgery waiting area were observed not to comply with NFPA 101 (2000 edition) 8.3 as they did not completely close.

On 04/22/14 at 4:10 P.M. in an interview, Staff A1 confirmed the observation.

17. On 04/22/14 at 4:18 P.M. observation above the drop down ceiling of the 30 minute smoke barrier near door 2A501 to surgery revealed a one foot by one foot square opening and three copper tubes with at least one inch unsealed annular spaces each.

On 04/22/14 at 4:18 P.M. in an interview, Staff A1 confirmed the observation.

18. On 04/22/14 at 4:30 P.M. observation above the drop down ceiling of the 30 minute smoke barrier around the corner from 2C606/MASD27 door revealed a one foot by one foot opening with multiple one inch metal conduits running through it.

On 04/22/14 at 4:30 P.M. in an interview, Staff A1 confirmed the observation.

19. On 04/22/14 at 4:38 P.M. observation of the door on utility room 2C686 revealed the door to be in a 30 minute smoke barrier and not completely closed as required by NFPA 101 (2000 edition) 8.3.

On 04/22/14 at 4:38 P.M. in an interview, Staff A1 confirmed the observation.

20. On 04/22/14 at 4:40 P.M. observation above the drop down ceiling of the 30 minute smoke barrier near door 2C686D (women's locker room) revealed a six inch drain pipe with an approximate one inch unsealed annular space.

On 04/22/14 at 4:40 P.M. in an interview, Staff A1 confirmed the observation.

21. On 04/22/14 at 5:08 P.M. observation above the drop down ceiling of the two hour fire barrier between the facility and the ambulatory surgery center near the door to stair seven revealed an open junction box having an open one inch conduit that passed through the wall.

On 04/22/14 at 5:08 P.M. in an interview, Staff A1 confirmed the observation.

On 04/23/14 at 11:29 A.M. a tour was taken of the facility's first floor with Staff A1.

22. On 04/23/13 at 11:29 A.M. observation above the drop down ceiling of the one hour fire/smoke barrier between doors MAFD60 and 1B178 (a bathroom) revealed a three inch by three inch penetration six inch pipes and an open junction box with an open one inch conduit that passing through the barrier.

On 04/23/14 at 11:29 A.M. in an interview, Staff A1 confirmed the observation.

23. On 04/23/14 at 11:34 A.M. observation of door 1B177 (on a clinical coordinator office) revealed it was in a one hour rated barrier and was not fire rated.

On 04/23/14 at 11:34 A.M. in an interview, Staff A1 confirmed the door was unrated.

24. On 04/23/14 at 11:35 A.M. observation in the corridor above the drop down ceiling of the one hour fire/smoke rated wall located near soiled utility room 1B176 revealed a broken one inch orange unsealed conduit passing through the barrier.

On 04/23/14 at 11:35 A.M. in an interview, Staff A1 confirmed the observation.

25. On 04/23/14 at 11:37 A.M. observation of the one hour fire/smoke rated wall inside soiled utility room 1B176 revealed a broken one inch orange conduit passing through the barrier.

On 04/23/14 at 11:37 A.M. in an interview, Staff A1 confirmed the observation.

26. On 04/23/14 at 11:54 A.M. observation of the double doors in the one hour fire/smoke barrier near stairway six and a staff break room revealed the doors to have a gap between the door leafs that was narrow at the top, gradually widening toward the floor such that over half the length of the doors had a gap of greater than one eighth of an inch.

On 04/23/14 at 11:54 A.M. in an interview, Staff A1 confirmed the doors had a gap of greater than an eighth of an inch.

27. On 04/23/14 at 11:58 A.M. observation above the drop down ceiling of the one hour rated wall dividing the staff break room (near stairway six) and the corridor revealed data cables running into a one inch by one inch opening in the barrier and an open electrical junction box.

On 04/23/14 at 11:58 A.M. in an interview, Staff A1 confirmed the observation.

28. On 04/23/14 at 1:56 P.M. observation above the drop down ceiling of the 30 minute rated barrier near case manager office 1C162 revealed a one inch by one inch square opening near a six inch pip.

On 04/23/14 at 1:56 P.M. in an interview, Staff A1 confirmed the observation.

