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Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/16/2011 the surveyor noted penetrations above the smoke doors located near exam room 2 (incomplete fire stop).
2. On 8/16/2011 the surveyor noted penetrations above the doors between Information Technology (IT) and the Central Storage room.

Based on observation the facility failed to provide doors that would resist the passage of smoke.

Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 8/16/2011 the surveyor noted that the storage room door (between stairs and elevator on 2nd floor) failed to properly close and latch.
2. On 8/16/2011 the surveyor noted that the door leading to roof access would not properly close and latch as it would hang up on a table while swinging closed.
3. On 8/16/2011 the surveyor noted that the door to the PA office would not properly close and latch hand had a gap around the door handle.
4. On 8/16/2011 the surveyor noted that the door to Radiology would not properly close and latch.
5. On 8/16/2011 the surveyor noted that the door to the blood draw room would not properly close and latch.

Based on observation, the hospital failed to display exit sign(s) in such a manor as to make the direction of travel to exits readily apparent.

Failure to display an exit sign directing building occupants toward the exits puts occupants of the facility at risk should exiting be required due to a fire or other emergency.

Findings include:

1. On 8/16/2011 the surveyor noted that the basement area of the facility lacked exit sign(s).

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/16/2011 the surveyor noted portable space heating devices in the Information Technology (IT) office and in the Imaging Department darkroom.

Based on observation the facility failed to prohibit the placement of trash collection receptacles of greater than 32 gallons in the facility. Failure on the part of the facility to prohibit receptacles of greater than 32 gallons puts patients, staff and visitors of the facility at risk from the effects of fire

Findings include:

1. On 8/16/2011 the surveyor noted a recycling container in Medical Records that was deemed to have an approximate capacity of 50 gallons. The space in which it was located lacked hazardous area protection as is required.

Based on observation and interview the facility failed to provide a medical gas system that has master alarm panels located in two separate locations as is required.

Failure on the part of the facility to provide master alarms in two separated locations puts patients at risk of not having an uninterrupted supply of oxygen.

Findings include:

1. On 8/16/2011 the surveyor noted that a master alarm for the medical gas system was located in a continuously occupied location (nurses station). On the same date the surveyor was informed that the system lacked a second master alarm, more specifically a second master alarm located in the principle working area of the individual responsible for the maintenance of the medical gas system; i.e. physical plant office.

Based on observation the facility failed to post appropriate signage for oxygen storage rooms to warn of oxidizing gases stored within and the need for no smoking.

Failure on the part of the facility to post appropriate warning signage puts patients, staff and visitors at risk of fire.

Findings include:

1. On 8/16/2011 the surveyor noted that the clean utility room contained 6 E and 1 D size oxygen cylinders. It was further noted that the door of the facility lacked appropriate signage to warn of stored oxidizing gas and no smoking.

2. On 8/16/2011 the surveyor noted that the designated medical gas storage room had signage that indicated "Oxygen Room" not "Caution, Oxidizing Gas(es) stored within. No Smoking" as is required.

Based on observation and supplied documents the facility failed to properly divide the various branches of the essential electrical system (EES). More specifically, separation of the life safety branch and critical branch.

Failure on the part of the facility to properly divide the various branches of the EES puts patients, staff and visitors of the facility at risk from the effects of an essential electrical system malfunction.

Findings include:

1. On 8/16/2011 the surveyor noted that the facility's essential electrical system (post automatic switching equipment) was routed into two (2) electrical panels (Panels E and K). Documentation provided lists the types of services supplied from the respective electrical panels. The listed services for Panel E indicate that there are both life safety branch items and critical branch items. As an example the Fire Alarm (fire life safety item) is on the same panel as is the Nurses Call (critical branch item).

