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Based on tour of the hospital and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ? hour fire resistance rating. The facility corridor was non-sprinklered with walls that properly extended above the ceiling. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the first, second, third and fourth floors of the hospital was completed with Staff P, Q, and R. The hospital was noted to have a partial automatic sprinkler system in that some corridors and patient care areas were not equipped with the sprinkler system. Observation of corridor walls in areas where there was no sprinkler system revealed the following corridor walls with penetrations.

1. On the second floor, outside the medication room, a penetration in the corridor wall above the ceiling tile and below the floor decking above, was observed surrounding a conduit passing through the wall.

2. On the third floor, above the ceiling tile at room 308, a penetration surrounding conduit, which passed through the corridor wall was observed.

3. On the fourth floor, a penetration was observed on the corridor wall above the ceiling tiles between room 401 and 403.

The penetrations in the corridor walls were observed and verified by the staff present on the tour.

Based on facility tour and staff interview and verification the facility failed to ensure that dutch doors in a corridor opening were equipped with positive latching on the upper door. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the hospital was completed with Staff P, Q, and R. On the first floor at the entrance to the file storage room, dutch doors were observed. The door was observed to have a 3/4 hour fire resistance rating and had an astragal in place at the division of the door. The lower half of the door was observed to be securely latched.

On 08/25/10 observation of the inside of the door with Staff B revealed the top of the dutch door did not have a mechanism to securely latch the door. Staff B verified there was no mechanism in place to ensure positive latching of the top door.

Based on tour of the hospital and staff interview and verification the facility failed to ensure that smoke barriers are constructed to provide at least one half hour fire resistance rating in accordance with 8.3. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the first, second, third and fourth floors of the hospital was completed with Staff P, Q, and R. Review of facility schematics for each hospital floor revealed each floor was divided by at least one, one hour fire resistant smoke barrier wall. Observation of fire rated smoke barrier walls on the second and third floors revealed penetrations in the walls at the following locations.

On the second floor;

1. The one hour smoke barrier wall was noted to extend into room 255. Observation of the smoke barrier, above the ceiling tiles, revealed a penetration in the wall surrounding a conduit which extended through the wall.

2. Observation above the ceiling tiles at the smoke barrier doors outside room 255 revealed a penetration in the fire rated smoke barrier around a unistrut and bolt.

3. Observation near room 207 revealed the presence of smoke barrier doors in the corridor. Observation above the ceiling tiles of the one hour fire rated wall which extended into room 207 revealed the smoke barrier wall was incomplete just above the ceiling tiles. The incomplete smoke barrier wall allowed for easy observation above the next patient room. Interview with Staff P verified that smoke doors located in the corridor were either placed incorrectly or the fire rated smoke barrier wall which extended from exterior wall to exterior wall was located in another area of the corridor. Staff P further verified the observation had previously been identified by the facility and was projected to be corrected in the near future.

On the third floor;

4. The one hour fire resistant wall was noted to extend into room 316. Observation above the ceiling tiles and below the floor decking above in room 316, revealed a penetration in the fire rated wall approximately 6 inches in diameter. Staff R observed and verified the location and size of the penetration.

Staff present on tour observed and verified the penetrations in the one hour fire rated smoke barrier walls.

Based on facility tour and staff interview and verification the facility failed to ensure that door openings in smoke barriers met the requirements of 7.2 with regards to locks on doors in the path of egress. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the hospital was completed with Staff P, Q, and R. Observation of the third floor revealed a fire rated corridor door located in a one hour fire rated smoke barrier wall. The one hour fire rated door was equipped with a door knob and dead bolt mechanism on the door.

If the dead bolt were locked, one means of egress would be blocked. The patient population on the third floor did not require special locking arrangements for safety. Staff P present on tour stated the dead bolt was not used to lock the door. Staff P verified the dead bolt should not be in place on the corridor door.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting of at least 1? hour duration was provided in accordance with 7.9 with regard to testing for 30 seconds per month. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included:

On 08/23 and 08/26/10 documentation of the facility monthly testing of the battery operated emergency lighting was reviewed. Review of the information for 2010 revealed there was no documented evidence that emergency lighting for the family birthing center had been tested for 30 seconds in the months of March and April. Information for testing of emergency lighting in the hospital operating rooms revealed there was no documented evidence that testing for 30 seconds was completed in May and June 2010.

Interview of Staff R on 08/26/10 at 3:40 P.M. verified the missing testing documentation of the emergency lighting for 30 seconds per month could not be located for the family birthing center and the hospital operating rooms.

