HospitalInspections.org

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that patient's doors protecting corridors on the first floor do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm with the facility's Engineer (employee #34), it was found that the following patient's rooms do not have the capability of latching when the doors are in the closed position, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire:

a. Patient's rooms on the first floor: #111, #115 and #117 (all room doors shall be verified for compliance).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that the facility failed to provide readily visible illuminated "exit" signs where the exit or way to reach the exit is not readily apparent to its occupants such as the side door of the adult and pediatric emergency rooms, for the waiting area of the operating room, laboratory department and exit signs did not illuminate when tested as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

1. There is the need of an illuminated exit sign for the emergency exit door near cubicle #7 located in the emergency room as observed with the facility's Engineer (employee #34) on 7/10/12 at 10:00 am.

2. There is a storage area near the pharmacy department that has a sign that states "Not an Exit" as observed on 7/10/12 at 1:55 pm with the facility's Engineer (employee #34). A sign stating "Not an Exit" also needs to be placed in this area but in Spanish, which is the predominant language at the hospital.

3. The pediatric emergency room was visited on 7/11/12 at 8:30 am and provided evidence that the door near the acute cubicle does not have an illuminated exit sign as found with the facility's Engineer (employee #34).

4. There is the need of an illuminated exit signs for the side exit door of the waiting room of the operating room department as observed on 7/11/12 at 11:45 am with the facility's Engineer (employee #34). Illuminated exit signs in these areas will help to safely guide patients and staff out of this area.

5. The laboratory department was visited on 7/11/12 at 1:20 pm and provided evidence that the side exit door does not have an illuminated exit sign as found with the facility's Engineer (employee #34)(must also remove the latch on this door). Also the front door exit sign did not illuminate when tested.

6. During the observational tour of the facility with the facility's Engineer (employee #34) from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm, the following areas did not have working illuminated exit signs:
a. The laboratory department was visited on 7/11/12 at 1:20 pm and provided evidence that the front door exit sign did not illuminate when tested.
b. The main material supply area located in a building next to the hospital was visited on 7/12/12 at 9:10 am and provided evidence that the front and back door exit signs did not illuminate when tested.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that exit components (stairway doors) do not provide protection against fire or smoke from other parts of the building due to the lack of the doors' ability to close completely on the second floor as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.1.1 and 19.3.2.1.

Findings include:

During the tour for life safety from fire, exit components (stair enclosures) were inspected and found that the enclosure (door) on the second floor of the internal staircase near the medical offices did not completely close (lacked positive latching) as observed on 7/10/12 at 12:00 noon with the facility's Engineer (employee #34). This fire door can be opened with a minimum force and can permit fire and toxic gases to enter this means of egress.

Based on observations made during the survey for life safety from fire with the facility ' s Engineer (employee #34), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided at outside staircases and hallways and some emergency lamps did not illuminate when tested as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility ' s Engineer (employee #34) from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm in the following areas:
a. At the outside staircases (2 stories high) located at the sides of the hospital (two staircases).
b. Outside of the Emergency rooms' main entrance/exit.
c. In the emergency rooms' triage room.
d. All medication preparation rooms (adult and pediatric emergency rooms, and the four wards).
e. At the X-ray department.
f. In the general material supply department located in a building next to the hospital (personnel are in this room until 7:00 pm).
g. In the acute dialysis room across from the pharmacy department.
h. In the pharmacy department.
i. In the recovery room of the operating room department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

2. The emergency battery operated lamps (EBOL) in the following areas were tested with the facility ' s Engineer (employee #34) and did not illuminate as observed from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm:
a. The EBOL in the hallway in front of the emergency room.
b. The EBOL located in the hallway in front of patient room #104.
c. The EBOL located in the hallway in front of patient room #117.
d. The EBOL located in the hallway in front of patient room #128.
e. The EBOL located in the hallway in front of patient room #129.
f. The EBOL located in the hallway in front of patient room #136.
g. The EBOL in operating suite #4.
h. The EBOL near the reception desk of the laboratory department.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that the facility failed to ensure that nursing wards and the emergency rooms (adult and pediatric) have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 7/12/12 at 3:10 pm with the facility's Engineer (employee #34) that nursing ward and emergency room personnel have a plan or assignment with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off and other tasks to perform. All personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Engineer (employee #33), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation which is not in accordance with the requirements of the LSC 2000 section 5.5.

