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Based on observation and interview, the facility failed to ensure 1 of 2 stairwells in the 2001 addition had an exit access from the ground floor which met the separation requirements to exit from the ground floor. NFPA 101 at 7.3.2.1 requires a separation shall have not less than a 1 hour fire resistance rating where the exits connect three or less stories. This deficient practice could affect all patients evacuated through the Southeast stairwell in the 2001 addition in the event of an emergency.

Findings include:

Based on an observation with the Director of Environmental Services on 02/11/10 at 11:40 a.m., the ground floor southeast stairwell door was a twenty minute fire rated door. This was acknowledged by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure 2 of 2 smoke detectors in the Intensive Care Unit (ICU) were not installed where air flow would adversely affect their operation. LSC 9.6.1.3 says the provisions of 9.6 cover the basic functions of a complete fire alarm system. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect 4 patients in the ICU in the event of an emergency.

Findings include:

Based on an observation with the Director of Environmental Services on 02/11/10 at 2:30 p.m., both of the smoke detectors in the ICU were located within three feet of an supply air duct. This was acknowledged by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure the spray pattern for 2 of 2 sprinkler heads in the kitchen pantry were unobstructed. LSC 9.7.5 requires all automatic sprinkler systems be inspected, tested and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Section 2-2.1.2 states unacceptable obstructions to spray patterns shall be corrected. This deficient practice would affect all kitchen staff personnel in the event of an emergency.

Findings include:

Based on an observation with Maintenance Man # 1 on 02/11/10 at 1:55 p.m., the spray pattern of the sprinkler heads in the kitchen pantry were obstructed by cardboard boxes. This was acknowledged by the Director of Environmental Services on 02/11/10 at 3:55 p.m., at the time of the exit interview.

Based on observation and interview, the facility failed to ensure 1 of 1 generators was in accordance with NFPA 99, 1999 Edition, Standard for Health Care Facilities. NFPA 99, Section 3-4.1.1.15 requires a remote annunciator to indicate alarm conditions of the emergency or auxiliary power source as follows: individual visual signals indicating when emergency or auxiliary power source is operating to power a load and when battery charger is malfunctioning and visual signals with a common audible signal to warn of the following: low lubricating oil pressure, low water temperature, excessive water temperature, low fuel, overcrank and overspeed. Additionally the remote annunciator shall be provided in a location readily observed by operating personnel at a regular work station. This deficient practice could affect all patients, staff and visitors in the 2008 addition.

Findings include:

Based on observations with Director of Environmental Services on 02/11/10 at 11:45 a.m. and again at 3:10 p.m., the annunciator panel for the generator suppling emergency power to the 2008 addition was located in the 2008 addition electrical room B118 which was not continuously occupied by staff personnel. This was acknowledged by the Director of Environmental Services at the time of observations.

Based on observation and interview, the facility failed to ensure 2 of 2 generators were in accordance with NFPA 99, 1999 Edition, Standard for Health Care Facilities. NFPA 99, Section 3-4.1.1.15 requires a remote annunciator to indicate alarm conditions of the emergency or auxiliary power source as follows: individual visual signals indicating when emergency or auxiliary power source is operating to power a load and when battery charger is malfunctioning and visual signals with a common audible signal to warn of the following: low lubricating oil pressure, low water temperature, excessive water temperature, low fuel, overcrank and overspeed. Additionally the remote annunciator shall be provided in a location readily observed by operating personnel at a regular work station. This deficient practice could affect all patients, staff and visitors in the original building.

Findings include:

Based on observations with Director of Environmental Services on 02/11/10 at 11:45 a.m. and again at 3:10 p.m., the two annunciator panels for the two generators supplying emergency power to the original building were located in the maintenance shop in the original building and it was not continuously occupied by staff personnel. This was acknowledged by the Director of Environmental Services at the time of observations.

Based on observation and interview, the facility failed to ensure 17 of 18 wet location resident care areas such as the pre/post operation area room in the 2008 addition were provided with ground fault circuit interrupter (GFCI) against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as patient care areas subjected to wet conditions while patients are present. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect any patients or staff in seventeen of the rooms in the pre/post op area.

