HospitalInspections.org

Based on observation and interview, the facility failed to ensure the interior finish for the walls of 1 of 1 exit corridors had a Class A or Class B flame spread rating (FSR). This deficient practice affects visitors, staff and 2 patients on the second floor.

Findings include:

Based on observations during a tour with the maintenance director on 02/10/10 between 12:10 p.m. and 1:40 p.m., the second floor exit corridor walls were covered with wall paper. The maintenance director said at the time of observations, he had no FSR information for the materials. He said the facility intended to remove all wallpaper from the facility but had not completed the task. No evidence of ongoing work of this nature was observed at the time of observation.

Based on observation and interview, the facility failed to ensure the interior finish for walls in 3 of 20 rooms on the unsprinklered second floor smoke compartment had a flame spread rating of Class A or B. This deficient practice could affect staff, visitors and 2 patients on the second floor.

Findings include:

Based on observations during a tour with the maintenance director on 02/10/10 between 12:10 p.m. and 1:40 p.m., wallpaper covered the walls of rooms 236, 240 and the doctor's sleeping room. The maintenance director said at the time of observations, there was no documentation the wallpaper had a flame spread rating of Class A or B. He said the facility intended to remove all wallpaper from the facility but had not completed the task. No evidence of ongoing work of this nature was observed at the time of observation.

1. Based on observation and interview, the facility failed to provide 1 of 44 corridor doors to resist the passage of smoke. This deficient practice affects patients, staff and visitors on the third floor with a census of 7 patients.

Findings include:

Based on observation during a tour with the maintenance director on 02/10/10 at 10:35 a.m., the corridor door to the third floor unsprinklered ice machine room was removed leaving the space open to the corridor. The maintenance director said, at the time of observation, the door had been removed "forever".

2. Based on observation and interview, the facility failed to ensure there were no impediments to closing 2 of 12 doors protecting corridor openings in the emergency and radiology smoke compartment. This deficient practice affects staff, visitors and 18 patients in the emergency and radiology smoke compartments.
Findings include:
Based on observation during a tour with the maintenance director on 02/10/10 at 2:15 p.m., corridor doors to the ophthalmology treatment/exam room and radiology (2) offices which were adjacent to one another, were prevented from closing by wooden wedges. The maintenance director agreed at the time of observation, the doors should not be held open. He also commented, wedges would be removed and "they would just be put back" (by staff).

Based on observation and interview, the facility failed to ensure the passage of pipe and/or cable through 1 of 4 smoke barrier walls in an electrical room was sealed to maintain the smoke resistance of each smoke barrier. LSC 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice affects any occupant in the room, typically 1 or 2 staff and/or contractors and patients and staff in an adjacent radiology treatment room.

Findings include:

Based on observation during a tour with the maintenance director on 02/10/10 at 2:25 p.m., the concrete smoke barrier/fire wall between the electrical equipment room and and adjacent radiology treatment room had two unsealed penetrations around two inch cables. Each unsealed penetration left a gap of one half inch in the wall. The maintenance director said, at the time of observation, they should have been sealed but would be gone when an expected renovation was done.

Based on observation and interview, the facility failed to ensure 6 of 6 stairway exit enclosures were provided with fire rated doors which met separation requirements for the 1 hour rated enclosures. LSC 7-2.2.5.1 requires all inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2 and meet the requirements of Section 8.2. LSC 7.1.3.2(a) requires exit separation shall not have less than a 1 hour fire resistance rating where the exit connects three stories or less. LSC 8.2.3.2.3.1 requires openings in 1 hour rated fire barriers to have a 1 hour fire protection in exit enclosures. This deficient practice affects all occupants.

Findings include:

Based on observations during a tour with the maintenance director on 02/10/10 between 10:50 a.m. and 3:20 p.m., exit stairway access doors from the basement and first, second, and third floors each had no fire rating label. The maintenance director said at the time of observations, all doors were original to the construction dates and there was no documented fire rating information available for any exit stairway door.