29. On 04/23/14 at 2:49 P.M. observation of double doors MASD51 in a 30 minute barrier revealed they did not close as required by NFPA 101, 8.3, of the life safety code.

On 04/23/14 at 2:49 P.M. in an interview, Staff A1 confirmed the observation.

30. On 04/23/14 at 3:05 P.M. observation above the drop down ceiling of the 30 minute barrier over double doors IC169 revealed two unsealed broken orange conduits passing through the barrier.

On 04/23/14 at 3:05 P.M. in an interview, Staff A1 confirmed the observation.

31. On 04/23/14 at 3:28 P.M. observation of the door to the modular building in the two hour barrier revealed it did not close, and observation of the barrier above the door revealed a blue wire with an unsealed annular space.

On 04/23/14 at 3:28 P.M. in an interview, Staff A1 confirmed the observations

32. On 04/23/14 at 3:41 P.M observation above the drop down ceiling of the two hour fire rated barrier on the east side of doors MAFD53 revealed a three inch conduit with green and red data cables with unsealed annular spaces.

On 04/23/14 at 3:41 P.M. in an interview, Staff A1 confirmed the observation.

33. On 04/23/14 at 3:48 P.M. observation above the drop down ceiling of the two hour fire rated wall within housekeeping stock room 107 revealed a one inch stainless steel conduit with an unsealed annular space..

On 04/23/14 at 3:48 P.M. in an interview, Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to ensure doors to soiled linen rooms were automatic or self-closing. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.

Findings include:

On 04/23/14 at 10:37 A.M. a tour was taken of the laboratory suit with Staff A1. Observation of the soiled utility room next to the conference room revealed its door was not equipped with a automatic or self-closing device.

On 04/23/14 at 10:37 A.M. in an interview, Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to ensure its gift shop that opened to the corridor was completely sprinklered and did not exceed 500 square feet. This has the potential to affect all patients, staff, and visitors to the facility. The census at the time of the survey was 117 patients.
Findings:
On 04/23/14 at 2:20 P.M. a tour was conducted of the gift shop on the first floor. The tour revealed the gift shop to be open to the corridor, with an open gate to close it off at night. It was observed sprinklered throughout and the storage area to have a smoke resistive perimeter.
On 04/24/14 at 2:45 P.M. Staff A1 confirmed the square footage of the gift shop to be greater than 500 square feet stating it to have approximately 900 square feet not including the storage area. He/she said there used to be a drop-down door to the gift shop, but that it was taken away.

Based on observation and interview, the facility failed to ensure emergency lighting of at least 90 minute duration was provided in accordance with NFPA 101 (2000 edition), 7.9. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.
Findings:
Review of the facility's documentation on testing of its emergency lighting did not reveal where the lights were tested for 30 seconds every 30 days or were tested for 90 minutes annually.
On 04/23/14 at 5:00 P.M. in an interview, Staff A1 stated the batteries to all the lights get changed, but only tests 10 percent of them for 90 minutes on an annual basis.

Based on interview and review of the facility's fire drills records, the facility failed to ensure its fire drills were held at unexpected times. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.
Findings:
Review of the facility's fire drills for the past 12 months revealed for the third shift, for the past four quarters, they were held at 6:05 A.M. plus or minus eight minutes.
On 04/24/14 at 2:45 P.M. in an interview, Staff A1 confirmed the timing of the third quarter fire drills.

Based on documentation review and staff interview the facility failed to ensure the a 90 second signal test was completed annually. This has the potential to affect all patients receiving services from the facility. The facility census at the time of the survey was 52.

Findings include:

Review of documentation completed on 04/23/14 revealed no documentation of an annual 90 second signal test to the monitoring company. This was verified by Staff BB on 04/23/14 at -12:40 PM.

Based on observation and interview, the facility failed to maintain evidence of smoke detector sensitivity testing. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.
Findings:
Review of the facility's smoke detector testing documentation failed to reveal documentation of its sensitivity testing.
On 04/24/14 at 2:45 P.M. in an interview, Staff A1 stated he/she did not have the documentation and the alarm company was also unable to get it.

