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Based on observation and interview, the facility failed to provide a minimum one half hour fire resistance rating between smoke compartments in accordance with 19.3.7.5 for four of 14 smoke zones, affecting all hospital staff, visitors and a census of 20 patients.

Findings included:

1. Observation on 03/15/11 at 3:20 PM showed unsealed openings around objects that penetrated the kitchen's smoke wall above the west doors next to the Purchasing Department as follows:
- One quarter-inch opening around blue computer cable,
- One inch square opening next to an inside corner of a steel truss,
- One inch by one and a half-inch opening around a water pipe that penetrated the wall.

2. Observation on 03/15/11 at 3:45 PM showed an unsealed one and one-half inch opening for cable and communication wire, and a one half-inch diameter opening for a single cable wire above the double doors between Radiology and Patient Administration.

3. Observation on 03/15/11 at 4:00 PM showed an unsealed, two and one half-inch opening for a communication cable above a pair of doors outside of Stress Testing, and a half-inch hole below a metal conduit that penetrated the smoke barrier.

4. Observation on 03/15/11 at 4:10 PM showed an unsealed two-inch by three-inch hole in a wall above the doors to the Intensive Care Unit (next to room 120 and 131) penetrated by a bundle of communication cables. Above the same pair of doors, four television cables penetrated through a second unsealed hole, about one half-inch diameter.

5. During an interview on 03/15/11 at 4:10 PM, Staff KK, Director of Plant Operations, documented the penetrations and stated the facility planned to seal the holes. Staff KK stated the department recently completed a certification class on sealing through-wall penetrations. Staff KK stated he/she suspected the facility probably had multiple above-ceiling penetrations in smoke walls throughout the facility and planned to begin a comprehensive repair operation in the spring by sealing every hole, crack, corner and crevice in smoke walls and fire walls, from one end of the building to the other. Staff KK stated he/she did not yet have a formal plan or procedure, but planned to begin imposing "Above Ceiling Permits" on contractors to hold them responsible for any disrepair or collateral damages they caused during installation of a product or service to the hospital.

Based on observations and interview, the facility failed to ensure a minimum 20-minute fire protection to smoke barriers in new construction (post 2000) between two dissimilar smoke compartments (new Lobby added in 2000 to west corridor of existing structure) in accordance with 18.3.7.8 of the Life Safety Code requirements. The deficient practice affected a total of five department work areas in the hospital; Medical Records, CT (Computerized Tomography) scanner., Administration, Physical Therapy and the Gift Shop, and potentially affected hospital staff, visitors, and the current census of 20 patients.

Findings included:

1. Observation on 03/15/11 at 9:10 AM revealed gaps of up to one-quarter inch between the meeting edge of a pair of self-closing fire doors that separated the lobby from the west corridor and the remainder of the hospital. The doors were on magnetic hold open devices and had no rabbets, bevels, or astragals (grooves or molding to create a smoke tight barrier and cover the gap between doors) to prevent the spread of smoke from one compartment to another. Smoke separation doors in new construction are required to be self closing and to resist passage of smoke using rabbet, bevels or astragals at the meeting edge and stops at head and sides.

2. During an interview on 03/15/11 at 3:18 PM, Staff KK, Director of Plant Operations, stated the lobby, gift shop and patient registration were part of the latest expansion to the original 1958 structure. Staff KK stated they would first try adjusting the doors to reduce the gap and if that was not sufficient, it would not present a problem to add an astragal or similar barrier strip to the meeting edges.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2002 edition of NFPA 13, 8.5.6.1, where high piled storage of large cardboard boxes threatened to severely impede or obstruct the sprinkler discharge pattern. This deficient practice, in a storage room located within the cafeteria, potentially affected the staff, visitors and current census of 20 patients.

Findings included:

1. Observation on 03/17/11 at 10:00 AM revealed numerous large cardboard cases of paper dinnerware (disposable cups, plates and bowls) stacked around the storeroom on wooden pallets shelves and pallets to heights of less than four inches from the ceiling. Several cases of paper dinnerware were stacked in the middle of the room to less than six inches from spray head of a pendant sprinkler and stacked on shelves and pallets against the wall around the perimeter of the room.

2. During an interview on 3/17/11 at 10:00 AM, Staff KK, Director of Plant Operations, stated that he/she could have some pallets or raised duckboard built to accommodate the supplies, and reorganize the stacked items to provide more clearance for sprinkler heads.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the current facility census of 20 patients.