Based on observation and interview, the facility failed to ensure 2 of 2 third floor and basement level exit means of egress corridors were free of all obstructions which could interfere with full instant use. This deficient practice could affect 15 staff observed on the basement level and staff visitors and 19 patients on the third floor.

Findings include:

1. Based on observations during a tour with the maintenance director between 11:45 a.m. and 12:10 p.m. on 02/10/10, exit corridors were used for storing equipment that was not in use:
a. In the main east west corridor on the third floor: a portable privacy screen, five overbed tables (with and without wheels), equipment cart with seven combustible cardboard cartons, two wheelchairs with foot rest attachments sitting on the seats, and a gerichair. In addition, two blood pressure machine, IV pumps and an EKG machine stood in the corridor plugged into outlets for recharging.
b. A second, "L" shaped, six foot wide third floor corridor exit way from a patient treatment/office area into the main exit corridor was used to store medical supplies on shelves in a dead end alcove approximately six feet by five and one half foot, as well as a linen cart and overbed table.
The maintenance director said at the time of observations, there was no room to store the equipment. He agreed in the event of an emergency, everything would have to be removed from the corridor in the event of a fire emergency.

2. Based on observation during a tour with the maintenance director at 2:40 p.m. on 02/10/10, the basement level exit corridor was used for the collection of three large utility carts laden with cardboard and a sixteen carton stack of combustible cardboard cartons stacked against the wall. A reel of four inch banding material stood in the corridor. The maintenance director said at the time of observation, the corridor site was used for the collection and organization of cardboard to be recycled.

3. Based on observation during a tour with the maintenance director at 2:45 p.m. on 02/10/10, three open, large receptacles were parked in the basement level exit corridor near the freight elevator. The maintenance director confirmed at the time of observation, the carts could usually be found there.

Based on observation and interview, the facility failed to ensure 2 of 2 common fire barrier walls provided complete separation from another occupancy. LSC 7.2.4.3.1 requires fire barriers separating building areas where there are horizontal exits shall have a 2 hour fire resistance rating and shall provide a separation that is continuous to ground. This deficient practice could affect visitors, staff and 2 patients on the unsprinklered second floor.

Findings include:

Based on observation during a tour with the maintenance director on 02/10/10 at 12:20 p.m., two common walls separating the second floor from another occupancy were incomplete. The concrete wall separating the two occupancies stopped above the lay in ceiling in every space along the entire length of the common walls. The maintenance director confirmed, the walls should have been completed from floor to ceiling to provide the required 2 hour fire barrier between the other, separately licensed residential occupancy.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 posted second floor evacuation floor plans accurately identified means of exit in the event of an emergency. This deficient practice could affect visitors, staff and 2 patients on the second floor.

Findings include:

Two second floor evacuation floor plan diagrams were reviewed. The first, used as part of the emergency evacuation plan was provided for review by the administrative services director on 02/10/10 at 1:40 p.m. The same evacuation diagram, posted in the second floor exit corridor was observed on 02/10/10 at 12:45 p.m. with the maintenance director. The diagram showed a corridor and walls which did not exist. The maintenance director said at the time of observation, the diagram had not been revised to include changes to corridor exitways made during renovations on the second floor. The maintenance director agreed at the times of review and observation, the diagrams could not be used to identify the actual location of corridor exitways on the second floor.

1. Based on record review and interview, the facility failed to ensure fire drills were conducted on every shift during 3 of the past 4 quarters. This deficient practice affects all occupants of the facility.

Findings include:

Based on a review of Fire Drill records provided for the past year with the administrative services director on 02/10/10 at 1:05 p.m., fire drills were not documented for the third shift during the first and fourth quarter, and the first shift of the second quarter of 2009. The administrative services director said she made an effort to vary the fire drills but was unaware of the requirement to conduct drills at least once per shift per quarter.

2. Based on record review and interview, the facility failed to ensure fire drills were conducted at unexpected times during 7 of 12 documented fire drills. This deficient practice affects all occupants.