Findings include:

1. Written documents about conducted fire drills for the facility were reviewed with the facility's Engineer (employee #33) on 7/12/12 at 3:30 pm and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that the facility failed to ensure that smoke detectors are available at all required areas such as housekeeping closets, biohazardous trash closets, hallways, operating department, pull stations are not located at needed areas and smoke detectors are not mounted at least three feet from air conditioner vents as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #34) from 7/10/12 through 7/13/12 from 8:30 am till 4:00 pm:
a. In the adult and pediatric emergency rooms (the installation of the required smoke detectors in these areas were completed on 7/10/12).
b. In the respiratory therapy department which was found with a large quantity of boxes with filed documents.
c. All housekeeping closets located throughout the hospital.
d. In all biohazardous storage closets and all dirty linen closets.
e. In all pantries with microwaves, refrigerators and coffee makers.
f. The second floor medicine ward hallway needs smoke detectors (the facility must ensure that they are not spaced more than 30 feet linearly one from the other).
g. The second floor intermediate ward hallway needs smoke detectors (the facility must ensure that they are not spaced more than 30 feet linearly one from the other).
h. The first floor surgery ward hallway needs smoke detectors (the facility must ensure that they are not spaced more than 30 feet linearly one from the other).
i. The first floor pediatric ward hallway needs smoke detectors (the facility must ensure that they are not spaced more than 30 feet linearly one from the other).
j. In the operating room department.
k. In the laboratory department (more are needed).
l. In the X-ray department.

2. The laboratory department was visited on 7/11/12 at 1:15 pm with the facility ' s Engineer (employee #34) and provided evidence that the pull station that is located in the middle of the department is not accessible to persons because it is blocked by equipment.

3. The smoke detector located in hallway near the dietitian's office of the kitchen was observed on 7/10/12 at 1:40 pm within three feet of the air conditioner vent. Air blown from air conditioner vents can affect the effectiveness of the smoke detector to detect smoke in the event of a fire.

4. The medical record department and the main material supply area located in a building next to the hospital were visited on 7/12/12 from 8:40 am till 9:20 am with the facility ' s Engineer (employee #34) and provided evidence that the back doors do not have pull stations.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Engineer (employee #33), it was determined that the facility is not performing visual inspections or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 7/12/12 at 10:00 am with the facility's engineer (employee #33) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

Based on observations made and measurements taken of the height of fire extinguishers during the survey for life safety from fire with the facility's Engineer #34), it was determined that the facility failed to ensure that portable fire extinguishers are mounted throughout the facility as required by the Life Safety Code of the NFPA 10 Section 1.5.10.

Findings include:

During the observational tour of the entire facility with the facility's (Engineer #34) from 7/10/12 through 7/13/12 from 8:00 am through 4:00 pm, it was found that fire extinguishers are placed throughout the facility and weigh less than 40 pounds. However the height of the top part of all of the fire extinguishers located throughout the facility were greater than five feet in height. According with NFPA 10, section 1.5.10, fire extinguishers weighing less than 40 pounds shall be installed so that the top part of the fire extinguisher is not more than five feet in height. The facility must lower the fire extinguishers to ensure that they are lower than five feet so that they can be accessible to all persons if needed.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour of the facility wards and emergency rooms from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm, it was determined that personnel are using closets to place dirty linen, however they are not protected as hazardous areas. All wards and the emergency rooms were found with full plastic bags of dirty linen in hampers. The facility's Engineer (employee #34) stated during an interview on 7/12/12 at 9:00 am that these closets are used as holding area until personnel make their rounds and remove them from the closets. These closets need smoke detectors connected to the alarm panel and extractors. The construction of these closets must be verified to ensure one hour fire rating (with 3/4 hour fire-rated doors) with positive latching and door closers and containers can not exceed 32 gallons within any 64 square foot area.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #34), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, propane gas tanks do not have seismic shut off devices, oxygen storage, the kitchen hood vents has a space at the ends and no evidence of the certified hood cleaning, use of extension cords, no documentation of seamise connection, use of regular garbage containers and no documentation of the large oxygen container system.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm with the facility's Engineer (employee #34) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. A type H oxygen cylinder was found in the minor surgery room of the emergency room near the entrance to this room. (This tank is used a spare tank for patients receiving respiratory therapy and the location of these patients who receive oxygen therapy is on seat in front of the minor surgery entrance door).
b. Two type E oxygen cylinders were found in front of the nursing station of the intermediate ward.
c. One type E oxygen cylinder was found in front of the nursing station of the surgery ward.

2. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Engineer (employee #34) and maintenance documentation was reviewed from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm and the following was determined:
a. No evidence was found of standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

3. The facility has an area with four large propane gas tanks located at the back of the hospital's kitchen in front of the elevated parking building as observed on 7/10/12 at 8:00 am and 2:00 pm with the facility's Engineer (employee #34) and provided evidence that they are not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required.
a. Also, on 7/13/12 at 8:00 am a car was parked in reverse and the bumper was within three feet of the first in-line propane tank. The tanks are protected with cement tubes to prevent accidentally hitting the tanks, but the front part of the tanks has a four foot open space where the bumper of a car can hit the first tank.

4. During the observational tour of the kitchen on 7/10/12 at 1:50 pm with the facility's Engineer (employee #34) the following was determined:
a. The hood vents located above the cooking stove was found with spaces at both corners which will not allow the vents to protect the duct system as designed.
b. The kitchen's hood exhaust system maintenance was requested, however no evidence was found of the updated required hood, duct and exhaust fans inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule.

5. The pharmacy department was visited on 7/10/12 at 2:00 pm with the facility's Engineer (employee #34) and was found with a regular extension cord hanging from the ceiling near the refrigerator. Extension cords are not recommended due to the potential for them to overheat.

6. The seamise connection to be used by the fire department was verified on 7/13/12 at 11:40 am with the facility's Engineer (employee #34), however no evidence was found of this connection inspection on a quarterly basis to verify visibility and accessibility, coupling and that the swivels are not damaged and rotate smoothly.

7. Regular garbage containers located at offices and work areas were verified on 7/10/12 from 9:00 am till 3:00 pm with the facility's Engineer (employee #34) and provided evidence that they are not made of fire rated material and tested as such. Rubber or plastic garbage containers that are not made of fire rated material can emit toxic fumes if they catch on fire.

8. During the observational tour of the operating room department on 7/11/12 at 11:00 am with the facility's Engineer (employee #34) it found that operating suite #4 had an extension cord directly on the floor.

9. On 7/10/12 at 8:00 am the elevated parking facility located to the side of the hospital was observed without a fire hose at the third floor fire hose box.

10. The facility has a large oxygen tank that supplies oxygen to the hospital located at the back of the hospital as observed on 7/11/12 at 10:30 am with the facility's Engineer (employee #34). The facility was requested evidence of periodic master alarm panel testing related to the audible and visual signals (high/low alarms for +/- 20% operating pressure), however the Engineer (employee #34) stated on 7/11/12 at 10:30 am that the system is working properly and so are the alarms, however he does not have documentation of tests performed to verify the alarms' status.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34) at the laboratory department, it was determined that the facility failed to provide a shower within the work area to drench persons with water if exposed to injurious corrosive materials as required by NFPA 99 Section 10.6.

Findings include:

The laboratory department was visited on 7/11/12 at 1:10 pm with the facility's Engineer (employee #34) and provided evidence that it does not have an emergency shower within the work area to drench persons with water if exposed to injurious corrosive materials for immediate emergency use.

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #33), it was determined that the facility failed to ensure that personnel perform weekly inspections of the electrical generator as required by the NFPA 99, section 3.4.4.1.

Findings include:

The facility lacks complete written evidence of the weekly inspections of the generator as reviewed on 7/12/12 at 10:00 am. The facility does not have a check list which includes coolant level, belts, oil pressure and oil change, hoses and pipes, main fuel tank level, leaks if any, oil filter, air filter, battery contacts and battery condition and other checks from NFPA-99.

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Engineer (employee #33), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 7/12/12 at 9:30 am about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #34), it was found that the facility failed to ensure hand sanitizer dispensers are not installed over an ignition source.

