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Based on observation and interview, the facility failed to maintain a minimum two-hour rated construction for 1 of 1 separation walls between business occupancy and health care occupancy. This deficient practice could affect 10 patients, staff, and visitors on the second floor.

Findings include:

Based on observations with Plant Operator #1 during a tour of the facility from 1:00 p.m. to 3:15 p.m. on 06/26/17, a one inch hole for the passage of an electrical conduit was noted in the two-hour rated tenant separation wall above the suspended ceiling above the corridor door set on the west end of second floor. The hole failed to maintain the minimum two-hour rated construction for the separation wall between the Medical Office Building and the health care occupancy. Based on interview at the time of the observations, Plant Operator #1 acknowledged the aforementioned hole in the tenant separation wall failed to maintain a minimum two-hour rated construction for the tenant separation wall and this was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

Based on observation and interview, the facility failed to maintain the building construction type of Type II (111) in 1 of 3 floor separations in the facility. This deficient practice could affect any patients, staff and visitors who would use the basement dining area as well as staff who work in the basement.

Findings include:

Based on observations with the plant services manager on 06/26/17 during a tour of the basement smoke and fire barrier walls from 11:45 a.m. to 12:30 p.m., the basement smoke barrier wall above the drop ceiling in the Plant Services Hall near the office had a twenty three foot by eight inch area covered in plywood on the underside of the concrete deck between the basement and first floor and the basement data room smoke barrier wall above the drop ceiling had a sixteen foot by two inch area covered in plywood on the underside of the concrete deck between the basement and first floor. Based on an interview with the plant services manager at the time of observations, it was stated the plywood was used as a form when the concrete decks were poured during construction and the contractors failed to remove the plywood. This was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

Based on observation and interview, the facility failed to ensure 1 of 1 basement exit sidewalk ramp was provided with handrails. LSC 7.2.5.4.2 states handrails complying with 7.2.2.4 shall be provided along both sides of a ramp run with a rise greater than 6 inches, unless otherwise provided in 7.2.5.4.4. This deficient practice could affect any number of patients, staff and visitors who would use the basement dining area as well as staff who work in the basement.

Findings include:

Based on observation with the plant services manager on 06/26/17 at 3:30 p.m., the basement dining room exit sidewalk discharge through a courtyard and onto a sloping concrete ramp leading to the paved parking lot. Furthermore, the sloping concrete ramp had a twenty two foot long ramp with a two foot rise from the bottom to the top of the ramp which was not provided with handrails. This was verified by the plant services manager at the time of observation and acknowledged at the exit conference on 07/03/17 at 10:45 a.m.

Based on observation and interview, the facility failed to maintain protection of 1 of 2 interior stairwells. LSC 19.3.1 requires vertical openings shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 8.6.5 states see 7.1.3.2.1 for enclosures of exits. LSC 7.1.3.2.1 states the separation shall have a minimum 1-hr fire resistance rating where the exit connects three stories or less. Existing penetrations shall be protected in accordance with 8.3.5. This deficient practice could affect 9 patients, staff and visitors on the second floor.

Findings include:

Based on observations with Plant Operator #1 during a tour of the facility from 1:00 p.m. to 3:15 p.m. on 06/26/17, the following openings were noted in the east stairwell above the suspended ceiling above the second floor stairwell entry door:
a. the two inch annular space surrounding each of two one inch in diameter pipes which penetrated the stairwell wall which were not firestopped.
b. two one inch diameter holes caused by the insertion of hooks into the wall to support cables run parallel to the stairwell wall which were not firestopped.
Each of the aforementioned holes did not maintain the fire resistance rating of the stairwell vertical opening. Based on interview at the time of the observations, Plant Operator #1 acknowledged the openings in the second floor stairwell wall failed to maintain the fire resistance rating of the east stairwell and this was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

Based on observation and interview, the facility failed to ensure 2 of 12 basement hazardous areas and 1 of 17 first floor hazardous areas, such as a combustible storage room over 50 square feet, and a maintenance workshop, were either provided with self closing device which would cause the doors to automatically close and latch into the door frames or provided with a room separated by smoke partitions. This deficient practice affects any number of patients and staff and visitors.