Findings include:

Based on a review of Fire Drill records provided for the past year with the administrative services director on 02/10/10 at 1:05 p.m., four fire drills conducted during the second shift (3:00 p.m. to 11:00 p.m.)were done between 3:10 p.m. and 3:20 p.m. The three fire drills done on the night shift (11:00 p.m. to 7:00 a.m.) were done between 5:30 a.m. and 6:00 a.m. The administrative services director agreed at the time of review, the fire drill times were not varied because she had done them when it was convenient to her schedule. In addition, it was noted the fire drills were usually done during the last week of the month, between the 23rd and 31st.

Based on record review and interview, the facility failed to ensure documentation for the sensitivity testing for 1 of 1 smoke detector fire protection systems was complete. LSC Section 9.6.1.3 says the provisions of 9.6 cover the basic functions of the fire alarm system, including fire detection systems. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, at 7-3.2.1 states, "Detector sensitivity shall be checked within one year after installation and every alternative year thereafter. After the second required calibration test, if sensitivity tests indicate the detectors have remained within their listed and marked sensitivity ranges, the length of time between calibration tests may be extended to a maximum of five years. If the frequency is extended, records of detector caused nuisance alarms shall be maintained. In zones or areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure each smoke detector is within its listed and marked sensitivity range it shall be tested using the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for the purpose.
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its acceptable sensitivity range.
(5) Other calibrated sensitivity test method acceptable to the authority having jurisdiction.
Detectors found to have sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of aerosol into the detector."
NFPA 72-1.1.2 requires system defects and malfunctions shall be corrected. This deficient practice affects all occupants.

Findings include:

Based on a review of Fire Alarm Test and Inspection Summary Reports dated 05/01/09 and 05/30/08 with the maintenance director on 02/10/10 at 12:55 p.m., an incomplete smoke detector sensitivity test record was included in the 2008 report in that the contractor tested only half the smoke detectors. The issue was confirmed by the maintenance director at the time of record review. The 2008 report included 20 smoke detectors which failed the testing and/or were noted to need replacement due to damage. The maintenance director also said he did not remember what service, if any, was done to replace failed detectors and/or retest them. He said he didn't have documentation to show work done and had no other record of inspection for smoke detectors which were not included in the 2008 test.

Based on record review and interview, the facility failed to ensure an annual test to check backflow preventers for 1 of 1 sprinkler systems was conducted as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 9-6.2.1. This deficient practice affects all visitors, staff, and 18 patients in the sprinklered emergency department.

Findings include:

Based on review of the annual Report of Inspection and Testing of the sprinkler system and quarterly sprinkler maintenance department test records with the maintenance director on 02/10/10 at 1:30 p.m., no backflow test was found with the records provided. The maintenance director said at the time of record review, all service and inspection of the sprinkler system was included in the records provided.

Based on observation and interview, the facility failed to keep 5 of 5 unattended trash collection receptacles with a capacity of more than 32 gallons located within a 64 square foot area, in a room protected as a hazardous area. This deficient practice affects basement level occupants where 15 staff were observed.

Findings include:

a. Based on observation during a tour with the maintenance director at 2:45 p.m. on 02/10/10, three open, partially filled large trash receptacles were parked in the basement level exit corridor near the freight elevator. The maintenance director confirmed at the time of observation, the carts, larger than 32 gallons, could usually be found there.
b. Based on observation during a tour with the maintenance director at 2:40 p.m. on 02/10/10, two trash receptacles were standing in the corridor outside the kitchen access door. A check of the receptacles revealed they were being used. The maintenance director agreed at the time of observation, the unattended receptacles each had the capacity to hold more than 32 gallons.

1. Based on observation, record review, and interview; the facility failed to ensure 4 of 9 reserve cylinders of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart. NFPA 99, Health Care Facilities, 8-3.1.11.2(h) requires cylinder or container restraint shall meet NFPA 99, 4-3.5.2.1(b)13 which requires oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. This deficient practice affects anyone in the northwest parking area adjacent to the bulk oxygen storage area.

