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Based on record review and interview, the facility failed to provide documentation of 30 second testing at 30 day intervals and annual testing for 1 1/2 hours for 32 of 32 battery powered emergency lighting fixtures. LSC 7.9.3 requires a functional test shall be conducted on every required battery powered emergency lighting system at 30 day intervals for not less than 30 seconds and an annual test shall be conducted for not less than 1 1/2 hours. Written records of visual inspections and tests shall be kept. This deficient practice could affect patients in the surgery and recovery areas, and visitors and staff in service and exam areas throughout the facility.

Findings include:

Based on review of facility fire safety inspection and test records with the director of materials management on 11/01/11 at 12:35 p.m., there was no record of 30 second monthly and 1 1/2 hour annual tests for the 32 battery powered emergency lighting fixtures located throughout the hospital. The director of materials management said at the time of record review, the testing had not been done.

Based on record review and interview, the facility failed to include the evacuation of the smoke compartment in the written fire plan for the protection of 5 of 5 inpatients in the event of an emergency. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all occupants.

Findings include:

Based on review of the Hospital Wide Code Red-Fire Safety Plan on 11/01/11 at 12:55 p.m. with the director of materials management, the plan referred to the rescue of persons in immediate danger. The plan addressed evacuation from the building but there was no reference to evacuation from one smoke compartment to another smoke compartment. The plan addressed containment of a fire only by covering the actual fire rather than separation by closing doors to the fire site. Extinguishment was addressed for "approved fire extinguishers" but nothing addressed what fire extinguishers were available and what materials the fire extinguisher was approved for. The director of materials management acknowledged at the time of record review, the fire plan failed to address all issues.

1. Based on record review and interview, the facility failed to ensure fire drills were conducted on every shift during 2 of the past 4 quarters. This deficient practice affects all occupants of the facility including staff, visitors, and residents.

Findings include:

Based on a review of Fire Drills provided for the past year with the director of materials management on 11/01/11 at 11:55 a.m., fire drill documentation was not found for the second and third shifts of the fourth quarter in 2010 and the first and third shifts for the third quarter in 2011. The director of materials management said at the time of record review, the drills had not been done.

2. Based on record review and interview, the facility failed to ensure fire drill documentation included all staff participating for all shifts during 4 of the past 4 quarters. LSC 4.7.2 requires drills include suitable procedures to ensure all persons subject to the drill participate. This deficient practice affects all occupants of the facility.

Findings include:

Based on a review of Fire Drills provided for the past year with the director of materials management on 11/01/11 at 11:55 a.m., the fire drill documentation for the past year listed less than the number of staff on duty for each drill document. The director of materials management acknowledged at the time of record review, not all staff had signed the fire drill participation record. Signatures were collected for those in the area of the immediate "fire" site as other staff were busy caring for patients.

Based on record review and interview, the facility failed to ensure a weekly test to check water flow conditions for 2 of 2 fire pumps was conducted as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 5-3.2.1. This deficient practice could affect all occupants.

Findings include:

Based on review of maintenance records on 11/01/11 at 12:15 p.m., checks of the fire pumps were documented on Sprinkler Inspection Reports dated 12/15/10, 03/09/11, 05/21/11, and 08/03/11 by the facility sprinkler inspection contractor. No record of a weekly test of the fire pumps was found. The director of materials management said at the time of record review, no other testing had been done, she had "just learned this week" how to perform the weekly test, and a test protocol was to begin next week.

Based on record review and interview, the facility failed to ensure 1 of 1 range hood's fire extinguishing equipment was inspected and approved every 6 months by properly trained and qualified persons. NFPA 96, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 8-2.1 requires the inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons. Furthermore, NFPA 96 8-2.1.1 requires actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, fire-actuated dampers, etc., shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. This deficient practice affects occupants of the kitchen where 4 staff were observed.

Findings include:

Based on a review of fire safety inspection records for the automatic range hood extinguishing system with the director of materials management on 11/01/11 at 1:30 p.m., the most recent inspection and service record for the commercial range hood fire equipment system was dated 10/05/11. No documentation for an inspection for the previous six month inspection was found. The director of materials management said at the time of record review, the previous test had not been done.

Based on interview and record review, the facility failed to provide the complete documentation for testing 1 of 1 emergency generators providing power to the emergency lighting systems for the east/west wing. LSC 7.9.2.3 and NFPA 99, Health Care Facilities, 3-4.4.1.1(a) requires monthly testing of the generator set shall be in accordance with NFPA 110, the Standard for Emergency and Standby Power Systems. NFPA 110, 6-4.2 requires generator sets in Level 1
and 2 service shall be exercised under operating conditions or not less than 30 percent of the EPS (Emergency Power Supply) nameplate rating at least monthly, for a minimum of 30 minutes. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affects all occupants of the east/west wing.

Findings include:

Based on review of the Generator Weekly Log Sheet with the director of materials management on 11/01/11 at 12:45 p.m., the generator load test was included on the weekly test record, but there was no information recorded for the actual test time a monthly load was conducted, operating temperatures or other information to indicate the generator was tested under load, and nothing to indicate the percent load carried when the generator was load tested. No load bank information was provided. The director of materials management said at the time of record review, she did not know the percent load carried on the generator during testing and everything was done "automatically", including a load test at 6:00 a.m. the first Friday of each month. No actual transfer time was ever documented.