Findings include:

Plastic pump bottles of hand sanitizers located in the hallway of the wards used by personnel to sanitize their hands were observed mounted above electrical receptacles near patient's rooms #105 and #213 with the facility's Engineer (employee #34) on 7/10/12 and 7/11/12 at 2:45 pm and 9:00 am.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that patient's doors protecting corridors on the first floor do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm with the facility's Engineer (employee #34), it was found that the following patient's rooms do not have the capability of latching when the doors are in the closed position, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire:

a. Patient's rooms on the first floor: #111, #115 and #117 (all room doors shall be verified for compliance).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that the facility failed to provide readily visible illuminated "exit" signs where the exit or way to reach the exit is not readily apparent to its occupants such as the side door of the adult and pediatric emergency rooms, for the waiting area of the operating room, laboratory department and exit signs did not illuminate when tested as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

1. There is the need of an illuminated exit sign for the emergency exit door near cubicle #7 located in the emergency room as observed with the facility's Engineer (employee #34) on 7/10/12 at 10:00 am.

2. There is a storage area near the pharmacy department that has a sign that states "Not an Exit" as observed on 7/10/12 at 1:55 pm with the facility's Engineer (employee #34). A sign stating "Not an Exit" also needs to be placed in this area but in Spanish, which is the predominant language at the hospital.

3. The pediatric emergency room was visited on 7/11/12 at 8:30 am and provided evidence that the door near the acute cubicle does not have an illuminated exit sign as found with the facility's Engineer (employee #34).

4. There is the need of an illuminated exit signs for the side exit door of the waiting room of the operating room department as observed on 7/11/12 at 11:45 am with the facility's Engineer (employee #34). Illuminated exit signs in these areas will help to safely guide patients and staff out of this area.

5. The laboratory department was visited on 7/11/12 at 1:20 pm and provided evidence that the side exit door does not have an illuminated exit sign as found with the facility's Engineer (employee #34)(must also remove the latch on this door). Also the front door exit sign did not illuminate when tested.

6. During the observational tour of the facility with the facility's Engineer (employee #34) from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm, the following areas did not have working illuminated exit signs:
a. The laboratory department was visited on 7/11/12 at 1:20 pm and provided evidence that the front door exit sign did not illuminate when tested.
b. The main material supply area located in a building next to the hospital was visited on 7/12/12 at 9:10 am and provided evidence that the front and back door exit signs did not illuminate when tested.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that exit components (stairway doors) do not provide protection against fire or smoke from other parts of the building due to the lack of the doors' ability to close completely on the second floor as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.1.1 and 19.3.2.1.

Findings include:

During the tour for life safety from fire, exit components (stair enclosures) were inspected and found that the enclosure (door) on the second floor of the internal staircase near the medical offices did not completely close (lacked positive latching) as observed on 7/10/12 at 12:00 noon with the facility's Engineer (employee #34). This fire door can be opened with a minimum force and can permit fire and toxic gases to enter this means of egress.

Based on observations made during the survey for life safety from fire with the facility ' s Engineer (employee #34), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided at outside staircases and hallways and some emergency lamps did not illuminate when tested as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility ' s Engineer (employee #34) from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm in the following areas:
a. At the outside staircases (2 stories high) located at the sides of the hospital (two staircases).
b. Outside of the Emergency rooms' main entrance/exit.
c. In the emergency rooms' triage room.
d. All medication preparation rooms (adult and pediatric emergency rooms, and the four wards).
e. At the X-ray department.
f. In the general material supply department located in a building next to the hospital (personnel are in this room until 7:00 pm).
g. In the acute dialysis room across from the pharmacy department.
h. In the pharmacy department.
i. In the recovery room of the operating room department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

2. The emergency battery operated lamps (EBOL) in the following areas were tested with the facility ' s Engineer (employee #34) and did not illuminate as observed from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm:
a. The EBOL in the hallway in front of the emergency room.
b. The EBOL located in the hallway in front of patient room #104.
c. The EBOL located in the hallway in front of patient room #117.
d. The EBOL located in the hallway in front of patient room #128.
e. The EBOL located in the hallway in front of patient room #129.
f. The EBOL located in the hallway in front of patient room #136.
g. The EBOL in operating suite #4.
h. The EBOL near the reception desk of the laboratory department.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that the facility failed to ensure that nursing wards and the emergency rooms (adult and pediatric) have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 7/12/12 at 3:10 pm with the facility's Engineer (employee #34) that nursing ward and emergency room personnel have a plan or assignment with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off and other tasks to perform. All personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Engineer (employee #33), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation which is not in accordance with the requirements of the LSC 2000 section 5.5.