Findings include:

Based upon review of a facility contractor inspection record, Bulk Oxygen Source Evaluation dated 04/22/09, with the maintenance director on 02/10/10 at 1:50 p.m., item 21, noted "reserve cylinders are not secured with fastenings to prevent accidental dislocations". The maintenance director said, at the time of record review the issue was corrected. Based on observation during a tour of the facility with the maintenance director on 02/10/10 at 2:35 p.m., four large reserve medical gas cylinders stood without support in the chain link fence enclosure immediately adjacent to the bulk oxygen storage tank for piped in oxygen. The maintenance director agreed at the time of observation, the cylinders should have been secured with the chain provided to prevent damage to the valve.

2. Based on observation, record review and interview; the facility failed to ensure 2 of 2 oxygen storage locations were labeled with signs as required by NFPA 99, The Standard for Health Care Facilities and NFPA 55, The Standard for the Storage of Compressed Gases and Cryogenic Fluids in Portable and Stationary Containers, Cylinders, and Tanks. NFPA 99, 8-3.1.11.3 requires a precautionary sign, readable from a distance of five feet, shall be conspicuously displayed on each door or gate of the storage enclosure. NFPA 55, 6.13.2.2 requires signs prohibiting smoking or open flames within 25 feet of the area's perimeter where oxidizing gases are stored or used. This deficient practice affects could affect anyone in the northwest parking lot, the ambulance bay and third floor patient room floor.

Findings include:

Based on observation during a tour with the maintenance director on 02/10/10 between 11:32 a.m. and 3:20 p.m., 16 reserve oxygen e-cylinders were stored in the the emergency department ambulance bay. No warning sign was posted in the ambulance bay. A sign posted on the chain link fence enclosure of the bulk oxygen and large reserve cylinder storage located in the northwest parking lot read, "No Smoking". Nothing visible from a distance of five feet served as a warning that oxygen was stored at the site. The maintenance director agreed, at the time of observations, oxygen signs should have been in place in the ambulance bay. He said he thought no smoking signs were good enough for the bulk oxygen storage location.

1. Based on observation and interview, the facility failed to provide emergency task lighting in and around 2 of 2 generator sets in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery-powered emergency lighting. This deficient practice could affect all occupants.

Findings include:

Based on observation with the maintenance director on 02/10/10 between 2:50 p.m. and 3:20 p.m., two generator sets located within the building lacked battery powered emergency lighting. The maintenance director confirmed at the time of observations, maintenance staff or contractors would have to use flashlights for task lighting in the event either generator failed concurrent with a power outage.

2. Based on interview and record review, the facility failed to provide the complete documentation for testing 2 of 2 emergency generators providing power to the emergency lighting systems. LSC 7.9.2.3 and NFPA 99, Health Care Facilities, 3-4.4.1.1(a) requires monthly testing of the generator set shall be in accordance with NFPA 110, the Standard for Emergency and Standby Power Systems. NFPA 110, 6-4.2 requires generator sets in Level 1 and 2 service shall be exercised under operating conditions or not less than 30 percent of the EPS (Emergency Power Supply) nameplate rating at least monthly, for a minimum of 30 minutes. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affects all occupants.

Findings include:

Based on review of the Boiler Room Cummins and 1983 Add Detroit Diesel emergency generator facility maintenance and testing records for the two emergency generator with the maintenance director on 02/10/10 at 1:55 p.m., the emergency generators were run under load for each weekly test for a minimum 30 minutes time. The test records did not include the time for the transfer of power from the main source to the generator, the percent load carried by each generator or exhaust temperature documentation. A review of a Power Systems PM Level Two Service Record dated 08/19/09 was conducted at the same time. These records noted a simulated utility outage to test the transfer switches, noting the amperage and voltage readings for each of three phases during testing. The record noted customer authorized load transfer was not applicable. This record had no documentation of the percent load carried by the generator when tested under load. The maintenance director said at the time of record review, there was no documentation of the load transfer time and he thought one generator ran under about 85% and the other 25% when under load but conceded he could not produce records to support the claim.

