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It was determined by observation during the survey, November 3, 2011, that a two hour (2) fire-rated separation between the Hospice facility and the remainder of the 4th Floor of the hospital building did not exist, in accordance with LSC section 19.1.2.

The facility did not contain a fire rated separation wall between the Hospice and the remainder of the fourth (4th) Floor of the facility as required per NFPA 101, section 19.1.2, which states that a two hour (2) separation must be continuous from outside wall to outside wall and extend from the floor to the underside of the ceiling deck between.

This deficiency was discussed with the Fire Prevention Safety Officer and the Hospice RN Manager during a tour of the facility.

Hospice Unit deficiencies:

Through observation during the survey, November 3, 2011, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the RN Manager of the Hospice Unit;
1) The door to the "Lounge" (#C4-412) would not latch into the frame, which prevented a positive smoke seal.
2) The door to resident room #C4-428 contained a large gape between the door and the door stop that was larger than one-half inch (1/2") in size, which prevented a positive smoke seal when the door was closed.

Hospital unit deficiencies:

Through observation during the survey, November 3, 2011, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Fire Prevention Safety Officer;
1) The facility contained three (3) 70/30 double doors that were not considered to be positive latching, on the "30 side", when in the closed position. The following doors contained slide locks on the "30 side" of the door for locking;
a) Room #C-441
b) Room #C-444
c) Room #C-446

2) Eight (8) corridor doors contained gaps larger than on-half inch (1/2") in size between the door and the door stop, which prevented a positive smoke seal when the door was closed.
a) Room #B4-156
b) Room #B4-158
c) Room #B4-151
d) Room #B4-119
e) Room #B4-149
f) Room #B4-148
g) Room#B4-142
h) Room #B4-116

Through observation during the survey, November 8, 2011, it was determined that the facility failed to maintain the doors to hazardous areas.

During the walk-through of the facility with the Hospital Safety Manager, the facility contained a storage room, utilized for storage of combustible materials, in the "C" wing of the Hospital. The rooms contained two (2) doors to the corridor, doors #C4-104 and #C4-105, which did not contain self-closing devices.

Per 19.3.2.1 "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Through observation during the survey, November 3, 2011, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition per NFPA 13.

During the walk through of the facility with the Maintenance Director:
1) One (1) quick response pendant style sprinkler head, located in the closet of resident room #C430, contained air in the frangible bulb portion of the sprinkler head, which indicated a possible leak or defect of the sprinkler head.
2) One (1) quick response sidewall sprinkler head, located in the RN office, contained paint on the working parts of the sprinkler.
Per NFPA 13 section 3-2.6.3 "Unless applied by the manufacturer, sprinklers shall not be painted, and any sprinklers that have been painted shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution."

Through observation during the survey, November 3, 2011, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walk through of the facility with the Hospital Safety Manager, items were stored in the corridor in several areas;
1) One (1) computer cart was stored in the corridor, outside room #C-445 at 11:05 a.m. and at 11:40 a.m.

2) Three (3) computer carts and one (1) chair stored in the corridor, outside #B4-151 at 12:20 p.m. and at 1:00 p.m.

3) One (1) computer cart stored in the corridor, outside room #B4-139 at 12:30 p.m. and again at 1:00 p.m.

4) Three (3) items stored in the corridor outside room #B4-134;
a) One (1) Hoyer lift
b) One (1) BP cuff machine
c) One (1) computer cart

5) One (1) computer cart stored in the corridor outside room #B4-131 at 12:10 p.m. and again at 1:00 p.m.

Per NFPA 101 2000 Edition, Chapter 7, section 7.1.10 "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use."

Through observation during the survey, November 3, 2011, it was determined that the facility was allowing the use of flammable decorations.

During the walk through of the facility with the Hospital Safety Manager, the facility contained flammable decorations in the corridor;
1) Outside of the nurse station, in "B" wing, the facility contained Halloween decorations in the corridor. The decorations consisted of two (2) pumpkins, plastic leaves, one (1) life sized cardboard picture cutout, and one (1) dressed up skeleton for the holidays

2) The facility contained one (1) life sized cardboard cutouts with a plastic cape, located in the corridors, indicating flu shot information. This cutout was located in the "A" wing of the hospital.

Through observation during the survey, November 3, 2011, it was determined that the facility failed to maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility with the Hospice RN Manager, the nurses station in the Hospice Unit contained extension cords and powerstrips installed incorrectly:
1) One (1) extension cord was plugged in to a powerstrip that powered electrical equipment.
2) Two (2) powerstrips were plugged into one another (piggybacked) to power electrical equipment.

Through observation during the survey, November 3, 2011, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walk through of the facility with the Hospice RD Manager, four (4) alcohol based hand rub dispensers (ABHR) were installed above an electrical source in the corridor (see below for a list). Per Chapter 19, section 19.3.2.7(6) "The dispensers shall not be installed over or directly adjacent to an ignition source."
1) In the corridor outside room #C424
2) In the corridor outside room #C429
3) In the corridor outside room #C430
4) In the corridor outside room #C432