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Based on observation and interview, the facility failed to ensure all patient room doors closed tightly in the door frame or were equipped with proper hardware for positive latching. This deficient practice affects all patients in these smoke compartments. The facility census was 117.

Findings included:

1. On the Forest Park campus, observations, during a tour of the facility conducted on 04/26/11, revealed the following:

- Observation at 9:30 AM on 04/26/11 showed the door to patient room 278 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 9:33 AM on 04/26/11 showed the door to patient room 280 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 9:40 AM on 04/26/11 showed the door to patient room 279 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 9:52 AM on 04/26/11 showed the door to patient room 275 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 9:53 AM on 04/26/11 showed the door to patient room 273 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 10:05 AM on 04/26/11 showed the door to patient room 266 would not remain tightly closed in the door frame and would not resist the passage of smoke.

Staff HH Director of Security and Staff II Engineering confirmed at that time the patient room doors would not tightly closed in the door frame.



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2. Observation of the Jefferson campus on 04/27/11 showed the following rooms had door hardware missing or used roller latches (does not positively latch or keep doors closed) for the following: Rooms 315, 316, 343, 345, 348, 349, and 360 were missing door latching hardware.

Rooms 220, 221, 222, 223, 224, 225, 226 260, 262, 263, 264 and 265 all had roller latches on the corridor doors which would not keep the doors positively latched.

All rooms were indicated on the revised bed count list provided by the facility as for patient use.

3. During tour of the Broadway campus on 04/26/11 patient room doors to rooms 517 and 624 did not latch securely and required repair.


Chapter 19.3.6.3.1 of the 2000 existing edition of the Life Safety Code published by the National Fire Protection Association (NFPA) states the following:
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of one and three-fourths inches thick, solid bonded core wood or of construction to resist the passage of smoke. Doors are provided with a means suitable for keeping the door closed. Use of roller latches is prohibited.

Based on observation, the facility failed to ensure that all cylinders of compressed medical gasses were individually secured to prevent damage from falling. The census of the facility was 117.

Findings included:

1. On the Broadway campus:

- Observation of a storage area for medical gasses in a service area on 04/26/11 showed that in one room there were eight tanks secured together with one chain. Two additional tanks were secured by one chain around both tanks. A second set of two tanks was also secured by one chain.

- Observation on 4/26/11 of a second room in this service area showed that one tank of compressed medical gas near the door had no method to secure it in an upright position. There was a group of 12 tanks secured together with one chain. A second group of 17 tanks was secured together with a single chain. Other groups of two tanks and five tanks were secured together with one chain across each group.

2. At the Forest park campus:

- Observations at 3:06 PM on 04/26/11 showed 4 "H"-size cylinders containing oxygen attached to the gas manifold and secured by only 1 chain and 4 "H"-size cylinders containing oxygen, not attached to the gas manifold, unsecured in the medical gas area of the facility.

Staff HH Director of Security and Staff II Engineering confirmed at that time the medical gas cylinders were not individually secure.


Chapter 5.1.3.3.2 of the 2002 edition of the Code NFPA (National Fire Protection Association) 99 for Health Care Facilities states that locations for central supply systems and the storage of medical gases shall meet the following requirements:
(7) be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling.

Based on observation and interview, the facility failed to ensure that for two of four surgical suites there were adequate electrical outlets and that the use of extension cords was limited. The census was 117.

Findings included:

1. Observation of operating room #3 on 04/28/11 at 9:25 AM showed that for permanent electrical outlets there were two isolation (monitors electrical fault hazards) panels to supply power to all equipment in the room with four outlets each. The panels require a specialized plug to be connected to the panel. It was observed that there were three additional plug strips (six devices can be plugged into this adding electrical outlets) two of which were in use.

One of the plug strips had four devices plugged into it and was connected then to an additional four outlet box having a total of three cords plugged into it. The four outlet box was connected by a short cord having the specialized plug to the isolation panel.

The second plug strip had three devices plugged into that and was connected by a short cord with a specialized plug into the isolation panel.

It was observed that two of the devices in the room have cords long enough to reach the isolation panel directly without being plugged into the first cord strip.

During an interview on 04/28/11 at 9:37 AM Staff PP (surgical supervisor) stated that there are not enough electrical outlets available in the operating room #3 and that is the reason the extension cords and plug strips are used.

