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Based on observation and interview, the facility failed to ensure rated, self-closing door in a protected egress to an exit is at least 20 minute fire-rated in accordance with 19.3.7.5. This deficient practice potentially affects all staff and patients that use the door as a designated egress from lower-level storage and office areas, two skills classrooms for elderly outpatients and medical records storage. The facility census was six.

Findings included:

1. Observation on 08/27/13 at 9:30 AM showed the fire rating label of an exit door had been obscured by paint and was not legible. The door was located at the end of a protected corridor that extended through the basement and opened into a ground level exit vestibule at the base of the north stair tower.

2. During an interview at the same date and time, Staff O, Chief Support Officer, stated that the door had just recently been repainted and he recalled he told the painter to tape over the door rating labels before painting. He stated he did not have a policy that specified fire-rating labels should be checked on regular Preventive Maintenance rounds.

Based on observation and interview, the totally sprinklered facility failed to ensure sprinkler coverage to all areas of the facility that exceed 24 square feet in dimension in accordance with 8.15.8.2, (NFPA 13, 2010 edition). This deficient practice potentially affects all patients and staff in the Emergency Department area. The facility census was six.

Findings included:

1. Observation on 08/26/13 at 2:50 PM showed a storage closet in the Emergency Department measured about four feet wide by three feet deep was not equipped with an automatic sprinkler. The closest sprinkler head was less than four feet away, just outside the closet. However, the closet's wood door, frame and Class A walls extended to the ceiling and potentially blocked any part of the spray pattern from entering the cabinet.

During an interview at the same date and time, Staff O, Chief Support Officer, acknowledged the observation and stated that the custom made doors and shelves were added during a renovation of the area and the redesigned entrance to the room blocked off a former doorway.

Based on observation and interview, the facility failed to ensure soiled linen or trash collection receptacles in excess of 32 gallons capacity were stored in accordance with 19.7.5.5. This deficient practice potentially affects staff, visitors and patients in a 25 bed hospital. The facility census was six.

Findings included:

1. Observation on 08/26/13 at 2:58 PM showed two, large capacity 44 gallon Rubbermaid waste containers stored in a soiled utility work room. The room was served by two entrances and was located between the med-surg patient rooms and an unoccupied three-bay observation area.

2. During an interview at the same date and time, the two staff working in the room at the time stated that the barrels were stored in the room and used for linen only.

Based on observation and interview, the facility failed to provide auxiliary lighting to illuminate an outdoor located generator set in accordance with NFPA 70, National Electrical Code, section 700-12(e) to provide auxiliary lighting in the event that the generator suffered damage and had to be started manually. This deficient practice potentially affects all staff, visitors and patients of the 25 bed facility. The facility census was six.

Findings included:

1. Observation on 08/26/13 at 3:00 PM showed a 250 kW generator located outside near the hospital without any type of emergency illumination attached to a pole, ground light or by other means. In the event of damage to the building or prime mover (generator motor unit) from severe weather or physical collision (such as results from tornado damage) the battery powered emergency light would provide necessary illumination on the unit while personnel attempt to override the equipment failure to start and run the unit manually.

2. During an interview at the same date and time, Staff O, Chief Support Officer, stated that the generator only had a light on the instrument panel.

Based on observation and interview, the facility failed to maintain a clear width and work area in accordance with NFPA 110, 7.2.2.1 of twice the clearance around the Electrical Power Supply (EPS) transfer switch as required by Article 110.26(a)(2) of NFPA 70 to ensure workers have adequate room to avoid contacting grounded components or incurring injury when retreating. This deficient practice potentially affects facility staff and any contracted repairmen who may be working on the hospital's electrical systems. The facility census was six.
Findings included:
1. Observation on 08/26/13 at 1:45 PM showed several pieces of excess medical equipment, beds, bed parts, furniture and several items awaiting repair or destined for replacement in a room identified as an Electrical/Mechanical room on the north end of the building's main level. Several pieces of furniture parts and equipment were stored within 12 inches and crowded access to the four large switch boxes and automatic transfer switch (ATS) for the emergency generator. The obstacles posed a potential hazard to anyone attempting to safely operate one or all of the circuit breaker boxes. There was no warning sign, safety bar or markings on the floor to serve as a visible reminder for staff to maintain a minimum 30 inch clear space in front of high voltage equipment.
2. During an interview on the same date and time, Staff O, Chief Support Officer, stated that, although the ATS switch was wired into the facility's electrical grid, the generator it would operate has not been installed yet. He stated that they had no specific policy or procedure that specified clearance of a safe work space around the electrical equipment, but the other things in the room could be moved back and re-arranged to meet code requirements.