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Based on observation and interview, the provider failed to maintain the twenty minute fire resistive rating of corridor doors in one randomly observed location (door into x-ray room). Findings include:

1. Observation at 8:15 a.m. on 12/1/15 revealed the corridor door to the x-ray room was held in the open position with a door kick down device. That device was an impediment to closing the door in an emergency. Interview with the plant operations director of at that time of the above observation confirmed that condition. He indicated he was not sure when that kick down was installed. He was unaware that type of door hold open device was not permitted.

Based on observation and interview, the provider failed to ensure staff were familiar with fire procedure policy. Findings include:

1. Observation at 12:15 p.m. on 12/1/15 during the fire drill revealed the nurse responding to the simulated fire failed to implement the provider's fire procedure policy. The provider had adopted the R.A.C.E (Rescue, Alarm, Contain, Extinguish) fire procedure policy. Upon discovering the fire simulation place card in the patient's room, he left the patient's room. He did not rescue the patient and did not close the door to that room to contain the smoke and fire. He later returned to remove the patient from the room and closed the door. The patient was moved to the corridor. The patient should have been moved to a safe location either in an adjoining smoke compartment or neighboring patient room. The location of the fire was not announced which lead to confusion from other responding staff when the fire alarm was sounded. The paging system was not functioning correctly at the time of the fire drill and prompted the confusion and inability to announce fire location.

Interview with the staff that responded to the fire drill at the time of the observation confirmed that observation. They indicated the drill did not go well. They revealed the drill was usually conducted in accordance with the R.A.C.E policy and not sure why this drill had not gone smoothly.

Based on observation and interview, the provider failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and inspected and tested quarterly in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

1. Observation and interview at 9:15 a.m. on 12/1/15 revealed a wet system riser under the stairs by the clinic lobby. That riser supplied a wet pipe system protecting the 1986 addition of the hospital. The plant operations supervisor indicated he had to access that riser quarterly to conduct the required quarterly flow test. Further observation of the riser revealed no inspector test connection was provided on that riser to properly conduct a quarterly flow test. The plant operations supervisor was unknowingly testing from the main two inch drain line. The quarterly flow test should have been conducted from a test line ending in a one-half inch diameter outlet that simulated the flow of a sprinkler head.

Further interview revealed he was unaware of that requirement and indicated he would start doing quarterly flows from the appropriate test line.

Based on observation, testing, and interview, the provider failed to ensure electrical wiring was installed in accordance with the National Electrical Code in one randomly observed location (north west exit). Findings include:

1. Observation at 8:10 a.m. on 12/1/15 revealed an electrical outlet on the exterior at the north west exit. Testing of that outlet with a circuit tester revealed that outlet was not provided with ground fault circuit interrupter (GFCI) protection. All exterior electrical outlets should have been provided with ground fault circuit interruption protection in accordance with the National Electric Code. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He indicated he was not aware that outlet was not provided with GFCI protection.

Based on observation and interview, the provider failed to maintain the twenty minute fire resistive rating of corridor doors in one randomly observed location (door into x-ray room). Findings include:

1. Observation at 8:15 a.m. on 12/1/15 revealed the corridor door to the x-ray room was held in the open position with a door kick down device. That device was an impediment to closing the door in an emergency. Interview with the plant operations director of at that time of the above observation confirmed that condition. He indicated he was not sure when that kick down was installed. He was unaware that type of door hold open device was not permitted.

Based on observation and interview, the provider failed to ensure staff were familiar with fire procedure policy. Findings include:

1. Observation at 12:15 p.m. on 12/1/15 during the fire drill revealed the nurse responding to the simulated fire failed to implement the provider's fire procedure policy. The provider had adopted the R.A.C.E (Rescue, Alarm, Contain, Extinguish) fire procedure policy. Upon discovering the fire simulation place card in the patient's room, he left the patient's room. He did not rescue the patient and did not close the door to that room to contain the smoke and fire. He later returned to remove the patient from the room and closed the door. The patient was moved to the corridor. The patient should have been moved to a safe location either in an adjoining smoke compartment or neighboring patient room. The location of the fire was not announced which lead to confusion from other responding staff when the fire alarm was sounded. The paging system was not functioning correctly at the time of the fire drill and prompted the confusion and inability to announce fire location.

Interview with the staff that responded to the fire drill at the time of the observation confirmed that observation. They indicated the drill did not go well. They revealed the drill was usually conducted in accordance with the R.A.C.E policy and not sure why this drill had not gone smoothly.

Based on observation and interview, the provider failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and inspected and tested quarterly in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

1. Observation and interview at 9:15 a.m. on 12/1/15 revealed a wet system riser under the stairs by the clinic lobby. That riser supplied a wet pipe system protecting the 1986 addition of the hospital. The plant operations supervisor indicated he had to access that riser quarterly to conduct the required quarterly flow test. Further observation of the riser revealed no inspector test connection was provided on that riser to properly conduct a quarterly flow test. The plant operations supervisor was unknowingly testing from the main two inch drain line. The quarterly flow test should have been conducted from a test line ending in a one-half inch diameter outlet that simulated the flow of a sprinkler head.

Further interview revealed he was unaware of that requirement and indicated he would start doing quarterly flows from the appropriate test line.

Based on observation, testing, and interview, the provider failed to ensure electrical wiring was installed in accordance with the National Electrical Code in one randomly observed location (north west exit). Findings include:

1. Observation at 8:10 a.m. on 12/1/15 revealed an electrical outlet on the exterior at the north west exit. Testing of that outlet with a circuit tester revealed that outlet was not provided with ground fault circuit interrupter (GFCI) protection. All exterior electrical outlets should have been provided with ground fault circuit interruption protection in accordance with the National Electric Code. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He indicated he was not aware that outlet was not provided with GFCI protection.