2. Observation on 04/28/11 at 9:40 AM of operating room suite #1 revealed that the anesthesia machine (which delivers controlled anesthesia and breathing support to patients) was plugged into a total of four separate cords to be connected to the isolation panel in the wall. Observation of the cord supplied by the manufacturer of the machine showed a specialized plug designed for the isolation panel. Interview at the time of observation with the surgical staff present in the room he/she stated that the cord from the anesthesia machine was too short to reach the wall and needed the additional cords to reach the isolation panel to be connected.

3. Chapter 8.4.1.2.4 of the National Fire Protection Association (NFPA) code for health care facilities NFPA 99 states that for line voltage equipment in anesthetizing locations the (1) cords shall be continuous...(5) cords shall be of sufficient length to reach any position in which the portable device is to be used.

Based on observation and record review, the facility failed to ensure that a policy was in place to address an impairment of the sprinkler system when it occurs for more than four hours in a 24-hour period. The census of the facility was 117.

Findings included:

1. Review of a policy titled "Loss of Fire Alarms", last revised on 11/07, showed that the purpose is to supply guidance to specific departments in case of fire alarm loss as to ensure fire safety. The policy lists tasks for three departments: the security and engineering department are to go on life safety alert as per interim life safety code; and the engineering department will notify the hospital operator, the alarm company and the administrator on duty. The operator will then inform the local fire department that the alarm is not functioning.

Under the section for security it stated that increased internal patrols of the affected part of the building with special emphasis on storage and unoccupied areas will be done. In the event of a fire security will notify the hospital operator to call the fire department and announce a code red (code for fire situation).

However, review of the policy found it did not specify if the security persons assigned to increased patrols would be performing other duties as well or that their only duty was to patrol the affected area. The policy did not specify notification of staff present upon discovery of fire other than notifying the switchboard to announce the code red by the person on patrol.

2. Observation of security patrols for the Jefferson building during tour on 04/27/11 showed that there is limited staff available in this building, the majority of the building is occupied by non-facility staff persons, and the facility policy did not specify how the notification function would occur in this setting.


Chapter 9.7.6.1 of the 2000 edition of the Life Safety Code published by the National Fire Protection Association stated that where a required automatic sprinkler alarm (9.6.1.8 for fire alarm) is out of service for more than four hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system had been returned to service.

Appendix A for 9.7.6 stated that a fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specially trained in fire prevention and in the use of fire extinguishers and occupant hose lines, in notifying the fire department, in sounding the building fire alarm, and in understanding the particular fire safety situation for public education purposes.

Based on observation and record review, the facility failed to ensure that a policy was in place to address an impairment of the fire alarm when it occurs for more than four hours in a 24 hour period. The census of the facility was 117.

Findings included:

1. Review of a policy titled "Loss of Fire Alarms", last revised on 11/07, showed that the purpose is to supply guidance to specific departments in case of fire alarm loss as to ensure fire safety. The policy lists tasks for three departments: the security and engineering department are to go on life safety alert as per interim life safety code, and the engineering department will notify the hospital operator, the alarm company and the administrator on duty. The operator will then inform the local fire department that the alarm is not functioning. Under the section for security it stated that increased internal patrols of the affected part of the building with special emphasis on storage and unoccupied areas will be done. In the event of a fire security will notify the hospital operator to call the fire department and announce a code red (code for fire situation).

However, review of the policy found it did not specify if the security persons assigned to increased patrols would be performing other duties as well or that their only duty was to patrol the affected area. The policy did not specify notification of staff present upon discovery of fire other than notifying the switchboard to announce the code red by the person on patrol.

2. Observation of security patrols for the Jefferson building during tour on 04/27/11 showed that there is limited staff available in this building and the majority of the building is occupied by non-facility staff persons and the policy did not specify how the notification function would occur in this setting.


Chapter 9.7.6.1 of the 2000 edition of the Life Safety Code published by the National Fire Protection Association stated that where a required automatic sprinkler alarm (9.6.1.8 for fire alarm) is out of service for more than four hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system had been returned to service.

Appendix A for 9.7.6 stated that a fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specially trained in fire prevention and in the use of fire extinguishers and occupant hose lines, in notifying the fire department, in sounding the building fire alarm, and in understanding the particular fire safety situation for public education purposes.