Findings include:

1. Written documents about conducted fire drills for the facility were reviewed with the facility's Engineer (employee #33) on 7/12/12 at 3:30 pm and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that the facility failed to ensure that smoke detectors are available at all required areas such as housekeeping closets, biohazardous trash closets, hallways, operating department, pull stations are not located at needed areas and smoke detectors are not mounted at least three feet from air conditioner vents as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #34) from 7/10/12 through 7/13/12 from 8:30 am till 4:00 pm:
a. In the adult and pediatric emergency rooms (the installation of the required smoke detectors in these areas were completed on 7/10/12).
b. In the respiratory therapy department which was found with a large quantity of boxes with filed documents.
c. All housekeeping closets located throughout the hospital.
d. In all biohazardous storage closets and all dirty linen closets.
e. In all pantries with microwaves, refrigerators and coffee makers.
f. The second floor medicine ward hallway needs smoke detectors (the facility must ensure that they are not spaced more than 30 feet linearly one from the other).
g. The second floor intermediate ward hallway needs smoke detectors (the facility must ensure that they are not spaced more than 30 feet linearly one from the other).
h. The first floor surgery ward hallway needs smoke detectors (the facility must ensure that they are not spaced more than 30 feet linearly one from the other).
i. The first floor pediatric ward hallway needs smoke detectors (the facility must ensure that they are not spaced more than 30 feet linearly one from the other).
j. In the operating room department.
k. In the laboratory department (more are needed).
l. In the X-ray department.

2. The laboratory department was visited on 7/11/12 at 1:15 pm with the facility ' s Engineer (employee #34) and provided evidence that the pull station that is located in the middle of the department is not accessible to persons because it is blocked by equipment.

3. The smoke detector located in hallway near the dietitian's office of the kitchen was observed on 7/10/12 at 1:40 pm within three feet of the air conditioner vent. Air blown from air conditioner vents can affect the effectiveness of the smoke detector to detect smoke in the event of a fire.

4. The medical record department and the main material supply area located in a building next to the hospital were visited on 7/12/12 from 8:40 am till 9:20 am with the facility ' s Engineer (employee #34) and provided evidence that the back doors do not have pull stations.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Engineer (employee #33), it was determined that the facility is not performing visual inspections or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 7/12/12 at 10:00 am with the facility's engineer (employee #33) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

Based on observations made and measurements taken of the height of fire extinguishers during the survey for life safety from fire with the facility's Engineer #34), it was determined that the facility failed to ensure that portable fire extinguishers are mounted throughout the facility as required by the Life Safety Code of the NFPA 10 Section 1.5.10.

Findings include:

During the observational tour of the entire facility with the facility's (Engineer #34) from 7/10/12 through 7/13/12 from 8:00 am through 4:00 pm, it was found that fire extinguishers are placed throughout the facility and weigh less than 40 pounds. However the height of the top part of all of the fire extinguishers located throughout the facility were greater than five feet in height. According with NFPA 10, section 1.5.10, fire extinguishers weighing less than 40 pounds shall be installed so that the top part of the fire extinguisher is not more than five feet in height. The facility must lower the fire extinguishers to ensure that they are lower than five feet so that they can be accessible to all persons if needed.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34), it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour of the facility wards and emergency rooms from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm, it was determined that personnel are using closets to place dirty linen, however they are not protected as hazardous areas. All wards and the emergency rooms were found with full plastic bags of dirty linen in hampers. The facility's Engineer (employee #34) stated during an interview on 7/12/12 at 9:00 am that these closets are used as holding area until personnel make their rounds and remove them from the closets. These closets need smoke detectors connected to the alarm panel and extractors. The construction of these closets must be verified to ensure one hour fire rating (with 3/4 hour fire-rated doors) with positive latching and door closers and containers can not exceed 32 gallons within any 64 square foot area.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #34), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, propane gas tanks do not have seismic shut off devices, oxygen storage, the kitchen hood vents has a space at the ends and no evidence of the certified hood cleaning, use of extension cords, no documentation of seamise connection, use of regular garbage containers and no documentation of the large oxygen container system.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm with the facility's Engineer (employee #34) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. A type H oxygen cylinder was found in the minor surgery room of the emergency room near the entrance to this room. (This tank is used a spare tank for patients receiving respiratory therapy and the location of these patients who receive oxygen therapy is on seat in front of the minor surgery entrance door).
b. Two type E oxygen cylinders were found in front of the nursing station of the intermediate ward.
c. One type E oxygen cylinder was found in front of the nursing station of the surgery ward.

2. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Engineer (employee #34) and maintenance documentation was reviewed from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm and the following was determined:
a. No evidence was found of standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

3. The facility has an area with four large propane gas tanks located at the back of the hospital's kitchen in front of the elevated parking building as observed on 7/10/12 at 8:00 am and 2:00 pm with the facility's Engineer (employee #34) and provided evidence that they are not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required.
a. Also, on 7/13/12 at 8:00 am a car was parked in reverse and the bumper was within three feet of the first in-line propane tank. The tanks are protected with cement tubes to prevent accidentally hitting the tanks, but the front part of the tanks has a four foot open space where the bumper of a car can hit the first tank.

4. During the observational tour of the kitchen on 7/10/12 at 1:50 pm with the facility's Engineer (employee #34) the following was determined:
a. The hood vents located above the cooking stove was found with spaces at both corners which will not allow the vents to protect the duct system as designed.
b. The kitchen's hood exhaust system maintenance was requested, however no evidence was found of the updated required hood, duct and exhaust fans inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule.

5. The pharmacy department was visited on 7/10/12 at 2:00 pm with the facility's Engineer (employee #34) and was found with a regular extension cord hanging from the ceiling near the refrigerator. Extension cords are not recommended due to the potential for them to overheat.

6. The seamise connection to be used by the fire department was verified on 7/13/12 at 11:40 am with the facility's Engineer (employee #34), however no evidence was found of this connection inspection on a quarterly basis to verify visibility and accessibility, coupling and that the swivels are not damaged and rotate smoothly.

7. Regular garbage containers located at offices and work areas were verified on 7/10/12 from 9:00 am till 3:00 pm with the facility's Engineer (employee #34) and provided evidence that they are not made of fire rated material and tested as such. Rubber or plastic garbage containers that are not made of fire rated material can emit toxic fumes if they catch on fire.

8. During the observational tour of the operating room department on 7/11/12 at 11:00 am with the facility's Engineer (employee #34) it found that operating suite #4 had an extension cord directly on the floor.

9. On 7/10/12 at 8:00 am the elevated parking facility located to the side of the hospital was observed without a fire hose at the third floor fire hose box.

10. The facility has a large oxygen tank that supplies oxygen to the hospital located at the back of the hospital as observed on 7/11/12 at 10:30 am with the facility's Engineer (employee #34). The facility was requested evidence of periodic master alarm panel testing related to the audible and visual signals (high/low alarms for +/- 20% operating pressure), however the Engineer (employee #34) stated on 7/11/12 at 10:30 am that the system is working properly and so are the alarms, however he does not have documentation of tests performed to verify the alarms' status.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #34) at the laboratory department, it was determined that the facility failed to provide a shower within the work area to drench persons with water if exposed to injurious corrosive materials as required by NFPA 99 Section 10.6.

Findings include:

The laboratory department was visited on 7/11/12 at 1:10 pm with the facility's Engineer (employee #34) and provided evidence that it does not have an emergency shower within the work area to drench persons with water if exposed to injurious corrosive materials for immediate emergency use.

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #33), it was determined that the facility failed to ensure that personnel perform weekly inspections of the electrical generator as required by the NFPA 99, section 3.4.4.1.

Findings include:

The facility lacks complete written evidence of the weekly inspections of the generator as reviewed on 7/12/12 at 10:00 am. The facility does not have a check list which includes coolant level, belts, oil pressure and oil change, hoses and pipes, main fuel tank level, leaks if any, oil filter, air filter, battery contacts and battery condition and other checks from NFPA-99.

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Engineer (employee #33), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 7/12/12 at 9:30 am about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.