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Based on observation the hospital failed to maintain doors protecting corridor openings to resist the passage of smoke and to ensure that there are no impediments to the closing of the doors. Failure of the doors to close and latch could result in toxic products of combustion and smoke to enter from the rooms into the exit corridor.

Findings:

1. On 3/13/2012 the surveyor observed the upper level north stairwell door by patient room # 5 that did not close and latch.

2. The surveyor also observed on 3/13/2012 doors without latches that included the soiled utility room, the clean utility room, and the shared door between the clean and the soiled utility rooms.

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Based on observation and interview with engineering staff the hospital failed to maintain corridor walls and doors as designed to resist the passage of smoke. Failure to maintain corridor walls and doors places the patients at risk to smoke exposure in corridor exits.

Findings:

1. During a tour of the hospital on 3/13/2012 the surveyor observed a roll down fire window between the dining room and the west wing nurse's station. Smoke detectors were on both sides of the roll down fire window. Engineering staff reported to the surveyor that the fire window did not operate with the fire alarm. The roll down fire window was not maintained and operational in the case of a fire.

2. On 3/13/2012 the surveyor observed communication cables that penetrated exit corridor walls and the fire stop repair work was not completed in the following areas:
1. Central supply
2. Emergency Department
3. Janitorial closets near room #2 and room #104
4. West wing nurse administration
5 Above fire smoke door by room #106
6. Laboratory
7. Upper and lower level elevator doors (plugs missing)

Based on observation the hospital failed to provide self closing positive latching doors in a non- sprinklered hazardous area that was not separated. Failure to maintain fire rated doors in a non-sprinklered hazardous area places the patients and staff at risk for possible injury in the case of a fire.

Finding:

On 3/13/2012 during fire safety rounds with engineering staff the surveyor observed there was no separation between the soiled linen room and the clean linen room, but the two spaces were combined. There was no fire sprinkler protection in the clean and soiled linen spaces. Also, the three doors leading out of the clean and soiled linen area were not equipped with self-closing and positive latching door hardware.

Based on observation the hospital failed to maintain stairways used as exits with self closing and latching doors.
Failure to maintain exit stairwells with self-closing and latching doors places the patient at risk for injury from the spread of a fire and exposure to smoke.

Finding:

On 3/13/2012 the surveyor observed the north stairwell door near room #5 did not close and latch as required and the lower level stairway door was not equipped with self-closing, positive latching hardware.

Based on observation the hospital failed to maintain the emergency egress lighting with a 1 1/2 hour duration. Failure to provide emergency lighting in corridors and exits increases the risk for injury to patients and staff in the case of a fire.

Finding:

On 3/13/2012 the surveyor found battery operated emergency egress lights in corridors and at exits were not maintained. The emergency lights did not light when tested in the following areas:
1. activity room
2. kitchen area and kitchen exit corridor
3. basement above the door by the vending machines.

Based on record review it was determined that the hospital failed to conduct fire drills at least quarterly on each shift to ensure that staff are familiar with fire safety procedures and can assist the patient in an emergency.

The lack of fire drill training for the facility staff places the patients at risk for injury in an emergency and in the case of a fire.

Findings include:

On 3/13/12 during a review of the fire drill records the surveyor found that the hospital missed fire drill training for staff on the night shift for the 2nd quarter and on the day shift for the 3rd quarter of 2011.

Based on interview and record review the hospital failed to maintain and to test smoke detectors according to the manufacturer's specifications. Failure to maintain and test smoke detectors according to the manufacturer's specifications for early warning alert places the patients at risk for possible injury by smoke and fire.

Findings:

During a review of smoke detector maintenance records on 3/2012 the surveyor found three (3) smoke detectors were reported defective and repaired in February for patient rooms #2, #3 and #6. However, previous monthly smoke detector testing and maintenance logs were missing for the patient rooms and documentation was not available for review.

Based on observation the hospital failed to provide automatic sprinkler protection throughout the hospital building. Failure to provide fire sprinkler protection places the patients and staff at risk for injury by the spread of a fire and the exposure to smoke.