Based on observation and interview, the facility failed to ensure all patient room doors closed tightly in the door frame or were equipped with proper hardware for positive latching. This deficient practice affects all patients in these smoke compartments. The facility census was 117.

Findings included:

1. On the Forest Park campus, observations, during a tour of the facility conducted on 04/26/11, revealed the following:

- Observation at 9:30 AM on 04/26/11 showed the door to patient room 278 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 9:33 AM on 04/26/11 showed the door to patient room 280 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 9:40 AM on 04/26/11 showed the door to patient room 279 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 9:52 AM on 04/26/11 showed the door to patient room 275 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 9:53 AM on 04/26/11 showed the door to patient room 273 would not remain tightly closed in the door frame and would not resist the passage of smoke.

- Observation at 10:05 AM on 04/26/11 showed the door to patient room 266 would not remain tightly closed in the door frame and would not resist the passage of smoke.

Staff HH Director of Security and Staff II Engineering confirmed at that time the patient room doors would not tightly closed in the door frame.



16639


2. Observation of the Jefferson campus on 04/27/11 showed the following rooms had door hardware missing or used roller latches (does not positively latch or keep doors closed) for the following: Rooms 315, 316, 343, 345, 348, 349, and 360 were missing door latching hardware.

Rooms 220, 221, 222, 223, 224, 225, 226 260, 262, 263, 264 and 265 all had roller latches on the corridor doors which would not keep the doors positively latched.

All rooms were indicated on the revised bed count list provided by the facility as for patient use.

3. During tour of the Broadway campus on 04/26/11 patient room doors to rooms 517 and 624 did not latch securely and required repair.


Chapter 19.3.6.3.1 of the 2000 existing edition of the Life Safety Code published by the National Fire Protection Association (NFPA) states the following:
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of one and three-fourths inches thick, solid bonded core wood or of construction to resist the passage of smoke. Doors are provided with a means suitable for keeping the door closed. Use of roller latches is prohibited.

Based on observation, the facility failed to ensure that all cylinders of compressed medical gasses were individually secured to prevent damage from falling. The census of the facility was 117.

Findings included:

1. On the Broadway campus:

- Observation of a storage area for medical gasses in a service area on 04/26/11 showed that in one room there were eight tanks secured together with one chain. Two additional tanks were secured by one chain around both tanks. A second set of two tanks was also secured by one chain.

- Observation on 4/26/11 of a second room in this service area showed that one tank of compressed medical gas near the door had no method to secure it in an upright position. There was a group of 12 tanks secured together with one chain. A second group of 17 tanks was secured together with a single chain. Other groups of two tanks and five tanks were secured together with one chain across each group.

2. At the Forest park campus:

- Observations at 3:06 PM on 04/26/11 showed 4 "H"-size cylinders containing oxygen attached to the gas manifold and secured by only 1 chain and 4 "H"-size cylinders containing oxygen, not attached to the gas manifold, unsecured in the medical gas area of the facility.

Staff HH Director of Security and Staff II Engineering confirmed at that time the medical gas cylinders were not individually secure.


Chapter 5.1.3.3.2 of the 2002 edition of the Code NFPA (National Fire Protection Association) 99 for Health Care Facilities states that locations for central supply systems and the storage of medical gases shall meet the following requirements:
(7) be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling.

Based on observation and interview, the facility failed to ensure that for two of four surgical suites there were adequate electrical outlets and that the use of extension cords was limited. The census was 117.

Findings included:

1. Observation of operating room #3 on 04/28/11 at 9:25 AM showed that for permanent electrical outlets there were two isolation (monitors electrical fault hazards) panels to supply power to all equipment in the room with four outlets each. The panels require a specialized plug to be connected to the panel. It was observed that there were three additional plug strips (six devices can be plugged into this adding electrical outlets) two of which were in use.

One of the plug strips had four devices plugged into it and was connected then to an additional four outlet box having a total of three cords plugged into it. The four outlet box was connected by a short cord having the specialized plug to the isolation panel.

The second plug strip had three devices plugged into that and was connected by a short cord with a specialized plug into the isolation panel.

It was observed that two of the devices in the room have cords long enough to reach the isolation panel directly without being plugged into the first cord strip.

During an interview on 04/28/11 at 9:37 AM Staff PP (surgical supervisor) stated that there are not enough electrical outlets available in the operating room #3 and that is the reason the extension cords and plug strips are used.

