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Observations, testing and an interview with staff revealed that all stairway exit doors are locked against egress with magnetic locks that do not comply with NFPA 101 "The Life Safety Code" (LSC) 2000 edition section 7.2.1.6.1 which requires doors to release and be openable after 30 seconds and hard surface exit discharges are provided from all exits. These deficient practices could affect patients, staff and visitors if the facility needs to be quickly evacuated.

Findings:
Observations, testing and an interview with staff during the facility tour on September 11, 2012 between 8:00 am and 3:30 pm, revealed that

1) All stairway doors are locked against egress and need a key card to exit to prevent vulnerable residents from falling down stairways or being exposed to dangers outside of the building. While these doors aa;so release upon activation of the fire alarm system, the fire sprinkler system, upon loss of power and with a manual fire alarm pull station near each door, not all floors have patients with clinical needs that require the locking of these doors, and

2) The north exit discharge from the Peak Performance gym is incomplete due to construction. Signs need to be provided that clearly indicate the exit, and a hard surface path for the exit, discharge to the north gate in accordance with LSC section 7.7.

This deficient practice was verified by the Director of Support Services (DG) at the exit conference.

Observations revealed that three of approximately two hundred smoke detectors were not installed in accordance with NFPA 72 " The National Fire Alarm Code" 1999 edition section 2-3.5.1. Improper location of smoke detectors may allow a delay in alarming staff, causing a delay in the response to the fire emergency, which would negatively impact all the residents, visitors and staff.

Findings:
Observations during the facility tour on September 10 and 11, 2012 between 2:45 pm and 5:00 pm and 8:00 am and 3:30 pm, revealed that the following smoke detectors are within 3 feet of an opening into the air handling system:

1) 3nd floor north near the nurse's station

2) The elevator lobby 4th floor, and

3) KDU lobby

These deficient practices were verified by the Director of Support Services (DG) at the exit conference.

Observations indicated that the automatic sprinkler system is not in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems sections 5-1.1 nor NFPA 25 Standard for Inspection, Testing and Maintenance of a Water-Based Fire protection System, 1998 edition section 6-3.6 . These deficient practices may allow the sprinkler system to fail and a fire to grow which will negatively impact all the residents, visitors and staff.

Findings include:
Observations during the facility tour on September 12, 2012 between 8:00 am and 9:30 am, and a review of documentation of the Sanford Bemidji Senior Behavioral Unit, revealed that:

1) The elevator machine room is not fire sprinkler protected and the elevator pit could not be accessed to determine if they are sprinkler protected, and

2) The fire sprinkler system gauges have not been re-calibrated, nor replaced, within the past 5 years as required by NFPA 25 Section 6-3.6.

This deficient practice was verified by the Director of Maintenance (CJ) at the exit conference.

Observations revealed that the automatic fire sprinkler system is not installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems sections 5-1.1 nor is it in accordance with NFPA 25 Standard for Inspection, Testing and Maintenance of a Water-Based Fire protection System, 1998 edition section 6-3.6. These deficient practices may allow a fire to grow which will negatively impact all the patients, visitors and staff.

Findings:
Observations during the facility tour on September 11, 2012 between 8:00 am and 3:30 pm, revealed that:

1) Various elevator machine rooms such as 1B045, are not fire sprinkler protected and the elevator pits could not be accessed to determine if they are fire sprinkler protected,

2) Room 1A033 is not fire sprinkler protected

3) The fire sprinkler system gauges have not been re-calibrated, nor replaced, within the past 5 years as required by NFPA 25 section 6-3.6.

These deficient practices were verified by the Director of Support Services (DG) at the exit conference.

Observations revealed that some corridors are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.1.10.1. These deficient practices could negatively affect the patients, staff and visitors of the facility if they need to be quickly evacuated from the facility.

Findings:
Observations during the facility tour on September 11, 2012 between 8:00 am and 3:30 pm, revealed that:

1) Various chairs obstruct the required width of the 3rd floor corridor near the elevator,

2) Various carts and chairs are in the CT scan corridor,

3) There is storage in the Pool hallway, and

4) Combustible storage was found in the north exit access from the 2nd floor training room.