Findings included:

1. Observation on 03/15/11 at 2:50 PM showed four "H" size cylinders grouped together with a chain wrapped around them and bolted to the wall of a closet inside the Surgery department. Eight "E" sized cylinders were also grouped together and likewise chained in unison to the wall. The room was properly ventilated, secured and served by an automatic sprinkler. None of the 12 cylinders of compressed gases were individually stabilized, supported by racks or chained in a manner to protect one from falling into the wall or another tank, potentially setting off a catastrophic chain of events that could propel one or more unsecured cylinders through the concrete block walls. The cylinders were all filled with Oxygen, Nitrous Oxide or Nitrogen compressed gases. (Highly compressed gasses are liquefied vapors that rapidly expand when oxidized or exposed to ambient air, causing a pressurized escape of the contents through any valve or opening. If the valve or control is knocked off or damaged, it could cause a rapid, uncontrolled release of pressure, which essentially turns the heavy metal cylinder into an unguided torpedo.)

2. During an interview on 03/15/11 at 2:55 PM, Staff D, Director of Surgical Services, stated he/she would submit a work order to Maintenance to have the cylinders individually chained to the wall.

Based on interview the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.7.6.1. of NFPA 101, to protect the patients, staff and visitors during repair or failure of automatic sprinkler system that exceeds four hours, affecting the staff, visitors and current facility census of 20 patients.

Findings included:

During an interview on 3/16/11 at 9:30 AM, Staff KK, the Director of Plant Operations stated that the facility did not have a formal written plan for a fire watch, but did utilize a personnel pool that excluded direct care staff, so they remained free to dedicate all of their attention to patient care. Staff KK stated he/she did not currently have a training plan, and had not conducted specific training for staff to perform this duty. Staff KK stated the local Fire Department was an all volunteer group and the last time they came out to the facility for a walk-through and consultation was in 2009. Staff KK stated that he/she planned to meet with the Fire Department Chief and look into arranging some cross training for hazmat response, fire watch, and use of fire extinguishers.

Based on interview the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.6.1.8 of NFPA 101, to protect the patients, staff and visitors during repair or failure of the fire alarm system that exceeds four hours, affecting the staff, visitors and current facility census of 20 patients.

Findings included:

During an interview on 3/16/11 at 9:30 AM, Staff KK, the Director of Plant Operations stated that the facility did not have a formal written plan for a fire watch, but did utilize a personnel pool that excluded direct care staff, so they remained free to dedicate all of their attention to patient care. Staff KK stated he/she did not currently have a training plan, and had not conducted specific training for staff to perform this duty. Staff KK stated the local Fire Department was an all volunteer group and the last time they came out to the facility for a walk-through and consultation was in 2009. Staff KK stated that he/she planned to meet with the Fire Department Chief and look into arranging some cross training for hazmat response, fire watch, and use of fire extinguishers.

Based on observation and interview, the facility failed to provide a minimum one half hour fire resistance rating between smoke compartments in accordance with 19.3.7.5 for four of 14 smoke zones, affecting all hospital staff, visitors and a census of 20 patients.

Findings included:

1. Observation on 03/15/11 at 3:20 PM showed unsealed openings around objects that penetrated the kitchen's smoke wall above the west doors next to the Purchasing Department as follows:
- One quarter-inch opening around blue computer cable,
- One inch square opening next to an inside corner of a steel truss,
- One inch by one and a half-inch opening around a water pipe that penetrated the wall.

2. Observation on 03/15/11 at 3:45 PM showed an unsealed one and one-half inch opening for cable and communication wire, and a one half-inch diameter opening for a single cable wire above the double doors between Radiology and Patient Administration.

3. Observation on 03/15/11 at 4:00 PM showed an unsealed, two and one half-inch opening for a communication cable above a pair of doors outside of Stress Testing, and a half-inch hole below a metal conduit that penetrated the smoke barrier.

4. Observation on 03/15/11 at 4:10 PM showed an unsealed two-inch by three-inch hole in a wall above the doors to the Intensive Care Unit (next to room 120 and 131) penetrated by a bundle of communication cables. Above the same pair of doors, four television cables penetrated through a second unsealed hole, about one half-inch diameter.

5. During an interview on 03/15/11 at 4:10 PM, Staff KK, Director of Plant Operations, documented the penetrations and stated the facility planned to seal the holes. Staff KK stated the department recently completed a certification class on sealing through-wall penetrations. Staff KK stated he/she suspected the facility probably had multiple above-ceiling penetrations in smoke walls throughout the facility and planned to begin a comprehensive repair operation in the spring by sealing every hole, crack, corner and crevice in smoke walls and fire walls, from one end of the building to the other. Staff KK stated he/she did not yet have a formal plan or procedure, but planned to begin imposing "Above Ceiling Permits" on contractors to hold them responsible for any disrepair or collateral damages they caused during installation of a product or service to the hospital.

Based on observations and interview, the facility failed to ensure a minimum 20-minute fire protection to smoke barriers in new construction (post 2000) between two dissimilar smoke compartments (new Lobby added in 2000 to west corridor of existing structure) in accordance with 18.3.7.8 of the Life Safety Code requirements. The deficient practice affected a total of five department work areas in the hospital; Medical Records, CT (Computerized Tomography) scanner., Administration, Physical Therapy and the Gift Shop, and potentially affected hospital staff, visitors, and the current census of 20 patients.