Findings include:

Based on observations on 06/26/17 and 06/27/17 during a tour of the facility with the plant services manager from 8:15 a.m. to 4:30 p.m., the basement East Hall maintenance workshop door, and the first floor emergency room storage room, which measured one hundred twenty square feet and had twenty shelves of combustible paper and plastic nursing and surgery supplies, each lacked a self closing device on the doors. Furthermore, the basement housekeeping storage room, which measured three hundred twelve square feet and had six wooden pallets of cardboard paper towels and paper and plastic supplies had a four inch unfinished area of drywall along the entire top of the twenty foot long south wall and along the top of the twenty foot long north wall. This was verified by the plant services manager at the time of observations and acknowledged at the exit conference on 07/03/17 at 10:45 a.m.

Based on observation and interview, the facility failed to provide emergency lighting in 3 of 3 operating rooms where general anesthesia is administered in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.2.2.11.1 states one or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered. The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room. Units shall be capable of providing lighting for 90 minutes and shall be tested monthly for 30 seconds and annually for 30 minutes. Section 3.3.17 defines battery-powered lighting units as individual unit equipment for backup illumination consisting of a rechargeable battery, battery-charging means, provisions for one or more lamps mounted on the equipment, or with terminals for remote lamps, or both, and relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment. This deficient practice could affect three patients and staff in operating rooms where general anesthesia or life support equipment is used.

Findings include:

Based on observations with the Operating Room Manager at 10:30 a.m. on 06/27/17, Operating Room 1, Operating Room 2 and Operating Room 3 were each not provided with battery operated emergency lighting to provide continuous illumination where general anesthesia is administered. Based on interview at the time of the observations, the Operating Room Manager stated patients in each of the aforementioned three operating rooms can be completely sedated and rendered immobile using general anesthesia and acknowledged there is no battery operated back up emergency lighting system to provide continuous illumination in each of the three operating rooms where general anesthesia is administered. This was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

Based on observation and interview, the facility failed to ensure 1 of 1 second floor air handling rooms was provided with a complete interior finish with a flame spread rating of Class A or Class B for a sprinklered facility. LSC 3.3.90.4 defines interior wall finish as the interior finish of columns, fixed or movable walls, and fixed or movable partitions. A.3.3.90.2 states interior finish is not intended to apply to surfaces within spaces such as those that are concealed or inaccessible. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with Plant Operator #1 during a tour of the facility from 1:00 p.m. to 3:15 p.m. on 06/26/17, the rectangular supporting framework for four separate outside air intake grills in the west wall of the second floor air handling unit room identified as Plant Services 6 consisted of exposed wood. Each of the four wood frames measured 120 inches by 240 inches. Based on interview at the time of the observations, Plant Operator #1 stated he was unaware of the flame spread rating of the wood studs or if they consisted of fire retardant treated wood and acknowledged the flame spread rating of the exposed wood framework for the air intake grills was not known. This was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

Based on observation and interview, the facility failed to ensure the spray pattern for automatic sprinklers were not obstructed in 1 of over 100 rooms in accordance with NFPA 13. NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition, Section 8.5.5.1 states sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2 and 8.5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Sections 8.5.5.2 and 8.5.5.3 do not permit continuous or noncontinuous obstructions less than or equal to 18 inches below the sprinkler deflector or in a horizontal plane more than 18 inches below the sprinkler deflector that prevent the spray pattern from fully developing. This deficient practice could affect 10 staff and visitors.

Findings include:

Based on observations with Plant Operator #1 during a tour of the facility from 1:00 p.m. to 3:15 p.m. on 06/26/17, the top shelf of shelving inside the storage room in the smoke compartment containing the Chief Executive's Office on the first floor was positioned twelve inches below the ceiling mounted pendant sprinkler which caused automatic sprinkler head spray pattern obstruction. In addition, one small cardboard box placed on the top shelf further reduced the distance below the ceiling sprinkler. Based on interview at the time of the observations, Plant Operator #1 acknowledged the aforementioned storage room had automatic sprinkler head spray pattern obstruction less than 18 inches below the sprinkler deflector which would prevent the spray pattern from fully developing. This was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems was provided with spare sprinklers of each type located throughout the facility. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. This deficient practice could affect all patients in the emergency room area of the first floor.

