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Based on observations and interviews, the facility failed to ensure that door openings closed to resist the passage of smoke into an exit corridor. This potentially exposed patients to smoke. Findings:


Observation during the facility tour on 11/10/2010 at 10:15 am revealed that the double doors opening from the 1st floor radiology suite to the corridor had the self closing hardware removed from one leaf. Interview with maintenance staff revealed they did not realize that self closing door hardware was required.


The above findings were acknowledged at the time by the Facilities Director and the Facilities Manager. The findings were also acknowledged by the Quality Manager and the Facilities Director during the exit conference on 11/10/2010 at 2:15 pm.





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Based on record review and interview the facility failed to conduct fire drills at least quarterly on every shift . This deficient practice affected all staff and patients. Findings:


A review of fire drill records on 11/10/2010 at 12:00 pm revealed there was no record of the night shift participating in fire drills from 04/1/2010 to 08/26/2010, and there was no record of the evening shift participating in fire drills from 03/31/2010 to 08/26/2010. Interview with the Security Supervisor on 11/10/2010 at 12:10 pm revealed that his department schedules and records the fire drills. In addition, he stated that he believed the fire drills had taken place but they were not able to locate the documentation.


The above findings were acknowledged at the time by the Facilities Director, the Facilities Manager, and the Security Supervisor. The findings were also acknowledged by the Quality Manager and the Facilities Director during the exit conference on 11/10/2010 at 2:15 pm.



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Based on record review and interview, the facility failed to ensure that the fire alarm system was properly maintained. This deficiency had the potential to expose patients, staff and visitors to a smoke or fire environment. Findings:


Record review on 11/09/2010 at 1:34 pm of the "Report of Inspection" for the fire alarm system, dated 08/04/2010, revealed that the service technician reported in the Deficiencies section that "Numerous smoke detectors were slow to respond when smoke tested. The age of these devices indicate that replacement should be considered."

Interview with the Facilities Manager and the Facility Director revealed they were aware of the problem and that the entire fire alarm system was scheduled to be replaced within the next 12 months.


Observations during the facility tour on 11/09/2010 at 4:00 pm and 11/10/2010 at 2:00 pm revealed that the fire alarm control panel was indicating trouble. The Facility Director and Facility Manager acknowledged the observation but were not able to determine what was causing the trouble indicator to be activated.


The above findings were acknowledged at the time by the Facilities Director, and the Facilities Manager. The findings were also acknowledged by the Quality Manager and the Facilities Director during the exit conference on 11/10/2010 at 2:15 PM.





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Based on record review and interview the facility failed to have a licensed sprinkler technician provide annual service for the automatic fire pump associated with the fire sprinkler system. This could potentially expose patients to a fire and/or smoke environment Findings:


Record review during the facility tour on 11/10/2010 at 8:30 am revealed the automatic fire pump associated with the automatic fire sprinkler system was tested by facility maintenance personnel rather than sprinkler service technicians who are licensed by the State of Alaska. All work on automatic fire sprinkler systems is required to be completed by individuals who hold permits issued by the State of Alaska.


The above findings were acknowledged at the time by the Facilities Director, and the Facilities Manager. The findings were also acknowledged by the Quality Manager and the Facilities Director during the exit conference on 11/10/2010 at 2:15 pm.





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Based on record review and interview the facility failed to have a technician with the appropriate permit provide annual service for the kitchen hood and duct fire suppression system. This could potentially exposed patients to a fire and/or smoke environment Findings:


Record review during the facility tour on 11/09/2010 at 2:00 pm revealed that the kitchen hood and duct automatic fire suppression system was tested by facility maintenance personnel rather than service technicians who are licensed by the State of Alaska. All work on automatic fire suppression systems is required to be completed by individuals who hold permits issued by the State of Alaska.


The above findings were acknowledged at the time by the Facilities Director, and the Facilities Manager. The findings were also acknowledged by the Quality Manager and the Facilities Director during the exit conference on 11/10/2010 at 2:15 pm.





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Based on observations and interview the facility failed to ensure that the upholstered furniture used in the facility was flame resistant. This deficient practice had the potential to affect patients, staff, and visitors. Findings:


Observations in the third floor lobby during the facility tour on 11/09/2010 at 2:45 pm revealed several upholstered couches and chairs that did not have product tags indicating the furniture met flammability and smoke generation requirements.


The above findings were acknowledged at the time by the Facilities Director, and the Facilities Manager. The findings were also acknowledged by the Quality Manager and the Facilities Director during the exit conference on 11/10/2010 at 2:15 pm.





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Based on record review and staff interview the facility failed to ensure the emergency generator was inspected and exercised under load, in accordance with NFPA 99, 3-4.4.1.3. This potentially exposed patients to loss of illumination of exit egresses, and loss of fire and smoke alarm equipment during a power outage. Findings:


Record review of generator maintenance documentation on 11/10/2010 at 12:50 pm revealed the log records were incomplete; it was not possible to determine if the three generators had all been exercised under load once a month. Further review revealed that a new log form was being used, with the first entry in October 2010. Review of this log revealed that Generator 1 and Generator 3 had both ben exercised for at least 30 minutes, but that Generator 2 had only been exercised for .3 hours in October.


The above findings were acknowledged at the time by the Facilities Director, and the Facilities Manager. The findings were also acknowledged by the Quality Manager and the Facilities Director during the exit conference on 11/10/2010 at 2:15 pm.







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