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 8/16/2011 the surveyor noted in the Information Technology room a multi-receptacle power strip hanging from an overhead receptacle box.
2. On 8/16/2011 the surveyor noted in the Information Technology room a multi-receptacle power strip connected to an extension cord.
3. On 8/16/2011 the surveyor noted in the Information Technology room a multi-receptacle power strip connected to a battery backup power supply.
4. On 8/16/2011 the surveyor noted in Medical Records and extension cord plugged into a multi-receptacle power strip.
5. On 8/16/2011 the surveyor noted in the boiler room noted 4 extension cords (2 in use) intended to be used for lighting units and other equipment.
6. On 8/16/2011 the surveyor noted in DNS office two extension cords. One cord was connected to a multi-receptacle power strip and the other was connected to an air conditioning unit.
7. On 8/16/2011 the surveyor noted an extension cord connected to a refrigerator in the employee break room.
8. On 8/16/2011 the surveyor noted an extension cord running through the wall of the clinic office to a receptacle in the reception area (main entrance) to which a power door opening unit was attached.
9. On 8/16/2011 the surveyor noted an extension cord plugged into a multi-receptacle power box located in the area of the reception desk.
10. On 8/16/2011 the surveyor noted a multi-receptacle adapter being used at the nurses station.

Based on document review that facility failed to provide a written policy for setting a fire watch when the sprinkler system is out of service for periods of more the 4 hours in a 24 hour period.

Failure on the part of the facility to have a fire watch policy regarding inoperable sprinkler system service puts patients, staff and visitors of the facility at risk from the effects of fire.

Findings include:

1. On 8/16/2011 the surveyor reviewed Fire Life Safety documentation/policies and noted that no policy was available addressing the need for setting a fire watch when the automatic sprinkler system would be out of service for more than four hours in a 24-hour period. It was noted however that a policy was available to address situations where the alarm system would be inoperable for the same length of time.

Based on observation the facility failed to install an alcohol based hand rub (ABHR) dispenser in an appropriate manner.

Failure to install ABHR dispensers appropriately puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

1. On 8/16/2011 the surveyor noted Alcohol Based Hand Rub (ABHR) dispensers improperly mounted as follows:

a) ABHR dispenser located above power outlet in room 79 (room number indicated on floor plan provided for reference).
b) ABHR dispenser located in clinic corridor (carpeted without sprinkler protection) near exams 3 and 5.
c. ABHR dispenser mounted to the Laboratory corridor door.

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/16/2011 the surveyor noted penetrations above the smoke doors located near exam room 2 (incomplete fire stop).
2. On 8/16/2011 the surveyor noted penetrations above the doors between Information Technology (IT) and the Central Storage room.

Based on observation the facility failed to provide doors that would resist the passage of smoke.

Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 8/16/2011 the surveyor noted that the storage room door (between stairs and elevator on 2nd floor) failed to properly close and latch.
2. On 8/16/2011 the surveyor noted that the door leading to roof access would not properly close and latch as it would hang up on a table while swinging closed.
3. On 8/16/2011 the surveyor noted that the door to the PA office would not properly close and latch hand had a gap around the door handle.
4. On 8/16/2011 the surveyor noted that the door to Radiology would not properly close and latch.
5. On 8/16/2011 the surveyor noted that the door to the blood draw room would not properly close and latch.

Based on observation, the hospital failed to display exit sign(s) in such a manor as to make the direction of travel to exits readily apparent.

Failure to display an exit sign directing building occupants toward the exits puts occupants of the facility at risk should exiting be required due to a fire or other emergency.

Findings include:

1. On 8/16/2011 the surveyor noted that the basement area of the facility lacked exit sign(s).

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/16/2011 the surveyor noted portable space heating devices in the Information Technology (IT) office and in the Imaging Department darkroom.

Based on observation the facility failed to prohibit the placement of trash collection receptacles of greater than 32 gallons in the facility. Failure on the part of the facility to prohibit receptacles of greater than 32 gallons puts patients, staff and visitors of the facility at risk from the effects of fire

Findings include:

1. On 8/16/2011 the surveyor noted a recycling container in Medical Records that was deemed to have an approximate capacity of 50 gallons. The space in which it was located lacked hazardous area protection as is required.

