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Based on observation and staff interview, the facility failed to meet the conditions to allow spaces to be open to the exit corridor. This would allow smoke to enter the exit corridor without early detection.

Findings are:
Observation on 11/12/15 from 11:45 am to 1:22 pm revealed:
1. A smoke detector failed to be installed in the Waiting Room by LDR, which was not separated from the exit corridor or supervised by a nurse station.
2. A smoke detector failed to be installed in the Outpatient Waiting Room, which was not separated from the exit corridor or supervised by a nurse station.
3. Smoke detectors failed to be installed in the Cafeteria, which was not separated from the exit corridor or supervised by a nurse station.
4. A smoke detector failed to be installed in the East Entrance Lobby near the Cafeteria, which was not separated from the exit corridor or supervised by a nurse station.

In an interview conducted at the time of observation, (11/12/15 from 11:45 am to 1:22 pm), Maintenance A confirmed that smoke detection failed to be installed in these areas.

NFPA 101, 2000, 18.3.6 Corridors.
18.3.6.1
Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5. (See also 18.2.5.9.)
Exception No. 1: Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.
Exception No. 2: Waiting areas shall be permitted to be open to the corridor, provided that the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 ft2 (55.7 m2).
(b) Each area is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.
Exception No. 3*: Spaces for nurses ' stations.
Exception No. 4: Gift shops open to the corridor where protected in accordance with 18.3.2.5.
Exception No. 5: In a limited care facility, group meeting or multipurpose therapeutic spaces shall be permitted to open to the corridor, provided that the following criteria are met:
(a) The space is not a hazardous area.
(b) The space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the space is arranged and located to allow direct supervision by the facility staff from the nurses ' station or similar location.
(c) The area does not obstruct access to required exits.

Based on observation and staff interview, the facility failed to provide smoke resistive doors for the 400 Linen Closet and the Conference Room B Storage Room. This condition would allow smoke to migrate into the exit corridor and use areas.

Findings are:
Observation on 11/12/15, from 1:57 pm to 2:09 pm revealed:
1. The 400 Linen Closet Door failed to latch when self-closed.
2. The Conference Room B Storage Room Door failed to latch when self-closed.

In an interview conducted at the time of observation, (11/12/15, from 1:57 pm to 2:09 pm), Maintenance A acknowledged the doors failed to latch.

Based on observation and staff interview, the facility failed to provide a latching set of fire doors in a two-hour fire separation in the Penthouse Hallway. This condition would allow fire to spread between the two-story and one-story areas of the Hospital.

Findings are:
Observation on 11/12/15 at 1:02 pm revealed the 90-minute fire doors in the Penthouse Hallway failed to fully close and latch when automatically closed.

In an interview conducted at the time of observation, (11/12/15 at 1:02 pm), Maintenance A acknowledged the doors failed to fully close and latch.

Based on record review and staff interview, the facility failed to conduct fire drills with varying times and dates. This condition would not provide simulated training for staff to respond to a fire emergency.

Findings are:
Record review on 11/12/15 at 10:26 am revealed fire drills failed to have at least one hour difference between each quarter for the past year on all three shifts:
1st Shift: 10/30/15 at 3:00 pm, 7/29/15 at 3:00 pm, 4/29/15 at 3:00 pm, and 1/30/15 at 9:30 am.
2nd Shift: 9/17/15 at 5:10 pm, 6/29/15 at 5:35 pm, 3/31/15 at 4:40 pm, and 12/30/14 at 4:50 pm.
3rd Shift: 8/31/15 at 10:00 pm, 5/29/15 at 11:00 pm, 2/4/15 at 1:00 am, and 11/30/14 at 11:00 pm.

Fire drill dates failed to be varied because the majority of fire drills were conducted within the last few days of the month.

In an interview conducted at the time of record review (11/12/15 at 10:26 am), Safety A acknowledged that the fire drill times and dates failed to be varied.

