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Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to patients from smoke, fumes or panic should a fire occur. The facility did not maintain three (3) of 30 plus sampled corridor doors to prevent impediments to closing them to limit the transfer of smoke / heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings are:

During the general life safety tour of the facility July 6, 2010 with the Chief Executive Officer (CEO) and Maintenance Manager, observed that the following doors had an impediment to closing / latching so they would limit the transfer of smoke should a fire occur:

1. The double automatic closing cross corridor fire doors that separated the operating arena (OR) from the emergency department (ER) wing were tested at 11:15 a.m. They would not close and seal / latch to limit the transfer of smoke / heated gases should a fire occur. These doors did release from the magnetic hold open device; however, these doors would not close and latch. The upper latching mechanisms (catches) on the framing were missing. Interview of the maintenance manager, at this time, revealed that these items would be replaced.

2. The fire door that separated the old immediate care unit (ICU) suite from the medical surgical wing (located near the nursing station) did not self close and latch upon testing at 1:15 p.m. It was equipped with a self closing mechanism as required. However, it was in need of an adjustment / repair. It would not provide a smoke tight barrier should a fire/ heated gases occur. Upon interview of the maintenance manager, at this time revealed, "this door will be repaired."

Interviews of the CEO, the Director of Support Services, the Human Resources Director and the Maintenance Manager during the closing conference at 3:05 p.m. on July 6, 2010, re-confirmed these findings.

NFPA 101-2000, 19.2.2.2.6, 19.3.6.3, 4.6.12.1; NFPA 90A & NFPA 80
Correction Date: 08/06/2010

Based on observations made and interviews with facility staff, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction per NFPA 101-2000 , 4.6.12.1-.4....'Features required by the Code...shall be thereafter permanently maintained'. One (1) out of 4 sampled smoke compartments had improperly sealed penetrations.

Findings are:

During the life safety tour and observations on July 6, 2010 with the Maintenance Manager and the Chief Executive Office (CEO), the following fixed barrier ceiling and walls were not maintained to limit the transfer of smoke / heated gases should a fire occur:

1. At 10:48 a.m., observed that the rated fire wall inside the transfer / fire panel / maintenance room on the north side of the building were not sealed to limit the transfer of smoke / heated gases. There were improperly sealed conduits running through this ceiling / wall. They were sealed with unapproved / non-rated foam material. Note: Penetrations must be resealed with a UL approved fire rated caulking compound. Interview of the maintenance manager, at this time, revealed that this wall will be properly sealed.

2. At 10:46 a.m., observed that the fixed ceiling inside the dialer / housekeeping room on the north corridor was not sealed to limit the transfer of smoke / heated gases. There was one unsealed penetration running through this ceiling / wall. Note: Penetrations must be resealed with a UL approved fire rated caulking compound. Interview of the director of facility management, at this time, revealed that this ceiling will be properly sealed.

3. At 10:57 a.m., observed that the corridor fire wall that separated the main mechanical room (old boiler room) from the main corridor was not sealed to limit the transfer of smoke / heated gases should a fire possibly occur. There was an unsealed hole running through this rated corridor (block) wall. This hole consisted of one 4 inch diameter hole with unsealed cables running through it. Interview of the maintenance manager, at this time, revealed that it will be sealed. Note: Penetrations must be resealed with a UL approved fire rated caulking compound, on both sides of each penetration.

Interviews of the CEO, the Director of Support Services, the Human Resources Director and the Maintenance Manager during the closing conference at 3:05 p.m. on July 6, 2010, re-confirmed these findings.

NOTE: These examples are not to be considered as the only penetrations of the building's fire/smoke barrier walls / ceilings. A thorough inspection of each fire/smoke barrier must be made along the full length and height of the wall to ensure that all penetrations are found and properly sealed.

NFPA 101-2000, 4.6.12.1-.4, 19.3.2, 19.3.3, 19.3.6, 19.3.7, 19.2.2.2.6, 8.3; 19.2.11.5; 7.2.1.8; NFPA 72 & NFPA 80
Correction Date: 08/06/2010

Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to patients from smoke, fumes or panic should a fire occur. The facility did not maintain four (4) of 20 plus sampled corridor doors to prevent impediments to closing them to limit the transfer of smoke / heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings are:

During the general life safety tour of the facility on July 6, 2010 with the Chief Executive Officer (CEO) and the Maintenance Manager, observed that the following doors had impediments to self closing and/or latching:

1. Direct observation / testing of the self closing corridor door to the mechanical (old boiler) room at 10:57 a.m., revealed that it would not self close and latch per requirements. It was equipped with a self closing mechanism as required. Testing revealed that this door's latching mechanism was in need of an adjustment. Thus, it would not allow this door to close and latch. This condition creates an impediment to closing / latching these doors so it works as intended / required (maintains positive latching). Interview of maintenance manager, at this time, revealed that this condition would be corrected.

2. Direct observation / testing of the self closing door that separated the kitchen from the lounge area at 11:15 a.m., revealed that it would not self close and latch per requirements. It was equipped with a self closing mechanism as required. Testing revealed that this door was binding on the frame. This condition creates an impediment to closing / latching these doors so they work as intended / required (maintains positive latching). Interview of maintenance manager, at this time, revealed that this condition would be corrected.