Based on observation and interview, the facility failed to ensure the interior finish for the walls of 1 of 1 exit corridors had a Class A or Class B flame spread rating (FSR). This deficient practice affects visitors, staff and 2 patients on the second floor.

Findings include:

Based on observations during a tour with the maintenance director on 02/10/10 between 12:10 p.m. and 1:40 p.m., the second floor exit corridor walls were covered with wall paper. The maintenance director said at the time of observations, he had no FSR information for the materials. He said the facility intended to remove all wallpaper from the facility but had not completed the task. No evidence of ongoing work of this nature was observed at the time of observation.

Based on observation and interview, the facility failed to ensure the interior finish for walls in 3 of 20 rooms on the unsprinklered second floor smoke compartment had a flame spread rating of Class A or B. This deficient practice could affect staff, visitors and 2 patients on the second floor.

Findings include:

Based on observations during a tour with the maintenance director on 02/10/10 between 12:10 p.m. and 1:40 p.m., wallpaper covered the walls of rooms 236, 240 and the doctor's sleeping room. The maintenance director said at the time of observations, there was no documentation the wallpaper had a flame spread rating of Class A or B. He said the facility intended to remove all wallpaper from the facility but had not completed the task. No evidence of ongoing work of this nature was observed at the time of observation.

1. Based on observation and interview, the facility failed to provide 1 of 44 corridor doors to resist the passage of smoke. This deficient practice affects patients, staff and visitors on the third floor with a census of 7 patients.

Findings include:

Based on observation during a tour with the maintenance director on 02/10/10 at 10:35 a.m., the corridor door to the third floor unsprinklered ice machine room was removed leaving the space open to the corridor. The maintenance director said, at the time of observation, the door had been removed "forever".

2. Based on observation and interview, the facility failed to ensure there were no impediments to closing 2 of 12 doors protecting corridor openings in the emergency and radiology smoke compartment. This deficient practice affects staff, visitors and 18 patients in the emergency and radiology smoke compartments.
Findings include:
Based on observation during a tour with the maintenance director on 02/10/10 at 2:15 p.m., corridor doors to the ophthalmology treatment/exam room and radiology (2) offices which were adjacent to one another, were prevented from closing by wooden wedges. The maintenance director agreed at the time of observation, the doors should not be held open. He also commented, wedges would be removed and "they would just be put back" (by staff).

Based on observation and interview, the facility failed to ensure the passage of pipe and/or cable through 1 of 4 smoke barrier walls in an electrical room was sealed to maintain the smoke resistance of each smoke barrier. LSC 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice affects any occupant in the room, typically 1 or 2 staff and/or contractors and patients and staff in an adjacent radiology treatment room.

Findings include:

Based on observation during a tour with the maintenance director on 02/10/10 at 2:25 p.m., the concrete smoke barrier/fire wall between the electrical equipment room and and adjacent radiology treatment room had two unsealed penetrations around two inch cables. Each unsealed penetration left a gap of one half inch in the wall. The maintenance director said, at the time of observation, they should have been sealed but would be gone when an expected renovation was done.

Based on observation and interview, the facility failed to ensure 6 of 6 stairway exit enclosures were provided with fire rated doors which met separation requirements for the 1 hour rated enclosures. LSC 7-2.2.5.1 requires all inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2 and meet the requirements of Section 8.2. LSC 7.1.3.2(a) requires exit separation shall not have less than a 1 hour fire resistance rating where the exit connects three stories or less. LSC 8.2.3.2.3.1 requires openings in 1 hour rated fire barriers to have a 1 hour fire protection in exit enclosures. This deficient practice affects all occupants.

Findings include:

Based on observations during a tour with the maintenance director on 02/10/10 between 10:50 a.m. and 3:20 p.m., exit stairway access doors from the basement and first, second, and third floors each had no fire rating label. The maintenance director said at the time of observations, all doors were original to the construction dates and there was no documented fire rating information available for any exit stairway door.