Findings include:

Based on observations with the Director of Environmental Services on 02/11/10 from 1:45 p.m. to 2:05 p.m., all of the rooms in the pre/post operation area in the 2008 addition with the exception of room eighteen had an electrical receptacle on the wall within three feet of a sink that were not provided with GFCI protection to prevent electric shock. Based on an interview with the Director of Environmental Services, when he tested with a GFCI testing device, none of the receptacle circuits were interrupted when the button was pressed therefore each of the seventeen room receptacles were not provided with GFCI protection to prevent electric shock.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period to protect 12 of 12 patients in accordance with LSC, Section 9.7.6.1. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice affects all patients in the facility.

Findings include:

Based on review of the fire watch policy titled "Policy & Procedure of Dekalb Memorial Hospital" section "Safety" under the "Prolonged Outages" heading with the Director of Environmental Services on 02/11/10 at 11:40 a.m., the facility did have a written policy and procedure for an impaired sprinkler system, however, the policy and procedure did not include the following:
a) contacting the local fire department
b) the person(s) conducting the fire watch shall have proper training
c) the person(s) conducting the fire watch shall have no other duties or responsibilities.
This was acknowledged by the Director of Environmental Services on 02/11/10 at 3:50 p.m. during the exit interview.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of 12 of 12 patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all 12 patients in the facility.

Findings include:

Based on review of the fire watch policy titled "Policy & Procedure of Dekalb Memorial Hospital" section "Safety" under the "Prolonged Outages" heading with the Director of Environmental Services on 02/11/10 at 11:40 a.m., the facility did have a written policy and procedure for an impaired fire alarm system, however, the policy and procedure did not include the following:
a) contacting the local fire department
b) the person(s) conducting the fire watch shall have proper training
c) the person(s) conducting the fire watch shall have no other duties or responsibilities.
This was acknowledged by the Director of Environmental Services on 02/11/10 at 3:50 p.m. during the exit interview.

Based on observation and interview, the facility failed to ensure 1 of 2 stairwells in the 2001 addition had an exit access from the ground floor which met the separation requirements to exit from the ground floor. NFPA 101 at 7.3.2.1 requires a separation shall have not less than a 1 hour fire resistance rating where the exits connect three or less stories. This deficient practice could affect all patients evacuated through the Southeast stairwell in the 2001 addition in the event of an emergency.

Findings include:

Based on an observation with the Director of Environmental Services on 02/11/10 at 11:40 a.m., the ground floor southeast stairwell door was a twenty minute fire rated door. This was acknowledged by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure 2 of 2 smoke detectors in the Intensive Care Unit (ICU) were not installed where air flow would adversely affect their operation. LSC 9.6.1.3 says the provisions of 9.6 cover the basic functions of a complete fire alarm system. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect 4 patients in the ICU in the event of an emergency.

Findings include:

Based on an observation with the Director of Environmental Services on 02/11/10 at 2:30 p.m., both of the smoke detectors in the ICU were located within three feet of an supply air duct. This was acknowledged by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure the spray pattern for 2 of 2 sprinkler heads in the kitchen pantry were unobstructed. LSC 9.7.5 requires all automatic sprinkler systems be inspected, tested and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Section 2-2.1.2 states unacceptable obstructions to spray patterns shall be corrected. This deficient practice would affect all kitchen staff personnel in the event of an emergency.

Findings include:

Based on an observation with Maintenance Man # 1 on 02/11/10 at 1:55 p.m., the spray pattern of the sprinkler heads in the kitchen pantry were obstructed by cardboard boxes. This was acknowledged by the Director of Environmental Services on 02/11/10 at 3:55 p.m., at the time of the exit interview.