3. At 11:48 a.m., the self closing corridor door to the cafeteria was observed to have two 1/2 inch diameter holes running through this door. This condition could affect the classification of this door and could allow smoke and fire gases to quickly spread, in the event of a fire. Interview of the maintenance manager, at this time, revealed that these holes were a result of replacing the handle / hardware with smaller ones, thus leaving these holes.

4. Direct observation / testing of the self closing corridor door to the Laboratory at 1:20 p.m., revealed that it would not self close and latch per requirements. It was equipped with a self closing mechanism as required. Testing revealed that this door's latching mechanism was missing. Thus, it would not allow this door to close and latch. This condition creates an impediment to closing / latching these doors so it works as intended / required (maintains positive latching). Interview of maintenance manager, at this time, revealed that this condition would be corrected.

Interviews of the CEO, the Director of Support Services, the Human Resources Director and the Maintenance Manager during the closing conference at 3:05 p.m. on July 6, 2010, re-confirmed these findings.

NFPA 101-2000, 19.2.2.2.6, 19.3.6.3, 7.2.1.8 & 4.6.12.1; NFPA 72; NFPA 90A & NFPA 80
Correction Date: 08/06/2010

Based on interviews with kitchen staff, the facility did not provide effective evidence that an in-service was conducted during every shift regarding the kitchen's hood fire suppression system. Therefore, the facility did not ensure that all staff members were familiar with specific aspects of the emergency procedures to include knowledge of the kitchen's fire suppression system activation process. Two sampled kitchen staff members were not familiar with fire procedures related to a grease laden fire under the hood system. This could possibly result in the staff being unprepared to execute their duties during a fire, endangering the building occupants. Per 19.7.1.2.....'Employees of health care facilities shall be instructed in life safety procedures and devices'.

Findings are:

Various interviews with staff were conducted on July 6, 2010 during this life safety survey. Determined that two kitchen staff members interviewed at 1:15 p.m. were not familiar with the emergency procedures should a grease laden fire occur. Neither one gave a clear cut picture of the procedures necessary for a grease laden fire. One stated that he/she "would pour flour onto it (grease fire)."

Also, the location of the emergency pull station was not readily noticeable / identifiable. Interview of the maintenance / safety manager, at this time, revealed that he would call the servicing company to help determine the location of the emergency pull station for this fire suppression system.

Interviews with administrative staff during the closing conference at 3:05 p.m., revealed an in-service addressing this issue will be conducted to ensure that all kitchen staff members are familiar with the emergency procedures.

NFPA 101-2006, 19.7.1.1/.2/.3./4; 4.6.12; NFPA 96; NFPA 10
Correction Date: 08/06/2010

Based on record review and direct observation, the facility failed to continuously maintain the required automatic sprinkler systems in reliable operating condition and failed to provide for a qualified contractor to complete the required test and inspection of the automatic sprinkler system as required in NFPA 101, 19.7.6, 9.7.5, 4.6.12.1; NFPA 13, 6.2.7.2; NFPA 25, 5.1 and Table 5.1.

Findings include:

Direct observation of the fire sprinkler riser area on the north side of the building (inside of the maintenance shop) on July 6, 2010 at 11:10 a.m., revealed that the fire sprinkler control valves had three attached red warning tags attached by their certified inspection company. These warning notes referred one to 'see annual inspection notes'. Record review at 1:40 p.m. of the annual inspection report's 'Discrepancy List' dated 02/11/2010 revealed several items that need to be addressed. Interview of the maintenance manager confirmed that these items had not been accomplished at this time. Interview of the Director of Support Services at 1:50 p.m., revealed that the list of items will be addressed and should be accomplished in 30 days.

Interviews of the Chief Executive Officer (CEO), the Director of Support Services, the Human Resources Director and the Maintenance Manager during the closing conference at 3:05 p.m. on July 6, 2010, re-confirmed these findings.

NFPA 101, 19.7.6, 9.7.5, 4.6.12.1; NFPA 13, 6.2.7.2; NFPA 25
Correction Date: 08/06/2010

Based on observations and tour with the interim director of facility management, the facility was not in compliance with the requirements of NFPA-101-2000-Life Safety Code, NFPA-90-A, NFPA-91, Requirements for Ventilating and Air Exhaust Systems. NFPA-101-2000-LSC Chapter 4.6.12.1 Maintenance and Testing: Whenever or wherever any device, equipment, or level of protection is required for compliance with the provisions of this code, such device, equipment or level of protection shall thereafter be continuously maintained in accordance of applicable NFPA requirements. One wing had little or no ceiling exhaust ventilation (exchange of air) when tested. One (1) in 6 sampled smoke zones was also affected.

The Findings Include:

During the life safety tour of the facility on July 6, 2010, observed / tested (with a tissue) the ceiling exhaust ventilation system in various sampled bathrooms, housekeeping closets and soiled utility rooms. At 11:20 a.m., little or no air movement / exchange was noted at the ceiling exhaust vent located inside the janitor's closet near the entrance to operating room #1 (OR 1). Interview of the maintenance manager / safety officer, revealed that this exhaust unit would be checked. Not having the exhaust working continuously could lead to increased odors within operating arena due to less than the required air exchanges (negative air flow) per hour.