Based on observation and interview, the facility failed to ensure 2 of 2 third floor and basement level exit means of egress corridors were free of all obstructions which could interfere with full instant use. This deficient practice could affect 15 staff observed on the basement level and staff visitors and 19 patients on the third floor.

Findings include:

1. Based on observations during a tour with the maintenance director between 11:45 a.m. and 12:10 p.m. on 02/10/10, exit corridors were used for storing equipment that was not in use:
a. In the main east west corridor on the third floor: a portable privacy screen, five overbed tables (with and without wheels), equipment cart with seven combustible cardboard cartons, two wheelchairs with foot rest attachments sitting on the seats, and a gerichair. In addition, two blood pressure machine, IV pumps and an EKG machine stood in the corridor plugged into outlets for recharging.
b. A second, "L" shaped, six foot wide third floor corridor exit way from a patient treatment/office area into the main exit corridor was used to store medical supplies on shelves in a dead end alcove approximately six feet by five and one half foot, as well as a linen cart and overbed table.
The maintenance director said at the time of observations, there was no room to store the equipment. He agreed in the event of an emergency, everything would have to be removed from the corridor in the event of a fire emergency.

2. Based on observation during a tour with the maintenance director at 2:40 p.m. on 02/10/10, the basement level exit corridor was used for the collection of three large utility carts laden with cardboard and a sixteen carton stack of combustible cardboard cartons stacked against the wall. A reel of four inch banding material stood in the corridor. The maintenance director said at the time of observation, the corridor site was used for the collection and organization of cardboard to be recycled.

3. Based on observation during a tour with the maintenance director at 2:45 p.m. on 02/10/10, three open, large receptacles were parked in the basement level exit corridor near the freight elevator. The maintenance director confirmed at the time of observation, the carts could usually be found there.

Based on observation and interview, the facility failed to ensure 2 of 2 common fire barrier walls provided complete separation from another occupancy. LSC 7.2.4.3.1 requires fire barriers separating building areas where there are horizontal exits shall have a 2 hour fire resistance rating and shall provide a separation that is continuous to ground. This deficient practice could affect visitors, staff and 2 patients on the unsprinklered second floor.

Findings include:

Based on observation during a tour with the maintenance director on 02/10/10 at 12:20 p.m., two common walls separating the second floor from another occupancy were incomplete. The concrete wall separating the two occupancies stopped above the lay in ceiling in every space along the entire length of the common walls. The maintenance director confirmed, the walls should have been completed from floor to ceiling to provide the required 2 hour fire barrier between the other, separately licensed residential occupancy.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 posted second floor evacuation floor plans accurately identified means of exit in the event of an emergency. This deficient practice could affect visitors, staff and 2 patients on the second floor.

Findings include:

Two second floor evacuation floor plan diagrams were reviewed. The first, used as part of the emergency evacuation plan was provided for review by the administrative services director on 02/10/10 at 1:40 p.m. The same evacuation diagram, posted in the second floor exit corridor was observed on 02/10/10 at 12:45 p.m. with the maintenance director. The diagram showed a corridor and walls which did not exist. The maintenance director said at the time of observation, the diagram had not been revised to include changes to corridor exitways made during renovations on the second floor. The maintenance director agreed at the times of review and observation, the diagrams could not be used to identify the actual location of corridor exitways on the second floor.

1. Based on record review and interview, the facility failed to ensure fire drills were conducted on every shift during 3 of the past 4 quarters. This deficient practice affects all occupants of the facility.

Findings include:

Based on a review of Fire Drill records provided for the past year with the administrative services director on 02/10/10 at 1:05 p.m., fire drills were not documented for the third shift during the first and fourth quarter, and the first shift of the second quarter of 2009. The administrative services director said she made an effort to vary the fire drills but was unaware of the requirement to conduct drills at least once per shift per quarter.

2. Based on record review and interview, the facility failed to ensure fire drills were conducted at unexpected times during 7 of 12 documented fire drills. This deficient practice affects all occupants.

