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Based on observation, record review and staff interview, the facility failed to fully sprinkler the MRI (Magnetic Resonance Imaging) Building an existing health care occupancy as required by NFPA 101, (2012), 19,3.5.3, 9.7.1.1 (1), NFPA 13 (2010), with the additional requirement provided in the CMS (Centers for Medicare and Medicaid Services) S&C (Survey and Certification) letter 11-05 LSC Revised 02.18.2011.

Findings included:

1. On 04/25/2017, the second day of survey, observation from 9:00 a.m. to 11:30 a.m. accompanied by the Facilities Manager revealed a MRI Building physically attached to the main hospital by a covered walkway. Continuing observation upon entering the building revealed smoke detectors and available egress through front and rear exits. There were no sprinkler heads observed. Staff interview of the Facilities Manager concurrent with tour confirmed the MRI building was protected by the hospital fire alarm system, however, the building was not sprinklered.

On 04/25/2017 staff interview of the Imaging Department Manager revealed some inpatients did receive MRI procedures in the MRI Building. A request was made for a listing of all inpatients billed for MRI procedures for the months of January and February, 2017.

On 04/25/2017 record review of the listings provided by the Imaging Department Manager of inpatients receiving MRI procedures revealed 29 inpatients in January, 2017 and 37 inpatients in February, 2017.

On 04/25/2017 record review of NFPA 101 (2012) 19.1.3.1 Multiple occupancies revealed in section "(1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self preservation". Record review of S&C-11-05-LSC REVISED 02.18.2011, revealed "CMS does not consider the number of patients in determining if a provider is a hospital or a CAH; therefore, a CMS-certified hospital or CAH does not need to have four or more inpatients at all times in order to be classified as a Health Care Occupancy. Occupancy classification must be determined regardless of the number of patients served at a hospital's or CAH's component facility". Therefore, the facility does provide MRI procedures to hospital inpatients in the MRI Building and the MRI Building is a Health Care Occupancy and must meet existing health care requirements of NFPA 101, (2012), Chapter 19,3.5.3, 9.7.1.1 (1), as well as NFPA 13 (2010).

NFPA 101, (2012), 19,3.5.3, 9.7.1.1 (1)
NFPA 13 (2010)
S&C-11-05-LSC REVISED 02.18.2011

Based on observation and staff interview, the facility failed to maintain smoke barriers as required by NFPA (2012), 8.5.2.1, 8.5.2.2, 8.5.4.1, 8.4.4, and 4.6.12.5.

Findings included:

1. On 04/24/2017 observation during the interior tour from 10:00 a.m. to 2:45 p.m. accompanied by the Facilities Manager revealed penetration of smoke barriers (corridor walls above the suspended ceiling) and opening protectives (doors in means of egress of fire/smoke barriers). Examples of observed penetrations included:
2nd floor, Behavioral Health Unit, the means of egress corridor walls above the suspended ceiling penetrated by cables; means of egress corridor walls above the suspended ceiling at the IT (Information Technology) room with penetration by a cable; multiple penetrations through the suspended ceiling in the computer equipment room in which it was not possible, due to the fragility of the equipment, to determine whether the exterior walls to the compartment have been penetrated.

Continuing observation revealed opening protectives (means of egress corridor doors) in which new door hardware had been installed and either the type of locking device or the wrong locking device had been installed resulting in 1/2 inch hole penetrations of the 1 1/2 inch substantial doors. Examples of observed penetrations included:
the Nursing Station dictation room with 2 penetrations at the latching device and the third floor Wound Care Office 2 penetrations, 1/2 inch holes, at the latching device. Staff interview of the Facilities Manager concurrent with the tour acknowledged the penetrations above the suspended ceiling, in the IT room and in corridor doors. The facility is required to conduct an inspection of means of egress corridor walls above the suspended ceiling as well as opening protectives, means of egress corridor doors, identifying penetrations and the correction of the deficiencies by qualified personnel and maintaining documentation of the findings and outcomes for the authority having jurisdiction.

NFPA (2012), 8.5.2.1, 8.5.2.2, 8.5.4.1, 8.4.4, 4.6.12.5

Based on observation and staff interview, the facility failed to maintain water closet (bathroom) ventilation as required by NFPA 101 (2012), 19.5.2.1, 9.2.1, 4.5.8, and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

Findings included:

1. On 04/24/2017, the first day of survey, observation during the interior tour from 10:00 a.m. to 2:45 p.m. accompanied by the Facilities Manager revealed installed water closet ventilation units failed to operate upon testing by applying a piece of tissue paper to the face of the ventilation return resulting in the tissue falling from the return indicating no suction by the ventilation unit. Examples of the failed units include patient rooms 333, 363, 365, 387 and 219. The facility is required to conduct an inspection of all patient room water closet ventilation units determining the operation and if impaired to correct the deficiency and record the findings for review by the authority having jurisdiction.

NFPA 101 (2012), 19.5.2.1, 9.2.1, 4.5.8
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems

Based on observation, record review and staff interview, the facility failed to maintain electrical safety as required by NFPA 101 (2012), 9.1.2, NFPA 70 (2011SB), Article 517 Health Care, NFPA 99 (2012), 10.5.2.1.2, 10.5.2.1.1, 10.5.8, 10.2.2.1.1, 6.4.4.1, and 6.4.4.1.2.1.

Findings included:

1. On 04/24/2017 observation during the interior tour from 10:00 a.m. to 2:45 p.m. accompanied by the Facilities Manager revealed in third floor patient rooms, electrical beds. Continuing observation when entering an empty patient room on the third floor and extracting the electric bed power cord from the duplex outlet revealed a three prong receptacle and the three prong power cord. Staff interview of the Facilities Manager, concurrent with tour, when asked whether all patient beds were three prong the response was "yes".

2. On 04/25/2017 record review from 11:30 a.m. to 2:45 p.m. revealed no documentation of the testing of electrical beds with three prong power cords as required by NFPA 101 (2012), 9.1.2, NFPA 70 (2011SB), Article 517 Health Care, NFPA 99 (2012), 10.5.2.1.2, 10.5.2.1.1, 10.5.8 and 10.2.2.1.1. Staff interview of the Facilities Manager and assistant acknowledged there was no documentation of the testing of the patient beds.

3. On 04/25/2017 record review from 11:30 a.m. to 2:45 p.m. revealed no documentation of the annual inspection and periodic exercise of the main and feeder circuit breakers of the essential electrical system as required by NFPA 99 (2012) 6.4.4.1, Maintenance and Testing of Essential Electrical System and 6.4.4.1.2.1. Staff interview of the Facilities Manager and assistant confirmed there was no documentation of an annual inspection and periodic exercise of the main and feeder circuit breakers of the essential electrical system.

NFPA 101 (2012), 9.1.2
NFPA 70 (2011SB), Article 517 Health Care
NFPA 99 (2012), 10.5.2.1.2, 10.5.2.1.1, 10.5.8, 10.2.2.1.1, 6.4.4.1, 6.4.4.1.2.1