Findings included:

1. Observation on 03/15/11 at 9:10 AM revealed gaps of up to one-quarter inch between the meeting edge of a pair of self-closing fire doors that separated the lobby from the west corridor and the remainder of the hospital. The doors were on magnetic hold open devices and had no rabbets, bevels, or astragals (grooves or molding to create a smoke tight barrier and cover the gap between doors) to prevent the spread of smoke from one compartment to another. Smoke separation doors in new construction are required to be self closing and to resist passage of smoke using rabbet, bevels or astragals at the meeting edge and stops at head and sides.

2. During an interview on 03/15/11 at 3:18 PM, Staff KK, Director of Plant Operations, stated the lobby, gift shop and patient registration were part of the latest expansion to the original 1958 structure. Staff KK stated they would first try adjusting the doors to reduce the gap and if that was not sufficient, it would not present a problem to add an astragal or similar barrier strip to the meeting edges.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2002 edition of NFPA 13, 8.5.6.1, where high piled storage of large cardboard boxes threatened to severely impede or obstruct the sprinkler discharge pattern. This deficient practice, in a storage room located within the cafeteria, potentially affected the staff, visitors and current census of 20 patients.

Findings included:

1. Observation on 03/17/11 at 10:00 AM revealed numerous large cardboard cases of paper dinnerware (disposable cups, plates and bowls) stacked around the storeroom on wooden pallets shelves and pallets to heights of less than four inches from the ceiling. Several cases of paper dinnerware were stacked in the middle of the room to less than six inches from spray head of a pendant sprinkler and stacked on shelves and pallets against the wall around the perimeter of the room.

2. During an interview on 3/17/11 at 10:00 AM, Staff KK, Director of Plant Operations, stated that he/she could have some pallets or raised duckboard built to accommodate the supplies, and reorganize the stacked items to provide more clearance for sprinkler heads.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the current facility census of 20 patients.

Findings included:

1. Observation on 03/15/11 at 2:50 PM showed four "H" size cylinders grouped together with a chain wrapped around them and bolted to the wall of a closet inside the Surgery department. Eight "E" sized cylinders were also grouped together and likewise chained in unison to the wall. The room was properly ventilated, secured and served by an automatic sprinkler. None of the 12 cylinders of compressed gases were individually stabilized, supported by racks or chained in a manner to protect one from falling into the wall or another tank, potentially setting off a catastrophic chain of events that could propel one or more unsecured cylinders through the concrete block walls. The cylinders were all filled with Oxygen, Nitrous Oxide or Nitrogen compressed gases. (Highly compressed gasses are liquefied vapors that rapidly expand when oxidized or exposed to ambient air, causing a pressurized escape of the contents through any valve or opening. If the valve or control is knocked off or damaged, it could cause a rapid, uncontrolled release of pressure, which essentially turns the heavy metal cylinder into an unguided torpedo.)

2. During an interview on 03/15/11 at 2:55 PM, Staff D, Director of Surgical Services, stated he/she would submit a work order to Maintenance to have the cylinders individually chained to the wall.

Based on interview the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.7.6.1. of NFPA 101, to protect the patients, staff and visitors during repair or failure of automatic sprinkler system that exceeds four hours, affecting the staff, visitors and current facility census of 20 patients.

Findings included:

During an interview on 3/16/11 at 9:30 AM, Staff KK, the Director of Plant Operations stated that the facility did not have a formal written plan for a fire watch, but did utilize a personnel pool that excluded direct care staff, so they remained free to dedicate all of their attention to patient care. Staff KK stated he/she did not currently have a training plan, and had not conducted specific training for staff to perform this duty. Staff KK stated the local Fire Department was an all volunteer group and the last time they came out to the facility for a walk-through and consultation was in 2009. Staff KK stated that he/she planned to meet with the Fire Department Chief and look into arranging some cross training for hazmat response, fire watch, and use of fire extinguishers.

Based on interview the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.6.1.8 of NFPA 101, to protect the patients, staff and visitors during repair or failure of the fire alarm system that exceeds four hours, affecting the staff, visitors and current facility census of 20 patients.

Findings included:

During an interview on 3/16/11 at 9:30 AM, Staff KK, the Director of Plant Operations stated that the facility did not have a formal written plan for a fire watch, but did utilize a personnel pool that excluded direct care staff, so they remained free to dedicate all of their attention to patient care. Staff KK stated he/she did not currently have a training plan, and had not conducted specific training for staff to perform this duty. Staff KK stated the local Fire Department was an all volunteer group and the last time they came out to the facility for a walk-through and consultation was in 2009. Staff KK stated that he/she planned to meet with the Fire Department Chief and look into arranging some cross training for hazmat response, fire watch, and use of fire extinguishers.