Findings include:

Based on a review of Fire Drill records provided for the past year with the administrative services director on 02/10/10 at 1:05 p.m., four fire drills conducted during the second shift (3:00 p.m. to 11:00 p.m.)were done between 3:10 p.m. and 3:20 p.m. The three fire drills done on the night shift (11:00 p.m. to 7:00 a.m.) were done between 5:30 a.m. and 6:00 a.m. The administrative services director agreed at the time of review, the fire drill times were not varied because she had done them when it was convenient to her schedule. In addition, it was noted the fire drills were usually done during the last week of the month, between the 23rd and 31st.

Based on record review and interview, the facility failed to ensure documentation for the sensitivity testing for 1 of 1 smoke detector fire protection systems was complete. LSC Section 9.6.1.3 says the provisions of 9.6 cover the basic functions of the fire alarm system, including fire detection systems. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, at 7-3.2.1 states, "Detector sensitivity shall be checked within one year after installation and every alternative year thereafter. After the second required calibration test, if sensitivity tests indicate the detectors have remained within their listed and marked sensitivity ranges, the length of time between calibration tests may be extended to a maximum of five years. If the frequency is extended, records of detector caused nuisance alarms shall be maintained. In zones or areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure each smoke detector is within its listed and marked sensitivity range it shall be tested using the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for the purpose.
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its acceptable sensitivity range.
(5) Other calibrated sensitivity test method acceptable to the authority having jurisdiction.
Detectors found to have sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of aerosol into the detector."
NFPA 72-1.1.2 requires system defects and malfunctions shall be corrected. This deficient practice affects all occupants.

Findings include:

Based on a review of Fire Alarm Test and Inspection Summary Reports dated 05/01/09 and 05/30/08 with the maintenance director on 02/10/10 at 12:55 p.m., an incomplete smoke detector sensitivity test record was included in the 2008 report in that the contractor tested only half the smoke detectors. The issue was confirmed by the maintenance director at the time of record review. The 2008 report included 20 smoke detectors which failed the testing and/or were noted to need replacement due to damage. The maintenance director also said he did not remember what service, if any, was done to replace failed detectors and/or retest them. He said he didn't have documentation to show work done and had no other record of inspection for smoke detectors which were not included in the 2008 test.

Based on record review and interview, the facility failed to ensure an annual test to check backflow preventers for 1 of 1 sprinkler systems was conducted as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 9-6.2.1. This deficient practice affects all visitors, staff, and 18 patients in the sprinklered emergency department.

Findings include:

Based on review of the annual Report of Inspection and Testing of the sprinkler system and quarterly sprinkler maintenance department test records with the maintenance director on 02/10/10 at 1:30 p.m., no backflow test was found with the records provided. The maintenance director said at the time of record review, all service and inspection of the sprinkler system was included in the records provided.

Based on observation and interview, the facility failed to keep 5 of 5 unattended trash collection receptacles with a capacity of more than 32 gallons located within a 64 square foot area, in a room protected as a hazardous area. This deficient practice affects basement level occupants where 15 staff were observed.

Findings include:

a. Based on observation during a tour with the maintenance director at 2:45 p.m. on 02/10/10, three open, partially filled large trash receptacles were parked in the basement level exit corridor near the freight elevator. The maintenance director confirmed at the time of observation, the carts, larger than 32 gallons, could usually be found there.
b. Based on observation during a tour with the maintenance director at 2:40 p.m. on 02/10/10, two trash receptacles were standing in the corridor outside the kitchen access door. A check of the receptacles revealed they were being used. The maintenance director agreed at the time of observation, the unattended receptacles each had the capacity to hold more than 32 gallons.

1. Based on observation, record review, and interview; the facility failed to ensure 4 of 9 reserve cylinders of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart. NFPA 99, Health Care Facilities, 8-3.1.11.2(h) requires cylinder or container restraint shall meet NFPA 99, 4-3.5.2.1(b)13 which requires oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. This deficient practice affects anyone in the northwest parking area adjacent to the bulk oxygen storage area.