Based on review of staff documentation and staff interview and verification the facility failed to ensure that staff were provided with fire drills at unexpected times. Lack of fire drills could potentially affect all patients and staff in the event of a fire event.

Findings included:

On 08/23/10 review of facility fire drills revealed there was no documented evidence of fire drills for the staff at the sleep center in 2010.

On 08/25/10 between the hours of 11:30 AM and 12:00 PM tour of the sleep study location was completed with Staff P, S and KK. Observation of the sleep study location revealed that it was leased space located in a Motel 6 near the hospital.

Interview of Staff KK stated that four motel rooms were leased and equipped for monitoring of patients during sleep studies. Staff KK stated the sleep study lab was recently re-located to the motel and had been providing patient services since 08/13/10 at the new location. Staff KK verified that two patients had received services the previous night and left the motel on the morning of the tour.

The leased rooms were noted to be on the second floor. One of the rooms was designated as a handicap accessible room. Staff KK indicated the shift for the staff assigned to the sleep lab was usually 8:00 P.M. until 8:00 A.M.

Staff KK and P were interview regarding fire drills completed for staff assigned to the new location. Staff KK verified the staff had not participated in a fire drill which outlined the specific fire plan for that location prior to or at the time of initiation of patient services at the new location.

Based on facility observation during tour and staff interview and verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The Life Safety Code survey was completed on 08/27/10.

Findings included:

On 08/24/10 between the hours of 8:00A.M. and 9:30 A.M. tour of the immediate care building was completed with Staff P. Observation of smoke detector placement revealed that smoke detectors were placed significantly less than 36 inches from devices affecting air flow in the following locations.

1. In the outpatient rehabilitation area, a smoke detector was placed significantly less than 36 inches from an air diffuser.

2. In the storage room of the urgent care a smoke detector was placed significantly less than 36 inches from an air diffuser.

Staff present on tour verified the location and distance of the smoke detectors from the air diffusers.

Based on facility observation during tour and staff interview and verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included:

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the first, second, third and fourth floors of the hospital was completed with Staff P, Q, and R. Observation of smoke detector placement revealed that smoke detectors were placed significantly less than 36 inches from devices affecting air flow in the following locations.

On the first floor:

1. Outside the chapel the smoke detector was significantly less than 36 inches from the air diffuser.

2. In the intensive care unit the smoke detector was significantly less than 36 inches from the air diffuser.

On the Second floor:

3. Outside room 267 smoke detector was significantly less than 36 inches from the air supply.

On the Fourth:

consider room 407 the smoke detector was significantly less than 36 inches from the air diffuser.

Staff present on tour verified the location and distances of the smoke detectors from the air devices.

Based on review of facility documentation and staff interview and verification the facility failed to ensure that the fire watch plan addressed the specific nature of the sytem shut down with regard to the automatic sprinkler system, the location, the increased hazards that could be involved and the necessary actions to mitigate the hazards. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/23/10 review of the facility fire watch was completed. The facility policy noted general guidelines which addressed the building when under construction or when workers were in an area working.

The policy stated that a temporary but equivalent system would be provided when the fire alarm or suppression systems were impaired. The policy further stated the temporary system would be tested monthly.

Review of the interim life safety policy revealed it did not address what specific actions would be taken in the event of impairment of the automatic sprinkler system, consideration as to the area affected by impairment of the automatic sprinkler system or the increased hazards for the population in the area affected.
The policy did not address what the temporary but equivalent system may include.

Interview on 08/23/10 at 2:30 P.M. with Staff P verified the policy was not specific with all actions that would be taken in the event the automatic sprinkler system was impaired.

Based on review of facility documentation and staff interview and verification the facility failed to ensure that the fire watch plan addressed the specific nature of the sytem shut down with regard to the fire alarm, the location, the increased hazards that could be involved and the necessary actions to mitigate the hazards. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/23/10 review of the facility fire watch was completed. The facility policy noted general guidelines which addressed the building when under construction or when workers were in an area working.

The policy stated that a temporary but equivalent system would be provided when the fire alarm or suppression systems were impaired. The policy further stated the temporary system would be tested monthly.

Review of the interim life safety policy revealed it did not address what specific actions would be taken in the event of impairment of the fire alarm system, consideration as to the area affected by impairment of the fire alarm system or the increased hazards for the population in the area affected.
The policy did not address what the temporary but equivalent system may include.

Interview on 08/23/10 at 2:30 P.M. with Staff P verified the policy was not specific with all actions that would be taken in the event the fire alarm system was impaired.