Based on observation and interview, the facility failed to ensure patient care areas were free of portable space heating devices. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.
Findings include:
1. On 04/21/14 at 1:50 P.M. a tour was conducted with Staff A1 of the third floor. Observation of the wound ostomy nurse office, which shared a smoke compartment containing sleeping patients, revealed a space heater.
On 04/21/14 at 1:50 P.M. in an interview, Staff A1 confirmed the observation.
2. At 3:38 P.M. in the anesthesia sleeping room a space heater was observed with attached instructions that read to not use within 3 feet of combustibles such as sheets. The room was observed to be of insufficient size to allow the space heater to operate without a combustible being within three feet of it.
On 04/21/14 at 3:38 P.M. in an interview, Staff A1 confirmed the observation.
3. At 3:55 P.M. a space heater was observed in the family birthing nurse manager office across from patient room 355 and within the same smoke compartment.
On 04/21/14 at 3:55 P.M. in an interview, Staff A1 confirmed the observation.

Based on observation and interview, the facility failed to ensure mobile soiled linen collection receptacles with capacities greater than 32 gallons were located in a room protected as a hazardous area when not attended.
Findings:
On 04/23/14 at 9:20 A.M. a tour was conducted of the ambulatory surgery center building with Staff A1. During tour at 10:05 A.M. a mobile soiled laundry cart was observed to have a capacity of greater than 32 gallons and parked unattended in a corridor.
On 04/24/14 at 2:45 P.M. in an interview, Staff A1 confirmed the cart was greater than 32 gallons.

Based on observation and interview, the facility failed to ensure anesthetizing locations were protected in accordance with NFPA 99. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.
Findings:
On 04/21/14 at 4:16 P.M. a tour was conducted of the operating room suites on the third floor with Staff A1. In front of the medical gas shut off valves for operating room number one and number two, medical paraphernalia was observed parked. In addition, Staff D, observed in surgical garb, in an interview at 4:16 P.M., was unable to explain where the medication gas shut off valves were.

Based on observation and interview, the facility failed to maintain its fire barriers as rated between the ambulatory surgery center and the main hospital.
Findings
On 04/23/14 at 9:20 A.M. a tour was conducted of the ambulatory surgery center building with Staff A1.
1. On 04/23/14 at 9:37 A.M. observation above the drop down ceiling of the two hour fire/smoke barrier between the main hospital and the ambulatory surgery building and inside the overflow waiting area in the northern wall, a six inch by six inch square penetration was observed in the drywall, and a six inch conduit with multiple green wires running out of it was observed to be lacking fire sealant.
On 04/23/14 at 9:37 A.M. in an interview, Staff A1 confirmed the observation.
2. On 04/23/14 at 9:45 A.M. observation above the drop down ceiling of the two hour fire barrier between stairway seven and the ambulatory surgery building, and observed from the corridor, revealed an open junction box with a open half inch conduit passing through the barrier.
On 04/23/14 at 9:45 A.M. in an interview, Staff A1 confirmed the observation.
3. On 04/23/14 at 9:51 A.M. observation of the southern door in stairwell number seven revealed it did not have a rating.
On 04/23/14 at 9:51 A.M. in an interview, Staff A1 confirmed the observation.

NFPA 101, 2000 edition
19.2.5.7
Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2 (930 m)
Based on review of the schematic for the second floor and the emergency department, and interview, the facility failed to maintain suite footage to not more than 10,000 square feet for non patient-sleeping suites. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.
Findings:
Review of the schematic of the second floor revealed emergency department was designated as a suite with 13,122 square feet.
On 04/24/14 at 2:45 P.M. in an interview Staff A1 confirmed the square footage of the emergency room.

Based on interview and record review, the facility does not have a fire watch system for when the automatic sprinkler system is down for longer than four hours for a scheduled shut down. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.
Findings:
Review of the facility's fire watch policy, approved 9/10/13, revealed a fire watch would not be implemented during a scheduled shutdown of the sprinkler system, even if the shut down lasts longer than four hours.
On 04/24/14 at 2:45 P.M. in an interview Staff A1 confirmed the policy as written.

Based on interview and record review, the facility does not have a fire watch system for when the fire alarm system is down for longer than four hours for a scheduled shut down. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 117 patients.
Findings:
Review of the facility's fire watch policy, approved 9/10/13, revealed a fire watch would not be implemented during a scheduled shutdown of the fire alarm system, even if the shut down lasts longer than four hours.
On 04/24/14 at 2:45 P.M. in an interview Staff A1 confirmed the policy as written.