Findings include:

Based on observation on 06/27/17 at 10:10 a.m. with the plant services manager, the first floor emergency room outside overhang had sidewall sprinklers mounted on the exterior of the building. Furthermore, the basement sprinkler riser room spare sprinkler cabinet was observed on 06/27/17 at 10:25 a.m. and spare sprinkler cabinet lacked spare sprinklers for the first floor emergency room outside overhang. This was verified by the plant services manager at the time of observation and acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

Based on observation and interview, the facility failed to ensure 1 of over 10 offices was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 19.3.6.1(7). LSC 19.3.6.1(7) states that spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be open to the corridor and unlimited in area, provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, and (b) Each space is protected by an automatic sprinklers, and (c) The space does not to obstruct access to required exits. This deficient practice could affect three patients, staff and visitors in the vicinity of the Human Resources Office on the first floor.

Findings include:

Based on observations with the Plant Services Maintenance Technician during a tour of the facility from 8:30 a.m. to 11:15 a.m. on 06/27/17, the Human Resources Office on the first floor is open to the corridor because a nonrated three foot by four foot sliding glass door set is in the corridor wall for the office. The office had no smoke detector and was open to the corridor due to the opening for the sliding doors. Furthermore, LSC 19.3.6.1(7) was not met because the room was not protected by an electrically supervised automatic smoke detection system. Based on interview at the time of observation, the Plant Services Maintenance Technician acknowledged the Physician and Consultant office on the first floor was open to the corridor and was not equipped with automatic smoke detection. This was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

1. Based on record review, observation and interview; the facility failed to ensure openings through 3 of over 20 smoke barrier walls were protected to maintain the fire resistance rating of the smoke barrier. LSC 19.3.7.3 refers to Section 8.5. Section 8.5.6.2 states penetrations for cables, conduits, pipes and similar items that pass through a wall constructed as a smoke barrier shall be protected by a system or material capable of resisting the transfer of smoke. Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of Section 8.3.5 to limit the spread of fire for a time period equal to the fire resistance of the assembly and Section 8.5.6. This deficient practice could affect 3 patients, staff and visitors on the first floor and any number of patients, staff and visitors who would use the basement dining area.

Findings include:

Based on review of facility blueprint documentation with the Plant Services Manager at 12:30 p.m. on 06/26/17, the smoke barrier wall by the elevators in the main entrance lobby on the first floor has a two-hour fire resistance rating and extends from outside wall to outside wall. Based on observations with the Plant Services Maintenance Technician during a tour of the facility from 8:30 a.m. to 11:15 a.m. on 06/27/17, a one inch hole for the passage of 10 data cables was noted above the suspended ceiling above the 90 minute fire resistance rated corridor door set by the elevators in the main entrance lobby on the first floor. Based on interview at the time of the observations, the Plant Services Maintenance Technician acknowledged the aforementioned hole in the smoke barrier wall did not maintain the fire resistance rating of the smoke barrier wall. Furthermore, based on observations of the basement smoke barrier walls with maintenance worker #1 on 06/26/17 from 12:20 p.m. to 1:30 p.m., the basement B zone one hour smoke barrier wall above the drop ceiling, located in the Back Hall leading into Fresenius Dialysis, had a one half inch gap along the thirty foot long top of the wall where the drywall met the concrete deck not fire stopped and the basement B zone smoke barrier wall above the drop ceiling outside the environmental services storage room had a six inch by four inch square area of drywall missing on the north wall where two water pipe penetrations were located. This was verified by maintenance worker #1 at the time of observations and acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

2. Based on observation and interview, the facility failed to ensure 1 of 3 ceiling smoke barriers was maintained to provide at least a one half hour fire resistance rating. This deficient practice could affect 2 staff and visitors on the second floor.