Interviews of the Chief Executive Officer (CEO), the Director of Support Services, the Human Resources Director and the Maintenance Manager during the closing conference at 3:05 p.m. on July 6, 2010, re-confirmed these findings.

NFPA-101-2000, LSC--19.5.2.1, 19.5.2.2, 4.6.12.1, 4.6.12.3, 9.2.1, 9.2.2; NFPA- 90 A; NFPA-91- 7.1, 7.3, 7.4, 7.5
Correction Date: 08/06/2010

Based on observations, the facility could not evidence that the generator was maintained / inspected to be functional at an optimal state. NFPA 101-2000, 4.6.12.1 requires that 'every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition'. Possible oil leakage was noted. The floor underneath the prime mover (engine) needs to be kept clean at all times. This makes it possible to determine if leaks are developing in the cooling, fuel or lubricating systems. This situation could possibly lead to down time in the future, especially during the hurricane season.

Findings are:

During an observation of the 80 KW generator on July 6, 2010 at 10:10 a.m. with the maintenance manager, observed what appeared to be black oil like substance on the flooring below the generator's engine and on the sides of the engine . Interview of the maintenance manager revealed that this situation would be evaluated to determine the possible cause/s of this buildup. "It will also be cleaned up (pressure washed)."

Interviews of the Chief Executive Officer (CEO), the Director of Support Services, the Human Resources Director and the Maintenance Manager during the closing conference at 3:05 p.m. on July 6, 2010, re-confirmed these findings.

NFPA 101-2000, 7.9.1, 4.6.12.1; NFPA 99, Chapter 3 & NFPA 110 (1999), 6-4.2.2 & 5-3.1; NFPA 70, 19.1.2
Correction Date: 08/06/2010

Based on an observation and interviews with facility staff, the facility did not maintain the following per the National Electric Code (NEC), Article 517 and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize hazards. Use of a temporary adapter for a high amperage / motorized device did not demonstrate compliance with the code / standard. Five (5) out of 30 plus electrical devices sampled did not operate as required.

Findings include:

Observations and interview of the maintenance manager / safety officer during the life safety tour on July 6, 2010, revealed that the following electrical applications were not in accordance with NFPA 70, the National Electrical Code:

1. At 10:15 a.m., observed that the electrical panel / box located inside of the mechanical room on the north side of the building was missing its protective cover. It was found on the floor. The physical integrity of this electrical panel / circuit breaker was not maintained per NEC 3-3.4.2.3 & 3-3.4.3. Interview of the maintenance manager, at this time, revealed that this cover will be securely mounted.

2. At 10:50 a.m., observed that two electrical cords / plugs to an oven and its fan motor located inside of kitchen appeared to be frayed / cut around the juncture of the cords and the plugs. Closer examination revealed that the outer protective covering on the cords was pulled / cut away from the contact point to these plugs, thus exposing the internal coated wiring. Interview of the maintenance / safety manager, at this time, revealed that they would immediately correct these conditions. The facility must maintain the physical integrity of each electrical device per NEC 3-3.4.2.3 & 3-3.4.3.

3. Direct observation at 11:40 a.m. revealed that a non-approved six (6) plug adapter located inside of the emergency room (ER) treatment area was plugged into a regular outlet. This device was not rated for use in wet areas; for patient care or for high amperage devices. Such a condition could place an increased electrical load (amperage) on this temporary device. Interview of the maintenance manager, at this time, revealed that this unit was not authorized for use in this facility. "We will use only hospital grade devices."

4. At 12:05 p.m., observed that the outlet box located inside of the vending alcove in the ER hallway was loosely secured. The outlet box had broken loose / pulled away from the securing bracket. The physical integrity of this outlet / receptacle was not maintained per NEC 3-3.4.2.3 & 3-3.4.3. Interview of the maintenance director, at this time, revealed that this outlet will be securely mounted.

5. At 1:50 p.m., observed that an electrical breaker panel MDP located inside the mechanical room was not marked per NFPA 70 (NEC), 384-13....'All panel board circuits shall be legibly identified as to the purpose or use on a circuit directory on the inside of the panel doors'. This panel had only identified circuits 14 through 17 (not properly identified / numbered). Each circuit needs to be properly numbered / labeled so that the appropriate circuit can be shut down when necessary / needed. Upon interview of maintenance manager, at this time, revealed the exact circuit identification will be posted as required.

Interviews of the Chief Executive Officer (CEO), the Director of Support Services, the Human Resources Director and the Maintenance Manager during the closing conference at 3:05 p.m. on July 6, 2010, re-confirmed these findings.

NFPA 70 , National Electric Code (NEC), 384-13 & NFPA 101-2000, 4.6.12.1-.4 NFPA 70, Article 517; NFPA 99 ,7-5.1.2.4, 9-2.1.2.1/.2 ,3-3.4.2.3,3-3.4.3
Correction Date: 08/06/2010