Findings include:

Based upon review of a facility contractor inspection record, Bulk Oxygen Source Evaluation dated 04/22/09, with the maintenance director on 02/10/10 at 1:50 p.m., item 21, noted "reserve cylinders are not secured with fastenings to prevent accidental dislocations". The maintenance director said, at the time of record review the issue was corrected. Based on observation during a tour of the facility with the maintenance director on 02/10/10 at 2:35 p.m., four large reserve medical gas cylinders stood without support in the chain link fence enclosure immediately adjacent to the bulk oxygen storage tank for piped in oxygen. The maintenance director agreed at the time of observation, the cylinders should have been secured with the chain provided to prevent damage to the valve.

2. Based on observation, record review and interview; the facility failed to ensure 2 of 2 oxygen storage locations were labeled with signs as required by NFPA 99, The Standard for Health Care Facilities and NFPA 55, The Standard for the Storage of Compressed Gases and Cryogenic Fluids in Portable and Stationary Containers, Cylinders, and Tanks. NFPA 99, 8-3.1.11.3 requires a precautionary sign, readable from a distance of five feet, shall be conspicuously displayed on each door or gate of the storage enclosure. NFPA 55, 6.13.2.2 requires signs prohibiting smoking or open flames within 25 feet of the area's perimeter where oxidizing gases are stored or used. This deficient practice affects could affect anyone in the northwest parking lot, the ambulance bay and third floor patient room floor.

Findings include:

Based on observation during a tour with the maintenance director on 02/10/10 between 11:32 a.m. and 3:20 p.m., 16 reserve oxygen e-cylinders were stored in the the emergency department ambulance bay. No warning sign was posted in the ambulance bay. A sign posted on the chain link fence enclosure of the bulk oxygen and large reserve cylinder storage located in the northwest parking lot read, "No Smoking". Nothing visible from a distance of five feet served as a warning that oxygen was stored at the site. The maintenance director agreed, at the time of observations, oxygen signs should have been in place in the ambulance bay. He said he thought no smoking signs were good enough for the bulk oxygen storage location.

1. Based on observation and interview, the facility failed to provide emergency task lighting in and around 2 of 2 generator sets in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery-powered emergency lighting. This deficient practice could affect all occupants.

Findings include:

Based on observation with the maintenance director on 02/10/10 between 2:50 p.m. and 3:20 p.m., two generator sets located within the building lacked battery powered emergency lighting. The maintenance director confirmed at the time of observations, maintenance staff or contractors would have to use flashlights for task lighting in the event either generator failed concurrent with a power outage.

2. Based on interview and record review, the facility failed to provide the complete documentation for testing 2 of 2 emergency generators providing power to the emergency lighting systems. LSC 7.9.2.3 and NFPA 99, Health Care Facilities, 3-4.4.1.1(a) requires monthly testing of the generator set shall be in accordance with NFPA 110, the Standard for Emergency and Standby Power Systems. NFPA 110, 6-4.2 requires generator sets in Level 1 and 2 service shall be exercised under operating conditions or not less than 30 percent of the EPS (Emergency Power Supply) nameplate rating at least monthly, for a minimum of 30 minutes. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affects all occupants.

Findings include:

Based on review of the Boiler Room Cummins and 1983 Add Detroit Diesel emergency generator facility maintenance and testing records for the two emergency generator with the maintenance director on 02/10/10 at 1:55 p.m., the emergency generators were run under load for each weekly test for a minimum 30 minutes time. The test records did not include the time for the transfer of power from the main source to the generator, the percent load carried by each generator or exhaust temperature documentation. A review of a Power Systems PM Level Two Service Record dated 08/19/09 was conducted at the same time. These records noted a simulated utility outage to test the transfer switches, noting the amperage and voltage readings for each of three phases during testing. The record noted customer authorized load transfer was not applicable. This record had no documentation of the percent load carried by the generator when tested under load. The maintenance director said at the time of record review, there was no documentation of the load transfer time and he thought one generator ran under about 85% and the other 25% when under load but conceded he could not produce records to support the claim.