Findings include:

Based on observations with Plant Operator #1 during a tour of the facility from 1:00 p.m. to 3:15 p.m. on 06/26/17, a one inch hole for the passage of a metal rod was noted in the ceiling of the second floor electrical room identified as Room E22 by the laundry. Based on interview at the time of the observations, Plant Operator #1 acknowledged the aforementioned hole in the ceiling smoke barrier did not maintain at least a one half hour fire resistance rating for the ceiling smoke barrier. This was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

Based on record review and interview, the facility failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2.
1. Use of alarms.
2. Transmission of alarms to fire department.
3. Emergency phone call to fire department
4. Response to alarms.
5. Isolation of fire.
6. Evacuation of immediate area.
7. Evacuation of smoke compartment.
8. Preparation of floors and building for evacuation.
9. Extinguishment of fire.
This deficient practice affects all patients, staff and visitors in the event of an emergency.

Findings include:

Based on record review on 06/26/17 at 11:45 a.m. with the plant services manager, the facility's fire safety plan labeled Fire Plan Harrison County Hospital lacked the following items required in the Life Safety Code;
a. The ALARM section on page 2 stated "pull manual alarm and notify the ED Registration Office, Ext. 2226, of the location and severity of the fire" but lacked where the manual pull station boxes are located throughout the facility and the ALARM section on page 2, number 1 stated the monitoring services will notify Central Dispatch of an alarm condition and what entrance the Fire Department should use but lacked how the transmission of the fire alarm occurs to the fire department. Furthermore, the Extinguish section on page 2 stated " EXTINGUISH the fire-Use PASS Procedure with Fire Extinguisher P- Pull the Pin, A- Aim the nozzle at the base of the fire, S- Squeeze the handle, S- Sweep the fire with the spray in a back-and-forth motion until the fire is out" but lacked the type and location of portable fire extinguishers located throughout the facility including the K Class fire extinguisher located in the kitchen and kitchen staff use of the K Class fire extinguisher in relation to the overhead hood extinguishing system located in the hood above the stoves. This was acknowledged by the plant services manager at exit conference on 07/03/17 at 10:45 a.m.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times on the 3 of 3 shifts and 4 of 4 quarters over the past year. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on review of Fire Drill Reports with the plant services manager during record review from 10:10 a.m. to 10:45 a.m. on 06/27/16, the following fire drills were conducted at similar times over the past year;
a. First shift fire drills (7 a.m. to 3:00 p.m.)., were held on 03/31/17 at 2:06 p.m. for the first quarter of 2017, 06/30/16 at 1:54 p.m. for the second quarter of 2016, and 12/30/16 at 1:47 p.m. for the fourth quarter of 2016.
b. Second shift fire drills (3:00 p.m. to 11:00 p.m.) were held on 02/28/17 at 5:46 p.m. for the first quarter of 2017, 05/31/17 at 5:58 p.m. for the second quarter of 2017, 08/31/16 at 5:59 p.m. for the third quarter of 2016, and 11/30/16 at 5:45 p.m. for the fourth quarter of 2016.
c. Third shift fire drills (11:00 p.m. to 7:00 a.m.) were held on 01/31/17 at 5:36 a.m. for the first quarter of 2017, 04/28/17 at 6:09 a.m. for the second quarter of 2017, 07/29/16 at 5:38 a.m. for the third quarter of 2016, and 10/28/16 at 5:35 a.m. for the fourth quarter of 2016. The lack of fire drills held at unexpected times for all shifts over the past year was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.

Based on record review, observation and interview; the facility failed to ensure 2 of 2 extension cords including power strips were not used as a substitute for fixed wiring. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition. NFPA 70, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect five staff and visitors.

Findings include:

Based on observations with the Plant Services Maintenance Technician during a tour of the facility from 8:30 a.m. to 11:15 a.m. on 06/27/17, the following was high voltage electric devices were plugged into power strips:
a. a refrigerator was plugged into a power strip in the office area behind the three desk check in area near the main entrance lobby on the first floor.
b. a refrigerator and a microwave oven were plugged into a power strip in the first floor Staff Office identified as Room 1254.
Based on interview at the time of the observations, the Plant Services Maintenance Technician acknowledged a power strip was being used as a substitute for fixed wiring at the aforementioned locations. This was acknowledged by the plant services manager at the exit conference on 07/03/17 at 10:45 a.m.