HospitalInspections.org

Based on observations, the facility failed to adequately maintain the two-hour barrier free of any unsealed penetrations.

Findings include:

On 8/30/10 at 2:36 p.m., an unsealed 6-inch PVC pipe carrying various cables, including the cables for the fire alarm panel, was found in the 2-hour wall of the tunnel that connected the new heating plant to the old heating plant. The penetration should have been sealed with fire rated material listed for two-hour fire wall assemblies.

Based on observations, the facility failed to maintain the fire and smoke resistance rating of wall and ceiling assemblies.

Findings include:

In accordance with Section 19.1.6.1 of NFPA 101, 2000 Edition, building construction type and height shall meet one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1.

The building was of Type II unprotected construction which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 standards, or be totally non-combustible type construction.

1. On 8/30/10 at 11:07 a.m. in the communications room that housed the fire alarm panel, a ceiling tile measuring approximately 2 feet by 2 feet was removed from its track exposing the space above it.

2. On 8/30/10 at 11:12 a.m. in room E107 (examination room), a ceiling tile measuring approximately 2 feet by 1 foot was removed from its track exposing the space above it.

3. On 8/30/10 at 2:38 p.m., a partially unsealed 3-inch conduit carrying a number of communication cables was found in mechanical room C196.

4. On 8/30/10 at 5:06 p.m. in room C117 (office), 3 ceiling tiles were removed from their tracks exposing the space above them.

Based on observations, the facility failed to ensure that smoke resistive construction of hazardous areas were vertically sealed and/or enclosed by fire/smoke resistive means.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

On 8/30/10 at 2:07 p.m., two 3-inch conduits carrying large number of communication cables were found unsealed with fire rated material in mechanical electrical room C172 in the housekeeping headquarters. The unsealed conduits extended through the ceiling assembly.

Based on observation, the facility did not ensure that all doors equipped with self closing and with magnetic hold hardware to allow the doors could automatically close to positive latching.

Findings include:

Hold-open devices that release when the corridor door is pushed or pulled shall be permitted per Section 19.3.6.3.3 of NFPA 101 LSC, (2000 Edition). However, a hold-open device can not be used on doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, fire barrier or hazardous area enclosure unless they conform with Section 7.2.1.8.2 of NFPA 101 LSC, (2000 Edition). Doors cannot be blocked open by furniture, door stops, chocks, wedges, or devices that necessitate manual releasing action to close the door.

On 8/30/10 at 1:34 p.m., the corridor door to the B wing nurse station charting room had a chair parked in front of it impeding it from positive latching with the activation of the fire alarm system. The door had a magnetic hold hardware that was interfaced with the fire alarm system and had a self closure device.

Based on observation, the facility did not ensure all smoke/fire barriers were free from unsealed penetrations.
Findings include:
In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).
On 8/30/10 at 4:45 p.m., there were unsealed penetrations in the smoke barrier near room S29 and in the smoke barrier near room S19, above the double doors above the lay in ceiling assembly. Staff Member A confirmed that the penetrations were created at the time of the new camera system installation.

Based on observations, the facility failed to maintain the fire resistive rating of fire/smoke barrier walls.

Findings include:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The smoke barrier wall above the E wing nursing station had an unsealed penetration around two conduits on 8/30/10 at 11:21 a.m.

2. The smoke barrier wall above the examination room on E wing had two unsealed penetrations, one being around a blue cable and one measuring 2 inches by 3 inches in the sheetrock on 8/30/10 at 11:25 a.m.

3. The smoke barrier access door (fire rated with self closure hardware) was tied open to a railing above the B wing nurses' station. Staff Member A removed the tie and closed the door when he observed the same issue. The sign on the door indicated "Fire Door Keep Closed".

Based on observations made during the survey, not all doors in a smoke barrier are a pair of opposed swing doors provided with wire glass vision panels.

Findings include:

The door in the smoke barrier between the C wing and D wing is a horizontal sliding door instead of a pair of opposed swing doors. In addition, the vision panel in the door was polycarbonate bullet proof panel, not wired glass panel as required.