Finding:

1. On 3/13/2012 during the fire inspection the surveyor found the North Wing Critical Access Hospital was not protected by an automatic fire suppression system.

2. During a tour of the kitchen on 3/13/2012 the surveyor observed fire sprinklers were missing in the walk-in cooler and the walk-in freezer.

Based on observation the hospital failed to restrict the use of portable electric heaters in the hospital employee areas where the portable electric heater did not have a tip over shutoff and the heating elements exceeded 212 degrees Fahrenheit. Failure to not restrict the use of portable electric heaters in the hospital could result in injury to the patients.

Finding:

During a tour of the patient care areas on 3/13/2012 the surveyor observed portable electric heaters in the director of nursing office and at the penthouse office desk. Both electric heaters were not provided with tip over switch protection to turn off the portable electric heaters.

Based on observation the hospital failed to ensure the Type 1 electrical system was properly installed and the emergency power system was safely divided into the critical branch, the life safety branch and the emergency system in accordance with NFPA 99.

Failure to maintain the emergency electrical system with the correct electrical supply branches places the patients at risk for possible failure of the life safety branch electrical circuit from equipment over loads.

Finding:

On 3/13/2012 the surveyor observed electrical circuits (Heli-pad Beacon Lights, Heli-pad Flood Lights, Long Term Care Emergency Electrical Receptacle, Lobby Hot Water Circuit, etc. ) on the life safety branch panel box that could overload the circuits. The hospital needs to ensure that only those electrical circuits allowed by NFPA are on the life safety branch.

Based on observation the hospital failed to install electrical wiring and to maintain electrical equipment in accordance with NFPA 70 and the National Electrical Code. Failure to safely install and maintain electrical equipment places the patients at risk for possible injury from electrical equipment failures and electrical fires.

Finding:

On 3/13/2012 during the fire safety rounds the surveyor observed improperly installed electrical wiring such as:

1. An electrical power strip hanging by its cord in room #104
2. An unapproved cube-style adapter without a built in circuit breaker in the Emergency Room
3. Vending machines plugged into a power strip and not into an approved electrical receptacle in the lower level lounge area.

Based on observation the hospital failed to maintain doors protecting corridor openings to resist the passage of smoke and to ensure that there are no impediments to the closing of the doors. Failure of the doors to close and latch could result in toxic products of combustion and smoke to enter from the rooms into the exit corridor.

Findings:

1. On 3/13/2012 the surveyor observed the upper level north stairwell door by patient room # 5 that did not close and latch.

2. The surveyor also observed on 3/13/2012 doors without latches that included the soiled utility room, the clean utility room, and the shared door between the clean and the soiled utility rooms.

'
Based on observation and interview with engineering staff the hospital failed to maintain corridor walls and doors as designed to resist the passage of smoke. Failure to maintain corridor walls and doors places the patients at risk to smoke exposure in corridor exits.

Findings:

1. During a tour of the hospital on 3/13/2012 the surveyor observed a roll down fire window between the dining room and the west wing nurse's station. Smoke detectors were on both sides of the roll down fire window. Engineering staff reported to the surveyor that the fire window did not operate with the fire alarm. The roll down fire window was not maintained and operational in the case of a fire.

2. On 3/13/2012 the surveyor observed communication cables that penetrated exit corridor walls and the fire stop repair work was not completed in the following areas:
1. Central supply
2. Emergency Department
3. Janitorial closets near room #2 and room #104
4. West wing nurse administration
5 Above fire smoke door by room #106
6. Laboratory
7. Upper and lower level elevator doors (plugs missing)

Based on observation the hospital failed to provide self closing positive latching doors in a non- sprinklered hazardous area that was not separated. Failure to maintain fire rated doors in a non-sprinklered hazardous area places the patients and staff at risk for possible injury in the case of a fire.

Finding:

On 3/13/2012 during fire safety rounds with engineering staff the surveyor observed there was no separation between the soiled linen room and the clean linen room, but the two spaces were combined. There was no fire sprinkler protection in the clean and soiled linen spaces. Also, the three doors leading out of the clean and soiled linen area were not equipped with self-closing and positive latching door hardware.

