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Based on document review and staff interview, fire drills are not held at varying times and are not held once per quarter per shift. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because staff members may not be adequately trained in the hospital ' s fire emergency procedures.

Findings include:

A. On 08/19/2015, at 2:15 PM, during the document review process, accompanied by the Maintenance Director, fire drill records indicate that the facility ' s fire drills are held for one shift only per quarter, not all shifts as required by 18.7.1.2.

B. On 08/19/2015, at 2:17 PM, during the document review process, accompanied by the Maintenance Director, fire drill records indicate that the facility ' s fire drills are not conducted at varying times as required by 18.7.1.2. Examples include:

1. 05/22/2014 drill held at 9:45 AM.
2. 08/07/2014 drill held at 10:00 AM.
3. 12/02/2014 drill held at 9:50 AM.

Based on document review and staff interview, the facility failed to ensure that the range hood fire extinguishing system was properly inspected on a monthly basis. This deficiency could affect all patients and staff if the system has sustained damage or is low on chemicals and did not operate properly during a cooking fire.

Findings include:

A. On 08/19/2015, at 1:45 PM, during the document review process, accompanied by the Maintenance Director, records documenting the monthly visual inspection of the range hood fire extinguishing system as required by NFPA 17 1998 9-2.1 were requested and were not provided.

OTHER DEFICIENCY NOT ON 2786

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the
survey walk-through, the provider shall institute the appropriate Interim Life Safety Measures
until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan
of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all
such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on direct observation during the survey walk through, the division of the emergency electrical system into life safety, critical, and equipment branches as required was not maintained. This deficiency could affect all patients and staff if the emergency electrical system failed to operate properly upon the loss of power.

Findings include:

A. On 08/19/2015, at 10:37 AM, during the survey walk through, accompanied by the Maintenance Director, a Life Safety Branch electrical panel was observed in the first floor electrical room that has a circuit labeled " walk in cooler. " This does not comply with NFPA 99 1999 3-4.2.2.2(b).

Based on direct observation during the survey walk through, the facility failed to provide battery powered emergency lighting in their operating rooms. This deficiency could affect any patient undergoing a procedure during a loss of power.

Findings include:

A. On 08/19/2015, at 11:25 AM, during the survey walk through, accompanied by the Maintenance Director, it was observed that neither OR 1 or OR 2 are equipped with battery powered emergency lighting as required by NFPA 99 1999 3-3.2.1.2(a)(5)(e).

Based on document review and staff interview, fire drills are not held at varying times and are not held once per quarter per shift. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because staff members may not be adequately trained in the hospital ' s fire emergency procedures.

Findings include:

A. On 08/19/2015, at 2:15 PM, during the document review process, accompanied by the Maintenance Director, fire drill records indicate that the facility ' s fire drills are held for one shift only per quarter, not all shifts as required by 18.7.1.2.

B. On 08/19/2015, at 2:17 PM, during the document review process, accompanied by the Maintenance Director, fire drill records indicate that the facility ' s fire drills are not conducted at varying times as required by 18.7.1.2. Examples include:

1. 05/22/2014 drill held at 9:45 AM.
2. 08/07/2014 drill held at 10:00 AM.
3. 12/02/2014 drill held at 9:50 AM.

Based on document review and staff interview, the facility failed to ensure that the range hood fire extinguishing system was properly inspected on a monthly basis. This deficiency could affect all patients and staff if the system has sustained damage or is low on chemicals and did not operate properly during a cooking fire.

Findings include:

A. On 08/19/2015, at 1:45 PM, during the document review process, accompanied by the Maintenance Director, records documenting the monthly visual inspection of the range hood fire extinguishing system as required by NFPA 17 1998 9-2.1 were requested and were not provided.

OTHER DEFICIENCY NOT ON 2786

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the
survey walk-through, the provider shall institute the appropriate Interim Life Safety Measures
until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan
of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all
such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on direct observation during the survey walk through, the division of the emergency electrical system into life safety, critical, and equipment branches as required was not maintained. This deficiency could affect all patients and staff if the emergency electrical system failed to operate properly upon the loss of power.

Findings include:

A. On 08/19/2015, at 10:37 AM, during the survey walk through, accompanied by the Maintenance Director, a Life Safety Branch electrical panel was observed in the first floor electrical room that has a circuit labeled " walk in cooler. " This does not comply with NFPA 99 1999 3-4.2.2.2(b).

Based on direct observation during the survey walk through, the facility failed to provide battery powered emergency lighting in their operating rooms. This deficiency could affect any patient undergoing a procedure during a loss of power.

Findings include:

A. On 08/19/2015, at 11:25 AM, during the survey walk through, accompanied by the Maintenance Director, it was observed that neither OR 1 or OR 2 are equipped with battery powered emergency lighting as required by NFPA 99 1999 3-3.2.1.2(a)(5)(e).