These deficient practices were verified by the Director of Support Services (DG) at the exit conference.

Observations and an interview with staff indicate that there are no temporary walls to separate the occupied areas in Peak Performance and the areas under construction. This deficient practice could negatively impact all patients , staff and guests if a fire occurs in the areas under construction and goes into the occupied spaces.

Findings:
Observations during the facility tour on September 11, 2012 between 8:00 am and 3:30 pm, revealed that in the Peak Performance Gym the windows have not been protected with temporary 1-hour fire rated assemblies to separate the occupied, fire sprinkler protected spaces, and the areas under construction.

This deficient practice was verified by the Director of Support Services (DG) at the exit conference.

The active electrodes or applicators of electrosurgical, surgical laser, or fiber optic devices shall be secured when not in active use as recommended.
NFPA 99 Health Care Facilities 1999 edition 7-6.2.3.1

An interview with a Minnesota Department of Health (MDH) surveyor and a review of Sanford Bemidji Medical Center policies indicated that the facility staff actions are not in accordance with NFPA 99 Health Care Facilities 1999 edition section 7-6.2.3.1. This deficient practice can cause a fire that will impact the patient and staff of the OR that it occurs in.

Findings:
An interview with the MDH Surveyor (JP), who observed surgery cases, on Friday September 13, 2012 at approximately 3:00 pm, revealed that, in one case observed in Sanford Bemidji Same Day Surgery Center, a surgeon did not follow the written policy when using electronic cauterizing, by laying it on the patient instead of returning it to it's holster. A review of past cases indicated that 2 procedures in the past year indicated a lack of following the written procedures and no training had been provided to mitigate the problem after these incidents were identified. A review of Sanford Health of Northern Minnesota (SHNM) written medical center policy SHNM:CS:PSS:OR-012 states that "The active electrode should be placed in a clean, dry, well-insulated safety holster when not in active use".

This deficient practice was verified by the Director of Support Services (DG) at the exit conference.

Observations, testing and an interview with staff revealed that all stairway exit doors are locked against egress with magnetic locks that do not comply with NFPA 101 "The Life Safety Code" (LSC) 2000 edition section 7.2.1.6.1 which requires doors to release and be openable after 30 seconds and hard surface exit discharges are provided from all exits. These deficient practices could affect patients, staff and visitors if the facility needs to be quickly evacuated.

Findings:
Observations, testing and an interview with staff during the facility tour on September 11, 2012 between 8:00 am and 3:30 pm, revealed that

1) All stairway doors are locked against egress and need a key card to exit to prevent vulnerable residents from falling down stairways or being exposed to dangers outside of the building. While these doors aa;so release upon activation of the fire alarm system, the fire sprinkler system, upon loss of power and with a manual fire alarm pull station near each door, not all floors have patients with clinical needs that require the locking of these doors, and

2) The north exit discharge from the Peak Performance gym is incomplete due to construction. Signs need to be provided that clearly indicate the exit, and a hard surface path for the exit, discharge to the north gate in accordance with LSC section 7.7.

This deficient practice was verified by the Director of Support Services (DG) at the exit conference.

Observations revealed that three of approximately two hundred smoke detectors were not installed in accordance with NFPA 72 " The National Fire Alarm Code" 1999 edition section 2-3.5.1. Improper location of smoke detectors may allow a delay in alarming staff, causing a delay in the response to the fire emergency, which would negatively impact all the residents, visitors and staff.

Findings:
Observations during the facility tour on September 10 and 11, 2012 between 2:45 pm and 5:00 pm and 8:00 am and 3:30 pm, revealed that the following smoke detectors are within 3 feet of an opening into the air handling system:

1) 3nd floor north near the nurse's station

2) The elevator lobby 4th floor, and

3) KDU lobby

These deficient practices were verified by the Director of Support Services (DG) at the exit conference.