Based on observations, the facility failed to maintain or establish the fire rated protection for hazardous areas.

Findings include:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

On 8/30/10 at 10:55 a.m., the main oxygen storage room door was examined. The door was metal with a self closure hardware. After 3 tries, the door would not close to positive latching.

Based on observations and review of plan review documents, the facility failed to maintain horizontal exits in accordance with the requirements of the Life Safety Code.

Finding include:

The 90-minute door leafs in the horizontal exit between A wing and B wing are not provided with a vision panel as required by Sections 7.2.4 and 19.2.2.5 of the Code.

Based on review of battery powered emergency light fixture testing logs, the facility did not ensure that the required 90-minute annual tests were conducted on all battery powered emergency light fixtures in the facility.

Findings include:

Section 7.9.3 of NFPA 101 states that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

1. The battery powered emergency lighting test logs were reviewed during the survey on 8/30/10. The logs lacked documentation that an annual test had been conducted for minimum of 90 minutes for the battery powered lights found in the generator room as well as the one found in the C wing fan deck staircase for 2009.

2. Additionally, there were no records of the monthly 30-second tests conducted on the battery powered emergency light fixture located in the C wing fan deck staircase.

Based on observations, the facility failed to maintain the continuous illumination for all exit signs.

Findings include:

Exit signs in accordance with sections 19.2.10.1 and 7.10.5.2 of NFPA 101, 2000 edition, shall be continuously illuminated. Exit signs that are internally illuminated must meet UL 924 standards and are listed for use only with all bulbs evenly and uniformly illuminating the letters.

On 8/30/10, two exit signs were observed to not be illuminating on E wing.

Based on review of the fire drill reports and records, the facility did not ensure that fire drills were conducted on all shifts at least quarterly.

Findings include:

In accordance with Life Safety Code 101 section 19.7.1.2, fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

The fire drill reports and records were reviewed at the facility on 8/30/10. There were no drill records showing drills were conducted in the main hospital for the April-June quarter for 2010.

Based on review of the fire drill reports and records, the facility did not ensure that fire drills were conducted on all shifts at least quarterly.

Findings include:

In accordance with Life Safety Code 101 section 19.7.1.2, fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

The fire drill reports and records were reviewed at the facility on 8/30/10. There were no records revealing that drills were conducted in the Spratt building for the afternoon and night shifts during the January-March 2010 quarter. Additionally, there were no drill records showing that drills were conducted for the October-December 2009 quarter.

Based on observations, the facility failed to maintain the fire alarm system in accordance with the standards of NFPA 72, 1999 edition.

Findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72, 1999 edition.

1. A Simplex Model 4020-8001 Fire Alarm Control Panel (FACP) was located in the Communication room on C wing was observed at 11:05 a.m. on 8/30/10. The disconnect means for the normal power serving this FACP was not identified at the panel.

2. The electrical panel board located in the mechanical room on E wing was examined at 5:15 p.m. on 8/30/10. Breaker number 19 in electrical panel CBC was listed as the power source for the FACP. This breaker did not have a red marking at it for identification purposes.

Based on observations, the facility failed to maintain the fire alarm system in accordance with the standards of NFPA 72, 1999 edition.

Findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72, 1999 edition.

Fire Alarm Control Panel (FACP) located on the corridor wall adjacent to the nurses' station was observed at 4:05 p.m. on 8/30/10. The disconnect means for the normal power serving this FACP was not identified at the panel.

Based on observations, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 13 and 25, 1999 edition.

Findings include:

1. Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

On 8/30/10 at 4:01 p.m., a sprinkler head had a missing escutcheon ring in storage room S22.

2. On 8/30/10 at 4:27 p.m., there was an annular space between the sprinkler escutcheon ring and the solid ceiling surface in S42.

3. In accordance with Section 5-6.6 of NFPA 13, the clearance between the deflector of standard pendent and upright spray sprinklers and the top of storage or obstruction shall be 18 inches or greater.