Based on record review and interview, the facility failed to provide documentation of 30 second testing at 30 day intervals and annual testing for 1 1/2 hours for 32 of 32 battery powered emergency lighting fixtures. LSC 7.9.3 requires a functional test shall be conducted on every required battery powered emergency lighting system at 30 day intervals for not less than 30 seconds and an annual test shall be conducted for not less than 1 1/2 hours. Written records of visual inspections and tests shall be kept. This deficient practice could affect patients in the surgery and recovery areas, and visitors and staff in service and exam areas throughout the facility.

Findings include:

Based on review of facility fire safety inspection and test records with the director of materials management on 11/01/11 at 12:35 p.m., there was no record of 30 second monthly and 1 1/2 hour annual tests for the 32 battery powered emergency lighting fixtures located throughout the hospital. The director of materials management said at the time of record review, the testing had not been done.

Based on record review and interview, the facility failed to include the evacuation of the smoke compartment in the written fire plan for the protection of 5 of 5 inpatients in the event of an emergency. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all occupants.

Findings include:

Based on review of the Hospital Wide Code Red-Fire Safety Plan on 11/01/11 at 12:55 p.m. with the director of materials management, the plan referred to the rescue of persons in immediate danger. The plan addressed evacuation from the building but there was no reference to evacuation from one smoke compartment to another smoke compartment. The plan addressed containment of a fire only by covering the actual fire rather than separation by closing doors to the fire site. Extinguishment was addressed for "approved fire extinguishers" but nothing addressed what fire extinguishers were available and what materials the fire extinguisher was approved for. The director of materials management acknowledged at the time of record review, the fire plan failed to address all issues.

1. Based on record review and interview, the facility failed to ensure fire drills were conducted on every shift during 2 of the past 4 quarters. This deficient practice affects all occupants of the facility including staff, visitors, and residents.

Findings include:

Based on a review of Fire Drills provided for the past year with the director of materials management on 11/01/11 at 11:55 a.m., fire drill documentation was not found for the second and third shifts of the fourth quarter in 2010 and the first and third shifts for the third quarter in 2011. The director of materials management said at the time of record review, the drills had not been done.

2. Based on record review and interview, the facility failed to ensure fire drill documentation included all staff participating for all shifts during 4 of the past 4 quarters. LSC 4.7.2 requires drills include suitable procedures to ensure all persons subject to the drill participate. This deficient practice affects all occupants of the facility.

Findings include:

Based on a review of Fire Drills provided for the past year with the director of materials management on 11/01/11 at 11:55 a.m., the fire drill documentation for the past year listed less than the number of staff on duty for each drill document. The director of materials management acknowledged at the time of record review, not all staff had signed the fire drill participation record. Signatures were collected for those in the area of the immediate "fire" site as other staff were busy caring for patients.

Based on record review and interview, the facility failed to ensure a weekly test to check water flow conditions for 2 of 2 fire pumps was conducted as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 5-3.2.1. This deficient practice could affect all occupants.

Findings include:

Based on review of maintenance records on 11/01/11 at 12:15 p.m., checks of the fire pumps were documented on Sprinkler Inspection Reports dated 12/15/10, 03/09/11, 05/21/11, and 08/03/11 by the facility sprinkler inspection contractor. No record of a weekly test of the fire pumps was found. The director of materials management said at the time of record review, no other testing had been done, she had "just learned this week" how to perform the weekly test, and a test protocol was to begin next week.

Based on record review and interview, the facility failed to ensure 1 of 1 range hood's fire extinguishing equipment was inspected and approved every 6 months by properly trained and qualified persons. NFPA 96, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 8-2.1 requires the inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons. Furthermore, NFPA 96 8-2.1.1 requires actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, fire-actuated dampers, etc., shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. This deficient practice affects occupants of the kitchen where 4 staff were observed.

Findings include:

Based on a review of fire safety inspection records for the automatic range hood extinguishing system with the director of materials management on 11/01/11 at 1:30 p.m., the most recent inspection and service record for the commercial range hood fire equipment system was dated 10/05/11. No documentation for an inspection for the previous six month inspection was found. The director of materials management said at the time of record review, the previous test had not been done.

Based on interview and record review, the facility failed to provide the complete documentation for testing 1 of 1 emergency generators providing power to the emergency lighting systems for the east/west wing. LSC 7.9.2.3 and NFPA 99, Health Care Facilities, 3-4.4.1.1(a) requires monthly testing of the generator set shall be in accordance with NFPA 110, the Standard for Emergency and Standby Power Systems. NFPA 110, 6-4.2 requires generator sets in Level 1
and 2 service shall be exercised under operating conditions or not less than 30 percent of the EPS (Emergency Power Supply) nameplate rating at least monthly, for a minimum of 30 minutes. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affects all occupants of the east/west wing.

Findings include:

Based on review of the Generator Weekly Log Sheet with the director of materials management on 11/01/11 at 12:45 p.m., the generator load test was included on the weekly test record, but there was no information recorded for the actual test time a monthly load was conducted, operating temperatures or other information to indicate the generator was tested under load, and nothing to indicate the percent load carried when the generator was load tested. No load bank information was provided. The director of materials management said at the time of record review, she did not know the percent load carried on the generator during testing and everything was done "automatically", including a load test at 6:00 a.m. the first Friday of each month. No actual transfer time was ever documented.