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Based on observation the facility failed to maintain smoke barriers so as to prevent the migration of smoke from one area to another.

Failure on the part of the facility to maintain smoke barriers puts patients, staff and visitors of the facility at risk from migrating smoke.

Findings include:

1. On 8/1/2011 the surveyor noted that double doors located near the birthing center had a gap in excess of 1/4 inch between doors.

2. On 8/1/2011 the surveyor noted that double doors located near the education center would not properly close due to problems with top latch devices.

Based on interview staff of the facility lacked the ability to access a written plan for the protection of patients and failed to readily identify the location(s) of fire alarm pull stations.

Failure on the part of staff to have access to action plans for the protection of patients confronted by non medical emergencies; and not knowing the location of fire alarm pull stations puts patients, staff and visitors of the facility at risk in an emergency.

Findings include:

1. On 8/1/2022 the surveyor was informed that the facility's emergency plan could not be made available electronically. It was suggested that the plan might not be available because it was being accessed by another user located in another location.

2. On 8/1/2011 the surveyor asked a member of the 3rd floor nursing staff where the fire alarm pull stations were located. He/she was unable to identify the locations of the pull stations.

3. On 8/1/2011 the surveyor asked a second member of the 3rd floor nursing staff where the fire alarm pull stations were located. He/she was able to located one pull station but lacked knowledge of a second pull station that was located closer to the nurses station.

Based on observation, the hospital failed to maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/1/2011 the surveyor noted that contractor installed halogen lighting was hanging from sprinkler lines in the shell spaces of the facility.

2. On 8/1/2011 the surveyor noted that a sprinkler head was not provided for the 1st floor environmental services room (room 1209A). Subsequent to the finding it was determined that the sprinkler head had not been dropped below the ceiling tile. Correction was made before survey exit.

Based on observation the facility failed to provide portable fire extinguishers as required for certain locations of the facility.

Failure to provide portable fire extinguishers as required (location and manner) puts patients, staff and visitors of the facility at risk from the effects of fire.

References:

NFPA 418 Standard for Heliports, 1995 and subsequent editions

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition, Chapter 1-6.3.

Findings include:

1. On 8/10/2010 the surveyor noted that a portable fire extinguisher provided for the Heliport takeoff and landing area had a 2-A:10-BC rating which is not appropriate for the intended use.

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/19/2011 the surveyor noted a portal space heater in health information management (HIM). The heater was equipped with heating elements that would heat to a temperature greater than 212 degrees F.

Based on document review the facility had set operational limits for relative humidity in anaesthetizing locations (operating rooms) at a level below 35% relative humidity which is unacceptable per code.

Failure on the part of the facility to set relative humidity levels within the proper range puts patients and staff of the facility at risk from fire.

Finding include:

1. On 8/19/2011 the surveyor noted that the posted range for relative humidity in the operating rooms was between 20% and 60% relative humidity.

Based on observation the facility failed to maintain its emergency electrical system in accordance with NFPA 99 Standard for Health Care Facilities 1999 edition and NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition. More specifically, the facility failed to provide emergency lighting in the space containing the emergency generator.

Failure on the part of the facility to maintain its emergency power system as is required puts patients, staff and visitors of the facility at risk should the emergency power system fail and repairs are required.

References: NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, Chapter 5-3.1 states: "The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch."

Findings include:

1. On 8/1/2011 the surveyor noted that the compartment containing the emergency generator was not provided with a battery-powered emergency lighting system as is required.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients,staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 8/1/2011 the surveyor noted that an electrical tray cover in electrical room 1552A had not been installed creating a situation wherein electrical wiring was exposed. The tray cover had been placed on equipment near the tray.

2. On 8/1/2011 the surveyor noted the improper use of extension cords in the 3rd floor shell space used by contractors.

Based on observation the facility failed to maintain smoke barriers so as to prevent the migration of smoke from one area to another.

Failure on the part of the facility to maintain smoke barriers puts patients, staff and visitors of the facility at risk from migrating smoke.

Findings include:

1. On 8/1/2011 the surveyor noted that double doors located near the birthing center had a gap in excess of 1/4 inch between doors.

2. On 8/1/2011 the surveyor noted that double doors located near the education center would not properly close due to problems with top latch devices.

Based on interview staff of the facility lacked the ability to access a written plan for the protection of patients and failed to readily identify the location(s) of fire alarm pull stations.

Failure on the part of staff to have access to action plans for the protection of patients confronted by non medical emergencies; and not knowing the location of fire alarm pull stations puts patients, staff and visitors of the facility at risk in an emergency.

Findings include:

1. On 8/1/2022 the surveyor was informed that the facility's emergency plan could not be made available electronically. It was suggested that the plan might not be available because it was being accessed by another user located in another location.

2. On 8/1/2011 the surveyor asked a member of the 3rd floor nursing staff where the fire alarm pull stations were located. He/she was unable to identify the locations of the pull stations.

3. On 8/1/2011 the surveyor asked a second member of the 3rd floor nursing staff where the fire alarm pull stations were located. He/she was able to located one pull station but lacked knowledge of a second pull station that was located closer to the nurses station.

Based on observation, the hospital failed to maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/1/2011 the surveyor noted that contractor installed halogen lighting was hanging from sprinkler lines in the shell spaces of the facility.

2. On 8/1/2011 the surveyor noted that a sprinkler head was not provided for the 1st floor environmental services room (room 1209A). Subsequent to the finding it was determined that the sprinkler head had not been dropped below the ceiling tile. Correction was made before survey exit.

Based on observation the facility failed to provide portable fire extinguishers as required for certain locations of the facility.

Failure to provide portable fire extinguishers as required (location and manner) puts patients, staff and visitors of the facility at risk from the effects of fire.

References:

NFPA 418 Standard for Heliports, 1995 and subsequent editions

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition, Chapter 1-6.3.

Findings include:

1. On 8/10/2010 the surveyor noted that a portable fire extinguisher provided for the Heliport takeoff and landing area had a 2-A:10-BC rating which is not appropriate for the intended use.

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/19/2011 the surveyor noted a portal space heater in health information management (HIM). The heater was equipped with heating elements that would heat to a temperature greater than 212 degrees F.

Based on document review the facility had set operational limits for relative humidity in anaesthetizing locations (operating rooms) at a level below 35% relative humidity which is unacceptable per code.

Failure on the part of the facility to set relative humidity levels within the proper range puts patients and staff of the facility at risk from fire.

Finding include:

1. On 8/19/2011 the surveyor noted that the posted range for relative humidity in the operating rooms was between 20% and 60% relative humidity.

Based on observation the facility failed to maintain its emergency electrical system in accordance with NFPA 99 Standard for Health Care Facilities 1999 edition and NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition. More specifically, the facility failed to provide emergency lighting in the space containing the emergency generator.

Failure on the part of the facility to maintain its emergency power system as is required puts patients, staff and visitors of the facility at risk should the emergency power system fail and repairs are required.

References: NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, Chapter 5-3.1 states: "The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch."

Findings include:

1. On 8/1/2011 the surveyor noted that the compartment containing the emergency generator was not provided with a battery-powered emergency lighting system as is required.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients,staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 8/1/2011 the surveyor noted that an electrical tray cover in electrical room 1552A had not been installed creating a situation wherein electrical wiring was exposed. The tray cover had been placed on equipment near the tray.

2. On 8/1/2011 the surveyor noted the improper use of extension cords in the 3rd floor shell space used by contractors.