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NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Patient room doors are arranged so that the patient can open the door from inside without using a key. 19.2.2.2.2.

This STANDARD is not met as evidenced by:

Based on observation, it was determined the facility failed to maintain approved door locking arrangements in accordance with NFPA 101 (2000) Chapter 19, Sections 19.2. This deficient practice could adversely affect 12 of 12 patients within the Mental Health Unit.

FINDINGS INCLUDE:

On 1/3/12 between 9:30 AM and 5:00 PM, while surveying in the Mental Health Unit, observation revealed 12 of 12 patient bedroom doors - and all bathroom doors located within the patient bedrooms - were equipped with single-keyed deadbolt locks. These locks were keyed from the corridor side, and no thumb-turn devices were installed on the egress side. This locking arrangement was not in accordance with the requirements at NFPA 101 (00) Chapter 19, Section 19.2.2.2.2 and the 2007 edition of Minnesota State Fire Code (MSFC) Chapter 10, Section 1008.1.8.

This deficient practice was verified with the assistant building engineer at the time of discovery.

Based on observation, the facility's fire alarm system was not installed in conformance with NFPA 101 (2000), Chapter 19, Section 19.3.4 and Chapter 9, Section 9.6.1.4 and NFPA 70 (1999) and NFPA 72 (1999). In a fire emergency, this deficient practice could adversely affect 66 of 66 patients.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, observation revealed that smoke detectors in the following areas were located within 3-feet of HVAC openings:
A). Gift Shop;
B). Old ambulance manager's office;
C). New ambulance quarters;
D). Lower level egress corridor, east-side;
E). Front Lobby;
F). Intensive Care Unit.

This arrangement was not in conformance with the requirements at NFPA 72 (1999) Chapter 2, Section 2-3.6.6.2.

These findings were confirmed with facility maintenance staff at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE REGULATION - A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with NFPA 70 National Electrical Code (1999 edition) and NFPA 72 National Fire Alarm Code (1999 edition). The system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70 (99) and NFPA 72 (99) and NFPA 101 Life Safety Code (2000 edition), Chapter 18 and Chapter 9, Section 9.6.1.4.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, while surveying in the Behavioral Health Services clinic, observation confirmed the main fire alarm control panel [FACP] was not protected by an automatic, interconnected smoke detector.

In a fire emergency, a non-functioning DACT could adversely affect the safety of all building occupants.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, observation revealed the following areas were not equipped with automatic fire sprinklers:
A). Rehabilitation Vestibule, lower-level;
B). Elevator pit #1;
C). Elevator pit #2;
D). Transformer Room;
E). High-voltage Room.

In a fire emergency, this deficient practice could adversely affect 66 of 66 patients.

These findings were confirmed with facility maintenance staff at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically, and are in conformance with NFPA 101 (2000 edition), Chapter 19, Sections 19.3.5 and 19.7.6, and Chapter 9, Section 9.7 and NFPA 13 (1999 edition) and NFPA 25 (1998 edition).

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, while surveying in the Hot Storage Room, observation revealed a fire sprinkler located within 12-inches of a water pipe. This arrangement was not in conformance with NFPA 13 (99), Chapter 5, Sections 5-5.5.2.1 and 5-5.6.

Continuous or noncontinuous obstructions less than or equal to 18-inches below a sprinkler deflector can prevent the spray pattern from fully developing. In a fire emergency, this deficient practice could adversely affect 66 of 66 patients.

This finding was verified with the assistant building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to provide battery-powered emergency lighting at all anesthetizing locations, in accordance with NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). In a power failure situation, this deficient practice could adversely affect the safety of an anesthetized patient, rendered incapable of self-preservation.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, while surveying in the facility's surgical suite, observation revealed that no battery-powered emergency lighting units were provided in Operating Rooms 1, 2, and 4. This arrangement was not in accordance with NFPA 99 (1999 edition) Chapter 3, Section 3-3.2.1.2 (5)(e).

This finding was verified with the surgical supervisor at the time of discovery.

OTHER LSC DEFICIENCY NOT ON 2786.

Minnesota State Fire Code (2007 edition), Section 907.2.10.1.1 - Single- or multiple-station smoke alarms shall be installed in sleeping areas of all Occupancy Group R-1 locations.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:40 PM, observation revealed three (3) Staff On-call sleeping rooms, and these sleeping rooms were not equipped with hard-wired, automatic smoke detectors. This arrangement was not in accordance with MSFC (07) Chapter 9, Sections 907.3.6 and 907.2.10.

These findings were confirmed with building maintenance staff at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Patient room doors are arranged so that the patient can open the door from inside without using a key. 19.2.2.2.2.