2. Observation on 04/28/11 at 9:40 AM of operating room suite #1 revealed that the anesthesia machine (which delivers controlled anesthesia and breathing support to patients) was plugged into a total of four separate cords to be connected to the isolation panel in the wall. Observation of the cord supplied by the manufacturer of the machine showed a specialized plug designed for the isolation panel. Interview at the time of observation with the surgical staff present in the room he/she stated that the cord from the anesthesia machine was too short to reach the wall and needed the additional cords to reach the isolation panel to be connected.

3. Chapter 8.4.1.2.4 of the National Fire Protection Association (NFPA) code for health care facilities NFPA 99 states that for line voltage equipment in anesthetizing locations the (1) cords shall be continuous...(5) cords shall be of sufficient length to reach any position in which the portable device is to be used.

Based on observation and record review, the facility failed to ensure that a policy was in place to address an impairment of the sprinkler system when it occurs for more than four hours in a 24-hour period. The census of the facility was 117.

Findings included:

1. Review of a policy titled "Loss of Fire Alarms", last revised on 11/07, showed that the purpose is to supply guidance to specific departments in case of fire alarm loss as to ensure fire safety. The policy lists tasks for three departments: the security and engineering department are to go on life safety alert as per interim life safety code; and the engineering department will notify the hospital operator, the alarm company and the administrator on duty. The operator will then inform the local fire department that the alarm is not functioning.

Under the section for security it stated that increased internal patrols of the affected part of the building with special emphasis on storage and unoccupied areas will be done. In the event of a fire security will notify the hospital operator to call the fire department and announce a code red (code for fire situation).

However, review of the policy found it did not specify if the security persons assigned to increased patrols would be performing other duties as well or that their only duty was to patrol the affected area. The policy did not specify notification of staff present upon discovery of fire other than notifying the switchboard to announce the code red by the person on patrol.

2. Observation of security patrols for the Jefferson building during tour on 04/27/11 showed that there is limited staff available in this building, the majority of the building is occupied by non-facility staff persons, and the facility policy did not specify how the notification function would occur in this setting.


Chapter 9.7.6.1 of the 2000 edition of the Life Safety Code published by the National Fire Protection Association stated that where a required automatic sprinkler alarm (9.6.1.8 for fire alarm) is out of service for more than four hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system had been returned to service.

Appendix A for 9.7.6 stated that a fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specially trained in fire prevention and in the use of fire extinguishers and occupant hose lines, in notifying the fire department, in sounding the building fire alarm, and in understanding the particular fire safety situation for public education purposes.

Based on observation and record review, the facility failed to ensure that a policy was in place to address an impairment of the fire alarm when it occurs for more than four hours in a 24 hour period. The census of the facility was 117.

Findings included:

1. Review of a policy titled "Loss of Fire Alarms", last revised on 11/07, showed that the purpose is to supply guidance to specific departments in case of fire alarm loss as to ensure fire safety. The policy lists tasks for three departments: the security and engineering department are to go on life safety alert as per interim life safety code, and the engineering department will notify the hospital operator, the alarm company and the administrator on duty. The operator will then inform the local fire department that the alarm is not functioning. Under the section for security it stated that increased internal patrols of the affected part of the building with special emphasis on storage and unoccupied areas will be done. In the event of a fire security will notify the hospital operator to call the fire department and announce a code red (code for fire situation).

However, review of the policy found it did not specify if the security persons assigned to increased patrols would be performing other duties as well or that their only duty was to patrol the affected area. The policy did not specify notification of staff present upon discovery of fire other than notifying the switchboard to announce the code red by the person on patrol.

2. Observation of security patrols for the Jefferson building during tour on 04/27/11 showed that there is limited staff available in this building and the majority of the building is occupied by non-facility staff persons and the policy did not specify how the notification function would occur in this setting.


Chapter 9.7.6.1 of the 2000 edition of the Life Safety Code published by the National Fire Protection Association stated that where a required automatic sprinkler alarm (9.6.1.8 for fire alarm) is out of service for more than four hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system had been returned to service.

Appendix A for 9.7.6 stated that a fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specially trained in fire prevention and in the use of fire extinguishers and occupant hose lines, in notifying the fire department, in sounding the building fire alarm, and in understanding the particular fire safety situation for public education purposes.