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Based on observation and interview, the facility failed to ensure separation between extended smoke compartments of the Emergency Department and a hospital corridor in accordance with 18.3.7.8, which requires smoke doors in newly constructed areas to be equipped with rabbets, bevels or astragals at the meeting edges to prevent the passage of smoke through the doors in a fire. This deficient practice potentially affects staff, visitors and patients. The facility census was six.

Findings included:

1. Observation on 12/02/13 at 1:55 PM showed no astragal on a pair of smoke doors between the emergency department and a hospital corridor that served as a designated emergency exit to prevent the passage of smoke.

During an interview on 12/02//13 at 2:00 PM, Staff U, Human Resources Director, stated that the doors were added during a 2008 when the emergency department was relocated and expanded. She stated that the hospital does not have a written preventive maintenance policy that involves periodically verifying the integrity of smoke walls and doors in smoke walls.

Based on observation and interview, the facility failed to ensure the integrity of soiled utility and combustible storage rooms with rated doors and rated door frames in hazardous areas as required by 8.4.1.3 and 19.3.2.1 by painting over the fire rating of the door. Painting over the fire rating of the door obscures the verification that the door is rated for the level of the hazardous area being protected. This deficient practice potentially affects staff, visitors and patients. The facility census was six.

Findings included:

1. Observation on 12/02/13 at 2:00 PM showed paint obscured the fire rating of a rated door frame of a soiled utility room in the Outpatient area.
2. Observation on 12/02/13 at 2:40 PM showed paint obscured the fire rating of a rated door frame of a soiled utility room in the Emergency Department.
3. Observation on 12/03/13 at 9:00 AM showed paint obscured the fire rating of a rated door frame of a large storage room (known as "CPD") in the recovery area.

During an interview on 12/02/13 at 2:10 AM, Staff T, Plant Manager confirmed the sighting and stated that there was no written policy or procedure for preventive maintenance to preserve labels on fire rated doors. He stated he did not know how many rated door labels or rated door frame labels in the building were painted over.

Based on observation, interview and record review, the facility failed to provide complete sprinkler coverage in accordance with NFPA 101, 19.3.5.1 and NFPA 13, 8.14.8.2 to protect eight enclosed closets, electrical, storage and utility rooms that exceed 24 cubic feet. This deficient practice potentially affects all staff, visitors and patients of the hospital. The facility census was six.

Findings included:

1. Observation on 12/02/13 at 1:45 PM showed the following did not have automatic sprinkler coverage:

-No sprinkler head was installed in the IT closet on the second floor Administration corridor next to the elevator shaft.
-No sprinkler head was installed in an electrical room in the second floor corridor between Administration and Rehab.
-No sprinkler head was installed in a second floor Janitor's closet near the entrance to Rehab Therapy room.
-No sprinkler head was installed in a large (five foot wide by six foot deep) alcove off of the Cardio-Pulmonary corridor.
-No sprinkler head was installed in a large (five foot wide by eight foot deep) closet next to CPD and the phone room.
-No sprinkler head was installed in the Biohazard storage room where infectious waste is stored.
-No sprinkler head was installed in the first floor Medical Records utility closet.
-No sprinkler head was installed in the (eight foot wide by 11 foot deep) fourth stall where Disaster Preparedness equipment is stored.
All of the rooms were available and in service, with furnishings or storage of multiple combustible items.

During an interview on 12/3/13 at 11:00 AM Staff T Plant Operations Manager stated that he was still on his first 90 days and had never been in some of the rooms. Staff U, HR Director stated that she's been there for years and multiple inspections but was not aware there were any rooms that remained unprotected.

Record review of an annual inspection, test and recertification of the facility's complete automatic sprinkler document dated 10/03/13 showed the following inspector's comments:
-First floor Cardio-Pulmonary room used for equipment storage has no (sprinkler) head.
-First floor (Room 193) S. Storage-one booth has no head
-First floor Medical Records storage closet has no coverage.