Based on observation and interview the facility failed to provide a medical gas system that has master alarm panels located in two separate locations as is required.

Failure on the part of the facility to provide master alarms in two separated locations puts patients at risk of not having an uninterrupted supply of oxygen.

Findings include:

1. On 8/16/2011 the surveyor noted that a master alarm for the medical gas system was located in a continuously occupied location (nurses station). On the same date the surveyor was informed that the system lacked a second master alarm, more specifically a second master alarm located in the principle working area of the individual responsible for the maintenance of the medical gas system; i.e. physical plant office.

Based on observation the facility failed to post appropriate signage for oxygen storage rooms to warn of oxidizing gases stored within and the need for no smoking.

Failure on the part of the facility to post appropriate warning signage puts patients, staff and visitors at risk of fire.

Findings include:

1. On 8/16/2011 the surveyor noted that the clean utility room contained 6 E and 1 D size oxygen cylinders. It was further noted that the door of the facility lacked appropriate signage to warn of stored oxidizing gas and no smoking.

2. On 8/16/2011 the surveyor noted that the designated medical gas storage room had signage that indicated "Oxygen Room" not "Caution, Oxidizing Gas(es) stored within. No Smoking" as is required.

Based on observation and supplied documents the facility failed to properly divide the various branches of the essential electrical system (EES). More specifically, separation of the life safety branch and critical branch.

Failure on the part of the facility to properly divide the various branches of the EES puts patients, staff and visitors of the facility at risk from the effects of an essential electrical system malfunction.

Findings include:

1. On 8/16/2011 the surveyor noted that the facility's essential electrical system (post automatic switching equipment) was routed into two (2) electrical panels (Panels E and K). Documentation provided lists the types of services supplied from the respective electrical panels. The listed services for Panel E indicate that there are both life safety branch items and critical branch items. As an example the Fire Alarm (fire life safety item) is on the same panel as is the Nurses Call (critical branch item).

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 8/16/2011 the surveyor noted in the Information Technology room a multi-receptacle power strip hanging from an overhead receptacle box.
2. On 8/16/2011 the surveyor noted in the Information Technology room a multi-receptacle power strip connected to an extension cord.
3. On 8/16/2011 the surveyor noted in the Information Technology room a multi-receptacle power strip connected to a battery backup power supply.
4. On 8/16/2011 the surveyor noted in Medical Records and extension cord plugged into a multi-receptacle power strip.
5. On 8/16/2011 the surveyor noted in the boiler room noted 4 extension cords (2 in use) intended to be used for lighting units and other equipment.
6. On 8/16/2011 the surveyor noted in DNS office two extension cords. One cord was connected to a multi-receptacle power strip and the other was connected to an air conditioning unit.
7. On 8/16/2011 the surveyor noted an extension cord connected to a refrigerator in the employee break room.
8. On 8/16/2011 the surveyor noted an extension cord running through the wall of the clinic office to a receptacle in the reception area (main entrance) to which a power door opening unit was attached.
9. On 8/16/2011 the surveyor noted an extension cord plugged into a multi-receptacle power box located in the area of the reception desk.
10. On 8/16/2011 the surveyor noted a multi-receptacle adapter being used at the nurses station.

Based on document review that facility failed to provide a written policy for setting a fire watch when the sprinkler system is out of service for periods of more the 4 hours in a 24 hour period.

Failure on the part of the facility to have a fire watch policy regarding inoperable sprinkler system service puts patients, staff and visitors of the facility at risk from the effects of fire.

Findings include:

1. On 8/16/2011 the surveyor reviewed Fire Life Safety documentation/policies and noted that no policy was available addressing the need for setting a fire watch when the automatic sprinkler system would be out of service for more than four hours in a 24-hour period. It was noted however that a policy was available to address situations where the alarm system would be inoperable for the same length of time.