Based on tour of the hospital and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ? hour fire resistance rating. The facility corridor was non-sprinklered with walls that properly extended above the ceiling. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the first, second, third and fourth floors of the hospital was completed with Staff P, Q, and R. The hospital was noted to have a partial automatic sprinkler system in that some corridors and patient care areas were not equipped with the sprinkler system. Observation of corridor walls in areas where there was no sprinkler system revealed the following corridor walls with penetrations.

1. On the second floor, outside the medication room, a penetration in the corridor wall above the ceiling tile and below the floor decking above, was observed surrounding a conduit passing through the wall.

2. On the third floor, above the ceiling tile at room 308, a penetration surrounding conduit, which passed through the corridor wall was observed.

3. On the fourth floor, a penetration was observed on the corridor wall above the ceiling tiles between room 401 and 403.

The penetrations in the corridor walls were observed and verified by the staff present on the tour.

Based on facility tour and staff interview and verification the facility failed to ensure that dutch doors in a corridor opening were equipped with positive latching on the upper door. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the hospital was completed with Staff P, Q, and R. On the first floor at the entrance to the file storage room, dutch doors were observed. The door was observed to have a 3/4 hour fire resistance rating and had an astragal in place at the division of the door. The lower half of the door was observed to be securely latched.

On 08/25/10 observation of the inside of the door with Staff B revealed the top of the dutch door did not have a mechanism to securely latch the door. Staff B verified there was no mechanism in place to ensure positive latching of the top door.

Based on tour of the hospital and staff interview and verification the facility failed to ensure that smoke barriers are constructed to provide at least one half hour fire resistance rating in accordance with 8.3. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the first, second, third and fourth floors of the hospital was completed with Staff P, Q, and R. Review of facility schematics for each hospital floor revealed each floor was divided by at least one, one hour fire resistant smoke barrier wall. Observation of fire rated smoke barrier walls on the second and third floors revealed penetrations in the walls at the following locations.

On the second floor;

1. The one hour smoke barrier wall was noted to extend into room 255. Observation of the smoke barrier, above the ceiling tiles, revealed a penetration in the wall surrounding a conduit which extended through the wall.

2. Observation above the ceiling tiles at the smoke barrier doors outside room 255 revealed a penetration in the fire rated smoke barrier around a unistrut and bolt.

3. Observation near room 207 revealed the presence of smoke barrier doors in the corridor. Observation above the ceiling tiles of the one hour fire rated wall which extended into room 207 revealed the smoke barrier wall was incomplete just above the ceiling tiles. The incomplete smoke barrier wall allowed for easy observation above the next patient room. Interview with Staff P verified that smoke doors located in the corridor were either placed incorrectly or the fire rated smoke barrier wall which extended from exterior wall to exterior wall was located in another area of the corridor. Staff P further verified the observation had previously been identified by the facility and was projected to be corrected in the near future.

On the third floor;

4. The one hour fire resistant wall was noted to extend into room 316. Observation above the ceiling tiles and below the floor decking above in room 316, revealed a penetration in the fire rated wall approximately 6 inches in diameter. Staff R observed and verified the location and size of the penetration.

Staff present on tour observed and verified the penetrations in the one hour fire rated smoke barrier walls.

Based on facility tour and staff interview and verification the facility failed to ensure that door openings in smoke barriers met the requirements of 7.2 with regards to locks on doors in the path of egress. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the hospital was completed with Staff P, Q, and R. Observation of the third floor revealed a fire rated corridor door located in a one hour fire rated smoke barrier wall. The one hour fire rated door was equipped with a door knob and dead bolt mechanism on the door.

If the dead bolt were locked, one means of egress would be blocked. The patient population on the third floor did not require special locking arrangements for safety. Staff P present on tour stated the dead bolt was not used to lock the door. Staff P verified the dead bolt should not be in place on the corridor door.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting of at least 1? hour duration was provided in accordance with 7.9 with regard to testing for 30 seconds per month. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included:

On 08/23 and 08/26/10 documentation of the facility monthly testing of the battery operated emergency lighting was reviewed. Review of the information for 2010 revealed there was no documented evidence that emergency lighting for the family birthing center had been tested for 30 seconds in the months of March and April. Information for testing of emergency lighting in the hospital operating rooms revealed there was no documented evidence that testing for 30 seconds was completed in May and June 2010.

Interview of Staff R on 08/26/10 at 3:40 P.M. verified the missing testing documentation of the emergency lighting for 30 seconds per month could not be located for the family birthing center and the hospital operating rooms.

Based on review of staff documentation and staff interview and verification the facility failed to ensure that staff were provided with fire drills at unexpected times. Lack of fire drills could potentially affect all patients and staff in the event of a fire event.