On 8/30/10 at 4:34 p.m., a florescent light fixture was installed approximately 7 inches below the sprinkler head in S37.

4. The facility could not provide copies of the quarterly sprinkler maintenance records for 1/3/10 and 5/17/10 for review.

Based on observations, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 13 and 25, 1999 edition.

Findings include:

1. Sprinklers shall be free of corrosion, foreign material, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall) per section 2-2.1.1 of NFPA 25.

On 8/30/10 at 1:43 p.m., the sprinkler head in room B158 had a heavy accumulation of dust.

2. On 8/30/10, the facility could not provide copies of the quarterly automatic sprinkler maintenance reports for 2/3/10 and 5/17/10 to the surveyor for review.

Based on observations, the facility did not ensure that portable fire extinguishers are always maintained in accordance with all the standards of NFPA 10.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

On 8/30/10 at 4:20 p.m., a fire extinguisher was in upright freestanding position in the south end nurses' station. When notified, Staff Member A placed the extinguisher in its proper hanging location.

Based on observation, the facility did not ensure ventilation met the standards of NFPA 90A.
Findings include:
On 8/30/10 at 4:31 p.m., the vent cover in S38, (the men's bathroom) had a very heavy accumulation of lint and dust and needed to be cleaned.

Based on observations and record review, the facility failed to maintain the fire suppression systems in the kitchen area in accordance with the standards of NFPA 96.

In accordance with 7-2.1.1 of NFPA 96 (1998 edition) a placard identifying the use of the "K" extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each "K" portable fire extinguisher in the cooking area.

Findings include:

On 8/30/10 at 2:20 p.m., there was no placard posted above the K type portable extinguisher in the kitchen in the main hospital. The hood suppression system was a wet chemical system.

Based on observation and staff interview, the facility failed to ensure that nonflammable gas cylinders were stored in accordance with the standards of NFPA 99.

Findings include:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99 (1999 edition) freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

1. On 8/30/10 at 1:48 p.m., an "E" size cylinder of oxygen was observed to be unsecured and in upright freestanding position in the nurses' station on A wing.

2. On 8/30/10 at 2:18 p.m., two cylinders of carbon dioxide were observed unsecured and in upright freestanding position in the kitchen.

Based on observations, the facility did not appropriately label a medical gas shut off valve as to its use.

Findings include:

In accordance with 4-3.5.4.2 of NFPA 99 (1999 edition) shutoff valves for medical gases shall be labeled to reflect the rooms that are controlled by such valves.

On 8/30/10 at 1:45 p.m., the oxygen shutoff valve located in the corridor wall on B wing lacked labeling to address the rooms that it served.

Based on discussions with staff and observations during the survey of the main hospital building on 8/30/10, facility did not ensure that all requirements of Chapter 4, Gas and Vacuum Systems, of NFPA 99 Health Care Facilities (1999 Edition) were adapted.

Findings include:

Upon review of the State agency records for waivers, it was found that Montana State Hospital of Warm Springs has on file an approved waiver signed by Francis Reuer of the Denver Regional Office. The waiver is approved for a time period of two years from the date of the letter (November 20, 2006) or until the next Life Safety Code Survey conducted by the Montana State Survey Agency.

At the time of the initial survey in 2000, the facility was advised that two master alarms were required. The B.C. Wing was 24-hour patient care and was considered Level 1 which required an alarm panel. The other panel should be in the engineering office where it can be monitored by the persons(s) responsible for maintaining equipment and responding to activating alarms. NFPA 99, 1996 4-3.1.1.21(b)2." This same requirement is found under NFPA 99, 1999 Edition, Section 4-3.1.2.2(b)2.

At the time of the survey conducted on 8/30/10, there still was no master alarm panel in the engineering office. The surveyor observed an audible alarm and strobe light that supposedly had been installed adjacent to the fire alarm control panel in the engineering area of the boiler plant but there was no master panel per NFPA 99 and there was no apparent way to even test the alarms signals that had been installed.

