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Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, it was determined the facility failed to install two alcohol-based hand-rub (ABHR) dispensers at a safe distance from hazardous locations as required by NFPA 101. The failed practice created a fire hazard in the Medical-Surgical Unit as well as the Emergency Department. Findings follow:

A. Review of NFPA 101 2012 Edition: 19.3.2.6 (8) showed ABHR dispensers shall not be installed above an ignition source within a 1-inch horizontal distance from each side of the ignition source.

B. Observation on 8/23/22 at 2:30 PM of the Emergency Department showed one ABHR dispenser was installed in the Cardiac Room directly above a duplex electrical receptacle. This finding was verified with the Director of Maintenance at the time of observation.

C. Observation on 8/23/22 at 2:45 PM of the Medical-Surgical Unit showed one ABHR dispenser was installed in Patient Room 146 within one horizontal inch of a light switch. This finding was verified with the Director of Maintenance at the time of observation.

Based on interview and review of National Fire Protection Association (NFPA) 101 2012 Edition, it was determined the facility failed to meet the provisions of the life safety from fire requirements in that a fire drill was not conducted during the second shift in two of four (3rd quater of 2021 and 2nd quater of 2022) quarters in the 14 months prior to the survey (July 2021 through August 2022). The failed practice had the likelihood to affect all staff and patients in that in the event of a fire the staff would not be trained to respond to the emergency, which could result in injury or death if the proper actions were not taken to preserve the lives of patients and staff. Findings follow:

A. Review of NFPA 101:21.7.1.6 showed fire drills were to be conducted by the facility once per shift per quarter.

B. Review of the facility's Fire Drill Log showed there were no drills conducted during the second shift's hours in the 3rd quarter of 2021 (July 2021 - September 2021) or the 2nd quarter of 2022 (April 2022 - June 2022). This was verified with the Director of Maintenance on 8/24/22 at 9:00 AM.

Based on interview and review of the facility's generator logs and National Fire Protection Association (NFPA) 101 and NFPA 110, it was determined the facility failed to maintain two of two emergency generators as required by NFPA 101 Life Safety Code 2012 Edition in that the emergency generators were not being tested under load monthly or inspected weekly and failed to ensure functionality in the event of an emergency. The failed practice had the likelihood to affect all patients, staff, and visitors in that in the event of a power outage emergency the generators may not function properly and could fail to support all equipment and emergency lighting relying on the essential electrical system for emergency power. Findings follow:

A. Review of NFPA 101 2012 Edition: 9.1.3 showed emergency generators must be installed and maintained in accordance with NFPA 110 Standard for Emergency and Standby Power Systems.

B. Review of NFPA 110 2010 Edition: 8.4.1 showed EPS (emergency power supply) systems shall be inspected weekly and exercised under load at least monthly. Further review of NFPA 110 2010 Edition: 8.4.2 showed diesel generator sets shall be exercised monthly under load for 30 minutes using either loading that maintains the minimum exhaust temperatures recommended by the manufacturer under operating temperature and not less than 30 percent of the EPS nameplate kW (kilowatt) rating. Further review of NFPA 110 2010 Edition: 8.4.2.3 showed diesel-powered EPS systems that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

C. Review on 8/22/22 at 1:15 PM of the facility's Generator Log showed the generators were being visually inspected once per month in the 12 months prior to the survey (September 2021 - August 2022). This finding was verified with the Director of Maintenance in an interview on 8/23/22 at 1:00 PM.

D. In an interview on 8/23/22 at 1:00 PM with the Director of Maintenance it was verified there was no documentation of the emergency generators being run under load for 30 minutes monthly or exercised annually in the 12 months prior to the survey (September 2021 through August 2022).

Based on interview and review of NFPA 99, it was determined the facility failed to maintain its medical gas central supply system, vacuum piped system, and related alarm systems in accordance with NFPA 99 standards in that no periodic testing was being performed on the medical gas and vacuum alarm systems and no regular maintenance or inspection was being performed of the piped medical gas or vacuum systems. The failed practice had the likelihood to affect all in-patients relying on oxygen in that the piped medical gas system could fail to deliver the necessary amount of oxygen to patients and the alarm system could fail to annunciate in the event of an emergency. Findings follow:

A. Review of NFPA 99 2012 Edition: 5.1.14.4.4 showed nonflammable medical gas central supply systems shall be inspected annually. Further review of NFPA 99 2021 Edition: 5.1.14.4.5 showed nonflammable medical gas and vacuum and related alarm systems shall have periodic testing procedures implemented, and NFPA 99 2012 Edition: 5.1.15 showed facilities shall have a routine maintenance program for their piped medical gas and vacuum systems.

B. In an interview on 8/23/2022 at 1:00 PM with the Director of Maintenance it was verified the piped medical gas central supply system, vacuum system, and related alarm systems did not have routine maintenance programs in place and were not being inspected or tested.