NFPA 101, 2000, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on observation, record review, and staff interview, the facility failed to have the fire alarm maintained, and have fire alarm notification installed in an enclosed courtyard. This condition would not provide early notification of a fire to occupants.

Findings are:
Observation on 11/12/15 at 11:48 am revealed an audio/visual fire alarm device failed to be installed in the enclosed courtyard, where it was necessary to re-enter the building to exit the courtyard.

Record review on 11/12/15 at 10:12 am revealed the fire alarm failed to be inspected at least semi-annually. The most recent inspection interval exceeded six months: 9/17/15 - 2/24/15.

In an interview conducted at the time of observation and record review, (11/12/15 from 10:12 am to 11:48 am), Maintenance A acknowledged the lack of notification. Safety A acknowledged that the fire alarm testing interval exceeded six months.

Based on observation and staff interview, the facility failed to install fire extinguishers so they were not more than five feet above the floor. This condition would prevent occupants from reaching the extinguisher.

Findings are:
Observation on 11/12/15, from 11:12 am to 11:28 am revealed:
1. The fire extinguisher in OR 1 was installed approximately six feet above the floor, and exceeded the maximum five feet above the floor to the top of the extinguisher.
2. The fire extinguisher in OR 2 was installed approximately six feet above the floor, and exceeded the maximum five feet above the floor to the top of the extinguisher.
3. The fire extinguisher in the Minor OR was installed approximately six feet above the floor, and exceeded the maximum five feet above the floor to the top of the extinguisher.

In an interview conducted at the time of observation, (11:12 am to 11:28 am), Maintenance A acknowledged the extinguishers were installed higher than five feet above the floor.

NFPA 10, 1999, 1-6.10
Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Based on record review and staff interview, the facility failed to conduct fire drills for the Lab quarterly. This condition would not provide adequate training for staff to react in the event of a fire.

Findings are:
Record review on 11/12/15, at 10:19 am revealed fire drills failed to be conducted so that a fire drill originated in the Lab at least quarterly.

In an interview conducted at the time of record review, (11/12/15, at 10:19 am), Safety A acknowledged that fire drills were not conducted in the Lab quarterly.

NFPA 99, 10-2.1.4.3*
Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually.

Based on observation and staff interview, the facility failed to meet the conditions to allow spaces to be open to the exit corridor. This would allow smoke to enter the exit corridor without early detection.

Findings are:
Observation on 11/12/15 from 11:45 am to 1:22 pm revealed:
1. A smoke detector failed to be installed in the Waiting Room by LDR, which was not separated from the exit corridor or supervised by a nurse station.
2. A smoke detector failed to be installed in the Outpatient Waiting Room, which was not separated from the exit corridor or supervised by a nurse station.
3. Smoke detectors failed to be installed in the Cafeteria, which was not separated from the exit corridor or supervised by a nurse station.
4. A smoke detector failed to be installed in the East Entrance Lobby near the Cafeteria, which was not separated from the exit corridor or supervised by a nurse station.

In an interview conducted at the time of observation, (11/12/15 from 11:45 am to 1:22 pm), Maintenance A confirmed that smoke detection failed to be installed in these areas.

NFPA 101, 2000, 18.3.6 Corridors.
18.3.6.1
Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5. (See also 18.2.5.9.)
Exception No. 1: Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.
Exception No. 2: Waiting areas shall be permitted to be open to the corridor, provided that the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 ft2 (55.7 m2).
(b) Each area is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.
Exception No. 3*: Spaces for nurses ' stations.
Exception No. 4: Gift shops open to the corridor where protected in accordance with 18.3.2.5.
Exception No. 5: In a limited care facility, group meeting or multipurpose therapeutic spaces shall be permitted to open to the corridor, provided that the following criteria are met:
(a) The space is not a hazardous area.
(b) The space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the space is arranged and located to allow direct supervision by the facility staff from the nurses ' station or similar location.
(c) The area does not obstruct access to required exits.