Based on observation and interview, the facility failed to ensure 1 of 1 generators was in accordance with NFPA 99, 1999 Edition, Standard for Health Care Facilities. NFPA 99, Section 3-4.1.1.15 requires a remote annunciator to indicate alarm conditions of the emergency or auxiliary power source as follows: individual visual signals indicating when emergency or auxiliary power source is operating to power a load and when battery charger is malfunctioning and visual signals with a common audible signal to warn of the following: low lubricating oil pressure, low water temperature, excessive water temperature, low fuel, overcrank and overspeed. Additionally the remote annunciator shall be provided in a location readily observed by operating personnel at a regular work station. This deficient practice could affect all patients, staff and visitors in the 2008 addition.

Findings include:

Based on observations with Director of Environmental Services on 02/11/10 at 11:45 a.m. and again at 3:10 p.m., the annunciator panel for the generator suppling emergency power to the 2008 addition was located in the 2008 addition electrical room B118 which was not continuously occupied by staff personnel. This was acknowledged by the Director of Environmental Services at the time of observations.

Based on observation and interview, the facility failed to ensure 2 of 2 generators were in accordance with NFPA 99, 1999 Edition, Standard for Health Care Facilities. NFPA 99, Section 3-4.1.1.15 requires a remote annunciator to indicate alarm conditions of the emergency or auxiliary power source as follows: individual visual signals indicating when emergency or auxiliary power source is operating to power a load and when battery charger is malfunctioning and visual signals with a common audible signal to warn of the following: low lubricating oil pressure, low water temperature, excessive water temperature, low fuel, overcrank and overspeed. Additionally the remote annunciator shall be provided in a location readily observed by operating personnel at a regular work station. This deficient practice could affect all patients, staff and visitors in the original building.

Findings include:

Based on observations with Director of Environmental Services on 02/11/10 at 11:45 a.m. and again at 3:10 p.m., the two annunciator panels for the two generators supplying emergency power to the original building were located in the maintenance shop in the original building and it was not continuously occupied by staff personnel. This was acknowledged by the Director of Environmental Services at the time of observations.

Based on observation and interview, the facility failed to ensure 17 of 18 wet location resident care areas such as the pre/post operation area room in the 2008 addition were provided with ground fault circuit interrupter (GFCI) against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as patient care areas subjected to wet conditions while patients are present. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect any patients or staff in seventeen of the rooms in the pre/post op area.

Findings include:

Based on observations with the Director of Environmental Services on 02/11/10 from 1:45 p.m. to 2:05 p.m., all of the rooms in the pre/post operation area in the 2008 addition with the exception of room eighteen had an electrical receptacle on the wall within three feet of a sink that were not provided with GFCI protection to prevent electric shock. Based on an interview with the Director of Environmental Services, when he tested with a GFCI testing device, none of the receptacle circuits were interrupted when the button was pressed therefore each of the seventeen room receptacles were not provided with GFCI protection to prevent electric shock.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period to protect 12 of 12 patients in accordance with LSC, Section 9.7.6.1. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice affects all patients in the facility.

Findings include:

Based on review of the fire watch policy titled "Policy & Procedure of Dekalb Memorial Hospital" section "Safety" under the "Prolonged Outages" heading with the Director of Environmental Services on 02/11/10 at 11:40 a.m., the facility did have a written policy and procedure for an impaired sprinkler system, however, the policy and procedure did not include the following:
a) contacting the local fire department
b) the person(s) conducting the fire watch shall have proper training
c) the person(s) conducting the fire watch shall have no other duties or responsibilities.
This was acknowledged by the Director of Environmental Services on 02/11/10 at 3:50 p.m. during the exit interview.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of 12 of 12 patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all 12 patients in the facility.

Findings include:

Based on review of the fire watch policy titled "Policy & Procedure of Dekalb Memorial Hospital" section "Safety" under the "Prolonged Outages" heading with the Director of Environmental Services on 02/11/10 at 11:40 a.m., the facility did have a written policy and procedure for an impaired fire alarm system, however, the policy and procedure did not include the following:
a) contacting the local fire department
b) the person(s) conducting the fire watch shall have proper training
c) the person(s) conducting the fire watch shall have no other duties or responsibilities.
This was acknowledged by the Director of Environmental Services on 02/11/10 at 3:50 p.m. during the exit interview.