Based on observation and interview, the facility failed to provide ventilation to stored medical gasses in accordance with NFPA 99, 4.3.1.1.2, which requires a dedicated ventilation system and one hour protection for supply systems greater than 3000 cubic feet. This deficient practice potentially affects all staff, visitors and patients. The facility census was six.

Findings included:

1. Observation on 12/03/13 at 3:38 PM showed approximately 20 " H " size cylinders and 25 "E" size cylinders of oxygen and other compressed medical gases in a 10 X 10 ft. storage room with sealed concrete block walls. The solid core wood door and metal door frame were not fire rated. The only ventilation provided for the room was a six inch square ceiling vent with no detectable air movement.

During an interview on 12/03/13, Staff T, Plant Manager, stated that the engineering firm currently performing air balance tests throughout the facility told him that they tested the room on 10/03/13 and there was no air being moved through it. He stated that he wasn't sure about what the problem was until he had a look. He stated that he did not have anything about the fan or ventilation on his preventive maintenance checklist.

Record review of the policy and procedure titled: Use of Medical and Other Gases dated October 6, 1993 stated that storage of flammable and oxidizing gases "shall be stored in rooms especially constructed for this use."

Based on observation and interview, the facility failed to protect occupants in accordance with 19.3.2.7, from electrical hazards associated with use of Alcohol-Based-Hand-Rub (ABHR-sanitizing solution sometimes used when soap and water are not readily available) in 12 of 18 rooms on the east wing, and 12 of 18 rooms on the south wing. This deficient practice affected staff, visitors and patients. The facility census was six.

Findings included:

1. Observation on 12/03/13 at 9:50 AM showed 12 of 13 rooms, 180, 181, 182, 183, 184, 186, 187, 188, 189, 190, 191, and 192 with ABHR dispensers mounted above handwashing sinks in each room, three inches or less from a duplex electrical outlet and a conventional wall-mounted light switch. All of the duplex electrical outlets were non-GFI (non Ground Fault Indicator) outlets, and posed a threat of electrocution and possible fire if the alcohol or water were accidentally splashed into the socket.

2. Observation on 12/03/13 at 1:00 PM showed 12 of 21 rooms, 220, 224, 223, 225, 227, 229, 238, 239, 240, 241, 242, 245 with ABHR dispensers mounted above handwashing sinks in each room, three inches or less from a duplex electrical outlet and a conventional wall-mounted light switch. All of the duplex electrical outlets were non-GFI outlets, and posed a threat of electrocution and possible fire if the alcohol or water were accidentally splashed into the socket.

GFI outlets each have a miniature circuit breaker that is individually grounded and automatically trips if a conductor such as a metal comb, wire hairpin or water crossed both poles.

During interviews on 12/14/13, Staff U, Human Resources Director, stated that they had cautioned the vendor who placed the dispensers to be aware of proximity to nearby electrical resources. She stated that apparently the facility safety committee had missed this during their last safety inspection, because there was no mention of them in the minutes. She stated that they did not have specific policy or preventive maintenance criteria for observation of safe/unsafe ABHR placement.

Based on observation and interview, the facility failed to ensure separation between extended smoke compartments of the Emergency Department and a hospital corridor in accordance with 18.3.7.8, which requires smoke doors in newly constructed areas to be equipped with rabbets, bevels or astragals at the meeting edges to prevent the passage of smoke through the doors in a fire. This deficient practice potentially affects staff, visitors and patients. The facility census was six.

Findings included:

1. Observation on 12/02/13 at 1:55 PM showed no astragal on a pair of smoke doors between the emergency department and a hospital corridor that served as a designated emergency exit to prevent the passage of smoke.

During an interview on 12/02//13 at 2:00 PM, Staff U, Human Resources Director, stated that the doors were added during a 2008 when the emergency department was relocated and expanded. She stated that the hospital does not have a written preventive maintenance policy that involves periodically verifying the integrity of smoke walls and doors in smoke walls.

Based on observation and interview, the facility failed to ensure the integrity of soiled utility and combustible storage rooms with rated doors and rated door frames in hazardous areas as required by 8.4.1.3 and 19.3.2.1 by painting over the fire rating of the door. Painting over the fire rating of the door obscures the verification that the door is rated for the level of the hazardous area being protected. This deficient practice potentially affects staff, visitors and patients. The facility census was six.