This STANDARD is not met as evidenced by:

Based on observation, it was determined the facility failed to maintain approved door locking arrangements in accordance with NFPA 101 (2000) Chapter 19, Sections 19.2. This deficient practice could adversely affect 12 of 12 patients within the Mental Health Unit.

FINDINGS INCLUDE:

On 1/3/12 between 9:30 AM and 5:00 PM, while surveying in the Mental Health Unit, observation revealed 12 of 12 patient bedroom doors - and all bathroom doors located within the patient bedrooms - were equipped with single-keyed deadbolt locks. These locks were keyed from the corridor side, and no thumb-turn devices were installed on the egress side. This locking arrangement was not in accordance with the requirements at NFPA 101 (00) Chapter 19, Section 19.2.2.2.2 and the 2007 edition of Minnesota State Fire Code (MSFC) Chapter 10, Section 1008.1.8.

This deficient practice was verified with the assistant building engineer at the time of discovery.

Based on observation, the facility's fire alarm system was not installed in conformance with NFPA 101 (2000), Chapter 19, Section 19.3.4 and Chapter 9, Section 9.6.1.4 and NFPA 70 (1999) and NFPA 72 (1999). In a fire emergency, this deficient practice could adversely affect 66 of 66 patients.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, observation revealed that smoke detectors in the following areas were located within 3-feet of HVAC openings:
A). Gift Shop;
B). Old ambulance manager's office;
C). New ambulance quarters;
D). Lower level egress corridor, east-side;
E). Front Lobby;
F). Intensive Care Unit.

This arrangement was not in conformance with the requirements at NFPA 72 (1999) Chapter 2, Section 2-3.6.6.2.

These findings were confirmed with facility maintenance staff at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE REGULATION - A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with NFPA 70 National Electrical Code (1999 edition) and NFPA 72 National Fire Alarm Code (1999 edition). The system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70 (99) and NFPA 72 (99) and NFPA 101 Life Safety Code (2000 edition), Chapter 18 and Chapter 9, Section 9.6.1.4.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, while surveying in the Behavioral Health Services clinic, observation confirmed the main fire alarm control panel [FACP] was not protected by an automatic, interconnected smoke detector.

In a fire emergency, a non-functioning DACT could adversely affect the safety of all building occupants.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, observation revealed the following areas were not equipped with automatic fire sprinklers:
A). Rehabilitation Vestibule, lower-level;
B). Elevator pit #1;
C). Elevator pit #2;
D). Transformer Room;
E). High-voltage Room.

In a fire emergency, this deficient practice could adversely affect 66 of 66 patients.

These findings were confirmed with facility maintenance staff at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically, and are in conformance with NFPA 101 (2000 edition), Chapter 19, Sections 19.3.5 and 19.7.6, and Chapter 9, Section 9.7 and NFPA 13 (1999 edition) and NFPA 25 (1998 edition).

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, while surveying in the Hot Storage Room, observation revealed a fire sprinkler located within 12-inches of a water pipe. This arrangement was not in conformance with NFPA 13 (99), Chapter 5, Sections 5-5.5.2.1 and 5-5.6.

Continuous or noncontinuous obstructions less than or equal to 18-inches below a sprinkler deflector can prevent the spray pattern from fully developing. In a fire emergency, this deficient practice could adversely affect 66 of 66 patients.

This finding was verified with the assistant building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to provide battery-powered emergency lighting at all anesthetizing locations, in accordance with NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). In a power failure situation, this deficient practice could adversely affect the safety of an anesthetized patient, rendered incapable of self-preservation.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:30 PM, while surveying in the facility's surgical suite, observation revealed that no battery-powered emergency lighting units were provided in Operating Rooms 1, 2, and 4. This arrangement was not in accordance with NFPA 99 (1999 edition) Chapter 3, Section 3-3.2.1.2 (5)(e).

This finding was verified with the surgical supervisor at the time of discovery.

OTHER LSC DEFICIENCY NOT ON 2786.

Minnesota State Fire Code (2007 edition), Section 907.2.10.1.1 - Single- or multiple-station smoke alarms shall be installed in sleeping areas of all Occupancy Group R-1 locations.

FINDINGS INCLUDE:

On 1/4/12 between 8:30 AM and 4:40 PM, observation revealed three (3) Staff On-call sleeping rooms, and these sleeping rooms were not equipped with hard-wired, automatic smoke detectors. This arrangement was not in accordance with MSFC (07) Chapter 9, Sections 907.3.6 and 907.2.10.

These findings were confirmed with building maintenance staff at the times of discovery.