Based on observation and staff interview, the facility failed to provide smoke resistive doors for the 400 Linen Closet and the Conference Room B Storage Room. This condition would allow smoke to migrate into the exit corridor and use areas.

Findings are:
Observation on 11/12/15, from 1:57 pm to 2:09 pm revealed:
1. The 400 Linen Closet Door failed to latch when self-closed.
2. The Conference Room B Storage Room Door failed to latch when self-closed.

In an interview conducted at the time of observation, (11/12/15, from 1:57 pm to 2:09 pm), Maintenance A acknowledged the doors failed to latch.

Based on observation and staff interview, the facility failed to provide a latching set of fire doors in a two-hour fire separation in the Penthouse Hallway. This condition would allow fire to spread between the two-story and one-story areas of the Hospital.

Findings are:
Observation on 11/12/15 at 1:02 pm revealed the 90-minute fire doors in the Penthouse Hallway failed to fully close and latch when automatically closed.

In an interview conducted at the time of observation, (11/12/15 at 1:02 pm), Maintenance A acknowledged the doors failed to fully close and latch.

Based on record review and staff interview, the facility failed to conduct fire drills with varying times and dates. This condition would not provide simulated training for staff to respond to a fire emergency.

Findings are:
Record review on 11/12/15 at 10:26 am revealed fire drills failed to have at least one hour difference between each quarter for the past year on all three shifts:
1st Shift: 10/30/15 at 3:00 pm, 7/29/15 at 3:00 pm, 4/29/15 at 3:00 pm, and 1/30/15 at 9:30 am.
2nd Shift: 9/17/15 at 5:10 pm, 6/29/15 at 5:35 pm, 3/31/15 at 4:40 pm, and 12/30/14 at 4:50 pm.
3rd Shift: 8/31/15 at 10:00 pm, 5/29/15 at 11:00 pm, 2/4/15 at 1:00 am, and 11/30/14 at 11:00 pm.

Fire drill dates failed to be varied because the majority of fire drills were conducted within the last few days of the month.

In an interview conducted at the time of record review (11/12/15 at 10:26 am), Safety A acknowledged that the fire drill times and dates failed to be varied.

NFPA 101, 2000, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on observation, record review, and staff interview, the facility failed to have the fire alarm maintained, and have fire alarm notification installed in an enclosed courtyard. This condition would not provide early notification of a fire to occupants.

Findings are:
Observation on 11/12/15 at 11:48 am revealed an audio/visual fire alarm device failed to be installed in the enclosed courtyard, where it was necessary to re-enter the building to exit the courtyard.

Record review on 11/12/15 at 10:12 am revealed the fire alarm failed to be inspected at least semi-annually. The most recent inspection interval exceeded six months: 9/17/15 - 2/24/15.

In an interview conducted at the time of observation and record review, (11/12/15 from 10:12 am to 11:48 am), Maintenance A acknowledged the lack of notification. Safety A acknowledged that the fire alarm testing interval exceeded six months.

Based on observation and staff interview, the facility failed to install fire extinguishers so they were not more than five feet above the floor. This condition would prevent occupants from reaching the extinguisher.

Findings are:
Observation on 11/12/15, from 11:12 am to 11:28 am revealed:
1. The fire extinguisher in OR 1 was installed approximately six feet above the floor, and exceeded the maximum five feet above the floor to the top of the extinguisher.
2. The fire extinguisher in OR 2 was installed approximately six feet above the floor, and exceeded the maximum five feet above the floor to the top of the extinguisher.
3. The fire extinguisher in the Minor OR was installed approximately six feet above the floor, and exceeded the maximum five feet above the floor to the top of the extinguisher.

In an interview conducted at the time of observation, (11:12 am to 11:28 am), Maintenance A acknowledged the extinguishers were installed higher than five feet above the floor.

NFPA 10, 1999, 1-6.10
Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).