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The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 04/10/12 at10:30 PM, the surveyor was not provided with documentation by the safety Associate responsible for conducting fire drills, that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC i.e. the facility was utilizing the exception in the LSC 19.7.1.2 for silent fire drills between the hours of 9:00 PM through 6:00 AM. Documentation reviewed indicated that the drills conducted were question and answer sessions with no overhead announcement as required and the staff was not required to practice closing doors, clearing hallways.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

On 04/11/12 at 09:40 AM, the surveyor was not provided with documentation from the Facilities Manager at Bradley Memorial Campus to indicate that the wet pipe sprinkler system at the facility had preventative maintenance conducted on it that is required every 5 (five) years by sections 2-1, 9-4.1.2 & 9-4.2.1 of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems; i.e. no record of obstruction investigation, (interior) alarm valve inspection, strainer, filter & orifice inspection or (interior) check valve inspections.

The facility did not ensure that means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10
On 04/10/12 at 11:05AM, the surveyor along with the Director of facilities observed that the egress corridor on the north wing, third floor had an desk built into a corridor alcove and staff were utilizing it as a RN/MD charting station with multiple chairs and work stations on wheels not maintaining the egress corridor as required by the LSC.

The facility did not ensure that draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are flame resistant in accordance with the provisions of 10.3.1 of the referenced, Life Safety Code, NFPA 13, Standard for the Installation of Sprinkler Systems and NFPA 701.

On 04/11/12 at 11:50 AM, the surveyor while accompanied by the Director of Engineering observed that portable, wheeled, privacy curtains throughout the Labor & Delivery/NICU Department were not provided with labels or tags that indicated they were constructed of materials that were flame resistant, as required by the Life Safety Code; i.e. items placed into service without verification/documentation of compliance with NFPA 701, for flame resistance.

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 04/10/12 at10:30 PM, the surveyor was not provided with documentation by the safety Associate responsible for conducting fire drills, that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC i.e. the facility was utilizing the exception in the LSC 19.7.1.2 for silent fire drills between the hours of 9:00 PM through 6:00 AM. Documentation reviewed indicated that the drills conducted were question and answer sessions with no overhead announcement as required and the staff was not required to practice closing doors, clearing hallways.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

On 04/11/12 at 09:40 AM, the surveyor was not provided with documentation from the Facilities Manager at Bradley Memorial Campus to indicate that the wet pipe sprinkler system at the facility had preventative maintenance conducted on it that is required every 5 (five) years by sections 2-1, 9-4.1.2 & 9-4.2.1 of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems; i.e. no record of obstruction investigation, (interior) alarm valve inspection, strainer, filter & orifice inspection or (interior) check valve inspections.

The facility did not ensure that means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10
On 04/10/12 at 11:05AM, the surveyor along with the Director of facilities observed that the egress corridor on the north wing, third floor had an desk built into a corridor alcove and staff were utilizing it as a RN/MD charting station with multiple chairs and work stations on wheels not maintaining the egress corridor as required by the LSC.

The facility did not ensure that draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are flame resistant in accordance with the provisions of 10.3.1 of the referenced, Life Safety Code, NFPA 13, Standard for the Installation of Sprinkler Systems and NFPA 701.

On 04/11/12 at 11:50 AM, the surveyor while accompanied by the Director of Engineering observed that portable, wheeled, privacy curtains throughout the Labor & Delivery/NICU Department were not provided with labels or tags that indicated they were constructed of materials that were flame resistant, as required by the Life Safety Code; i.e. items placed into service without verification/documentation of compliance with NFPA 701, for flame resistance.