Findings included:

1. Observation on 12/02/13 at 2:00 PM showed paint obscured the fire rating of a rated door frame of a soiled utility room in the Outpatient area.
2. Observation on 12/02/13 at 2:40 PM showed paint obscured the fire rating of a rated door frame of a soiled utility room in the Emergency Department.
3. Observation on 12/03/13 at 9:00 AM showed paint obscured the fire rating of a rated door frame of a large storage room (known as "CPD") in the recovery area.

During an interview on 12/02/13 at 2:10 AM, Staff T, Plant Manager confirmed the sighting and stated that there was no written policy or procedure for preventive maintenance to preserve labels on fire rated doors. He stated he did not know how many rated door labels or rated door frame labels in the building were painted over.

Based on observation, interview and record review, the facility failed to provide complete sprinkler coverage in accordance with NFPA 101, 19.3.5.1 and NFPA 13, 8.14.8.2 to protect eight enclosed closets, electrical, storage and utility rooms that exceed 24 cubic feet. This deficient practice potentially affects all staff, visitors and patients of the hospital. The facility census was six.

Findings included:

1. Observation on 12/02/13 at 1:45 PM showed the following did not have automatic sprinkler coverage:

-No sprinkler head was installed in the IT closet on the second floor Administration corridor next to the elevator shaft.
-No sprinkler head was installed in an electrical room in the second floor corridor between Administration and Rehab.
-No sprinkler head was installed in a second floor Janitor's closet near the entrance to Rehab Therapy room.
-No sprinkler head was installed in a large (five foot wide by six foot deep) alcove off of the Cardio-Pulmonary corridor.
-No sprinkler head was installed in a large (five foot wide by eight foot deep) closet next to CPD and the phone room.
-No sprinkler head was installed in the Biohazard storage room where infectious waste is stored.
-No sprinkler head was installed in the first floor Medical Records utility closet.
-No sprinkler head was installed in the (eight foot wide by 11 foot deep) fourth stall where Disaster Preparedness equipment is stored.
All of the rooms were available and in service, with furnishings or storage of multiple combustible items.

During an interview on 12/3/13 at 11:00 AM Staff T Plant Operations Manager stated that he was still on his first 90 days and had never been in some of the rooms. Staff U, HR Director stated that she's been there for years and multiple inspections but was not aware there were any rooms that remained unprotected.

Record review of an annual inspection, test and recertification of the facility's complete automatic sprinkler document dated 10/03/13 showed the following inspector's comments:
-First floor Cardio-Pulmonary room used for equipment storage has no (sprinkler) head.
-First floor (Room 193) S. Storage-one booth has no head
-First floor Medical Records storage closet has no coverage.

Based on observation and interview, the facility failed to provide ventilation to stored medical gasses in accordance with NFPA 99, 4.3.1.1.2, which requires a dedicated ventilation system and one hour protection for supply systems greater than 3000 cubic feet. This deficient practice potentially affects all staff, visitors and patients. The facility census was six.

Findings included:

1. Observation on 12/03/13 at 3:38 PM showed approximately 20 " H " size cylinders and 25 "E" size cylinders of oxygen and other compressed medical gases in a 10 X 10 ft. storage room with sealed concrete block walls. The solid core wood door and metal door frame were not fire rated. The only ventilation provided for the room was a six inch square ceiling vent with no detectable air movement.

During an interview on 12/03/13, Staff T, Plant Manager, stated that the engineering firm currently performing air balance tests throughout the facility told him that they tested the room on 10/03/13 and there was no air being moved through it. He stated that he wasn't sure about what the problem was until he had a look. He stated that he did not have anything about the fan or ventilation on his preventive maintenance checklist.

Record review of the policy and procedure titled: Use of Medical and Other Gases dated October 6, 1993 stated that storage of flammable and oxidizing gases "shall be stored in rooms especially constructed for this use."