Observations indicated that the automatic sprinkler system is not in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems sections 5-1.1 nor NFPA 25 Standard for Inspection, Testing and Maintenance of a Water-Based Fire protection System, 1998 edition section 6-3.6 . These deficient practices may allow the sprinkler system to fail and a fire to grow which will negatively impact all the residents, visitors and staff.

Findings include:
Observations during the facility tour on September 12, 2012 between 8:00 am and 9:30 am, and a review of documentation of the Sanford Bemidji Senior Behavioral Unit, revealed that:

1) The elevator machine room is not fire sprinkler protected and the elevator pit could not be accessed to determine if they are sprinkler protected, and

2) The fire sprinkler system gauges have not been re-calibrated, nor replaced, within the past 5 years as required by NFPA 25 Section 6-3.6.

This deficient practice was verified by the Director of Maintenance (CJ) at the exit conference.

Observations revealed that the automatic fire sprinkler system is not installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems sections 5-1.1 nor is it in accordance with NFPA 25 Standard for Inspection, Testing and Maintenance of a Water-Based Fire protection System, 1998 edition section 6-3.6. These deficient practices may allow a fire to grow which will negatively impact all the patients, visitors and staff.

Findings:
Observations during the facility tour on September 11, 2012 between 8:00 am and 3:30 pm, revealed that:

1) Various elevator machine rooms such as 1B045, are not fire sprinkler protected and the elevator pits could not be accessed to determine if they are fire sprinkler protected,

2) Room 1A033 is not fire sprinkler protected

3) The fire sprinkler system gauges have not been re-calibrated, nor replaced, within the past 5 years as required by NFPA 25 section 6-3.6.

These deficient practices were verified by the Director of Support Services (DG) at the exit conference.

Observations revealed that some corridors are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.1.10.1. These deficient practices could negatively affect the patients, staff and visitors of the facility if they need to be quickly evacuated from the facility.

Findings:
Observations during the facility tour on September 11, 2012 between 8:00 am and 3:30 pm, revealed that:

1) Various chairs obstruct the required width of the 3rd floor corridor near the elevator,

2) Various carts and chairs are in the CT scan corridor,

3) There is storage in the Pool hallway, and

4) Combustible storage was found in the north exit access from the 2nd floor training room.

These deficient practices were verified by the Director of Support Services (DG) at the exit conference.

Observations and an interview with staff indicate that there are no temporary walls to separate the occupied areas in Peak Performance and the areas under construction. This deficient practice could negatively impact all patients , staff and guests if a fire occurs in the areas under construction and goes into the occupied spaces.

Findings:
Observations during the facility tour on September 11, 2012 between 8:00 am and 3:30 pm, revealed that in the Peak Performance Gym the windows have not been protected with temporary 1-hour fire rated assemblies to separate the occupied, fire sprinkler protected spaces, and the areas under construction.

This deficient practice was verified by the Director of Support Services (DG) at the exit conference.

The active electrodes or applicators of electrosurgical, surgical laser, or fiber optic devices shall be secured when not in active use as recommended.
NFPA 99 Health Care Facilities 1999 edition 7-6.2.3.1

An interview with a Minnesota Department of Health (MDH) surveyor and a review of Sanford Bemidji Medical Center policies indicated that the facility staff actions are not in accordance with NFPA 99 Health Care Facilities 1999 edition section 7-6.2.3.1. This deficient practice can cause a fire that will impact the patient and staff of the OR that it occurs in.

Findings:
An interview with the MDH Surveyor (JP), who observed surgery cases, on Friday September 13, 2012 at approximately 3:00 pm, revealed that, in one case observed in Sanford Bemidji Same Day Surgery Center, a surgeon did not follow the written policy when using electronic cauterizing, by laying it on the patient instead of returning it to it's holster. A review of past cases indicated that 2 procedures in the past year indicated a lack of following the written procedures and no training had been provided to mitigate the problem after these incidents were identified. A review of Sanford Health of Northern Minnesota (SHNM) written medical center policy SHNM:CS:PSS:OR-012 states that "The active electrode should be placed in a clean, dry, well-insulated safety holster when not in active use".

This deficient practice was verified by the Director of Support Services (DG) at the exit conference.