Findings included:

On 08/23/10 review of facility fire drills revealed there was no documented evidence of fire drills for the staff at the sleep center in 2010.

On 08/25/10 between the hours of 11:30 AM and 12:00 PM tour of the sleep study location was completed with Staff P, S and KK. Observation of the sleep study location revealed that it was leased space located in a Motel 6 near the hospital.

Interview of Staff KK stated that four motel rooms were leased and equipped for monitoring of patients during sleep studies. Staff KK stated the sleep study lab was recently re-located to the motel and had been providing patient services since 08/13/10 at the new location. Staff KK verified that two patients had received services the previous night and left the motel on the morning of the tour.

The leased rooms were noted to be on the second floor. One of the rooms was designated as a handicap accessible room. Staff KK indicated the shift for the staff assigned to the sleep lab was usually 8:00 P.M. until 8:00 A.M.

Staff KK and P were interview regarding fire drills completed for staff assigned to the new location. Staff KK verified the staff had not participated in a fire drill which outlined the specific fire plan for that location prior to or at the time of initiation of patient services at the new location.

Based on facility observation during tour and staff interview and verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The Life Safety Code survey was completed on 08/27/10.

Findings included:

On 08/24/10 between the hours of 8:00A.M. and 9:30 A.M. tour of the immediate care building was completed with Staff P. Observation of smoke detector placement revealed that smoke detectors were placed significantly less than 36 inches from devices affecting air flow in the following locations.

1. In the outpatient rehabilitation area, a smoke detector was placed significantly less than 36 inches from an air diffuser.

2. In the storage room of the urgent care a smoke detector was placed significantly less than 36 inches from an air diffuser.

Staff present on tour verified the location and distance of the smoke detectors from the air diffusers.

Based on facility observation during tour and staff interview and verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included:

On 08/24/10 between the hours of 10:50 A.M. and 3:50 P.M. tour of the first, second, third and fourth floors of the hospital was completed with Staff P, Q, and R. Observation of smoke detector placement revealed that smoke detectors were placed significantly less than 36 inches from devices affecting air flow in the following locations.

On the first floor:

1. Outside the chapel the smoke detector was significantly less than 36 inches from the air diffuser.

2. In the intensive care unit the smoke detector was significantly less than 36 inches from the air diffuser.

On the Second floor:

3. Outside room 267 smoke detector was significantly less than 36 inches from the air supply.

On the Fourth:

consider room 407 the smoke detector was significantly less than 36 inches from the air diffuser.

Staff present on tour verified the location and distances of the smoke detectors from the air devices.

Based on review of facility documentation and staff interview and verification the facility failed to ensure that the fire watch plan addressed the specific nature of the sytem shut down with regard to the automatic sprinkler system, the location, the increased hazards that could be involved and the necessary actions to mitigate the hazards. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/23/10 review of the facility fire watch was completed. The facility policy noted general guidelines which addressed the building when under construction or when workers were in an area working.

The policy stated that a temporary but equivalent system would be provided when the fire alarm or suppression systems were impaired. The policy further stated the temporary system would be tested monthly.

Review of the interim life safety policy revealed it did not address what specific actions would be taken in the event of impairment of the automatic sprinkler system, consideration as to the area affected by impairment of the automatic sprinkler system or the increased hazards for the population in the area affected.
The policy did not address what the temporary but equivalent system may include.

Interview on 08/23/10 at 2:30 P.M. with Staff P verified the policy was not specific with all actions that would be taken in the event the automatic sprinkler system was impaired.

Based on review of facility documentation and staff interview and verification the facility failed to ensure that the fire watch plan addressed the specific nature of the sytem shut down with regard to the fire alarm, the location, the increased hazards that could be involved and the necessary actions to mitigate the hazards. The hospital had a capacity of 139 certified beds with a census of 64 patients at the time of the survey. The Life Safety Code survey was completed on 08/27/10.

Findings included;

On 08/23/10 review of the facility fire watch was completed. The facility policy noted general guidelines which addressed the building when under construction or when workers were in an area working.

The policy stated that a temporary but equivalent system would be provided when the fire alarm or suppression systems were impaired. The policy further stated the temporary system would be tested monthly.

Review of the interim life safety policy revealed it did not address what specific actions would be taken in the event of impairment of the fire alarm system, consideration as to the area affected by impairment of the fire alarm system or the increased hazards for the population in the area affected.
The policy did not address what the temporary but equivalent system may include.

Interview on 08/23/10 at 2:30 P.M. with Staff P verified the policy was not specific with all actions that would be taken in the event the fire alarm system was impaired.