Based on observation the hospital failed to maintain stairways used as exits with self closing and latching doors.
Failure to maintain exit stairwells with self-closing and latching doors places the patient at risk for injury from the spread of a fire and exposure to smoke.

Finding:

On 3/13/2012 the surveyor observed the north stairwell door near room #5 did not close and latch as required and the lower level stairway door was not equipped with self-closing, positive latching hardware.

Based on observation the hospital failed to maintain the emergency egress lighting with a 1 1/2 hour duration. Failure to provide emergency lighting in corridors and exits increases the risk for injury to patients and staff in the case of a fire.

Finding:

On 3/13/2012 the surveyor found battery operated emergency egress lights in corridors and at exits were not maintained. The emergency lights did not light when tested in the following areas:
1. activity room
2. kitchen area and kitchen exit corridor
3. basement above the door by the vending machines.

Based on record review it was determined that the hospital failed to conduct fire drills at least quarterly on each shift to ensure that staff are familiar with fire safety procedures and can assist the patient in an emergency.

The lack of fire drill training for the facility staff places the patients at risk for injury in an emergency and in the case of a fire.

Findings include:

On 3/13/12 during a review of the fire drill records the surveyor found that the hospital missed fire drill training for staff on the night shift for the 2nd quarter and on the day shift for the 3rd quarter of 2011.

Based on interview and record review the hospital failed to maintain and to test smoke detectors according to the manufacturer's specifications. Failure to maintain and test smoke detectors according to the manufacturer's specifications for early warning alert places the patients at risk for possible injury by smoke and fire.

Findings:

During a review of smoke detector maintenance records on 3/2012 the surveyor found three (3) smoke detectors were reported defective and repaired in February for patient rooms #2, #3 and #6. However, previous monthly smoke detector testing and maintenance logs were missing for the patient rooms and documentation was not available for review.

Based on observation the hospital failed to provide automatic sprinkler protection throughout the hospital building. Failure to provide fire sprinkler protection places the patients and staff at risk for injury by the spread of a fire and the exposure to smoke.

Finding:

1. On 3/13/2012 during the fire inspection the surveyor found the North Wing Critical Access Hospital was not protected by an automatic fire suppression system.

2. During a tour of the kitchen on 3/13/2012 the surveyor observed fire sprinklers were missing in the walk-in cooler and the walk-in freezer.

Based on observation the hospital failed to restrict the use of portable electric heaters in the hospital employee areas where the portable electric heater did not have a tip over shutoff and the heating elements exceeded 212 degrees Fahrenheit. Failure to not restrict the use of portable electric heaters in the hospital could result in injury to the patients.

Finding:

During a tour of the patient care areas on 3/13/2012 the surveyor observed portable electric heaters in the director of nursing office and at the penthouse office desk. Both electric heaters were not provided with tip over switch protection to turn off the portable electric heaters.

Based on observation the hospital failed to ensure the Type 1 electrical system was properly installed and the emergency power system was safely divided into the critical branch, the life safety branch and the emergency system in accordance with NFPA 99.

Failure to maintain the emergency electrical system with the correct electrical supply branches places the patients at risk for possible failure of the life safety branch electrical circuit from equipment over loads.

Finding:

On 3/13/2012 the surveyor observed electrical circuits (Heli-pad Beacon Lights, Heli-pad Flood Lights, Long Term Care Emergency Electrical Receptacle, Lobby Hot Water Circuit, etc. ) on the life safety branch panel box that could overload the circuits. The hospital needs to ensure that only those electrical circuits allowed by NFPA are on the life safety branch.

Based on observation the hospital failed to install electrical wiring and to maintain electrical equipment in accordance with NFPA 70 and the National Electrical Code. Failure to safely install and maintain electrical equipment places the patients at risk for possible injury from electrical equipment failures and electrical fires.

Finding:

On 3/13/2012 during the fire safety rounds the surveyor observed improperly installed electrical wiring such as:

1. An electrical power strip hanging by its cord in room #104
2. An unapproved cube-style adapter without a built in circuit breaker in the Emergency Room
3. Vending machines plugged into a power strip and not into an approved electrical receptacle in the lower level lounge area.