Based on observations, the facility did not maintain the electrical system or its components in accordance with the standards of NFPA 70, 1999 edition and NFPA 99, 1999 edition.

Findings include:

1. Faceplates on receptacles shall be installed so as to completely cover the opening and seat against the mounting surface per Article 410-56(d) of NFPA 70.

The E wing nurses' station was observed on 8/30/10 at 11:15 a.m. There was an faceplate missing on one receptacle in this room located under the desk.

2. In accordance with Section 370.28(c) of NFPA 70 (1999 edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110.

On 8/30/10 at 1:21 p.m. a junction box cover plate was left open near the cat walk over A wing. When notified, Staff Member A fastened the cover plate on to the junction box.

Based on observations, the facility failed to adequately maintain the two-hour barrier free of any unsealed penetrations.

Findings include:

On 8/30/10 at 2:36 p.m., an unsealed 6-inch PVC pipe carrying various cables, including the cables for the fire alarm panel, was found in the 2-hour wall of the tunnel that connected the new heating plant to the old heating plant. The penetration should have been sealed with fire rated material listed for two-hour fire wall assemblies.

Based on observations, the facility failed to maintain the fire and smoke resistance rating of wall and ceiling assemblies.

Findings include:

In accordance with Section 19.1.6.1 of NFPA 101, 2000 Edition, building construction type and height shall meet one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1.

The building was of Type II unprotected construction which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 standards, or be totally non-combustible type construction.

1. On 8/30/10 at 11:07 a.m. in the communications room that housed the fire alarm panel, a ceiling tile measuring approximately 2 feet by 2 feet was removed from its track exposing the space above it.

2. On 8/30/10 at 11:12 a.m. in room E107 (examination room), a ceiling tile measuring approximately 2 feet by 1 foot was removed from its track exposing the space above it.

3. On 8/30/10 at 2:38 p.m., a partially unsealed 3-inch conduit carrying a number of communication cables was found in mechanical room C196.

4. On 8/30/10 at 5:06 p.m. in room C117 (office), 3 ceiling tiles were removed from their tracks exposing the space above them.

Based on observations, the facility failed to ensure that smoke resistive construction of hazardous areas were vertically sealed and/or enclosed by fire/smoke resistive means.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

On 8/30/10 at 2:07 p.m., two 3-inch conduits carrying large number of communication cables were found unsealed with fire rated material in mechanical electrical room C172 in the housekeeping headquarters. The unsealed conduits extended through the ceiling assembly.

Based on observation, the facility did not ensure that all doors equipped with self closing and with magnetic hold hardware to allow the doors could automatically close to positive latching.

Findings include:

Hold-open devices that release when the corridor door is pushed or pulled shall be permitted per Section 19.3.6.3.3 of NFPA 101 LSC, (2000 Edition). However, a hold-open device can not be used on doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, fire barrier or hazardous area enclosure unless they conform with Section 7.2.1.8.2 of NFPA 101 LSC, (2000 Edition). Doors cannot be blocked open by furniture, door stops, chocks, wedges, or devices that necessitate manual releasing action to close the door.

On 8/30/10 at 1:34 p.m., the corridor door to the B wing nurse station charting room had a chair parked in front of it impeding it from positive latching with the activation of the fire alarm system. The door had a magnetic hold hardware that was interfaced with the fire alarm system and had a self closure device.

Based on observation, the facility did not ensure all smoke/fire barriers were free from unsealed penetrations.
Findings include:
In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).
On 8/30/10 at 4:45 p.m., there were unsealed penetrations in the smoke barrier near room S29 and in the smoke barrier near room S19, above the double doors above the lay in ceiling assembly. Staff Member A confirmed that the penetrations were created at the time of the new camera system installation.

Based on observations, the facility failed to maintain the fire resistive rating of fire/smoke barrier walls.

Findings include:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The smoke barrier wall above the E wing nursing station had an unsealed penetration around two conduits on 8/30/10 at 11:21 a.m.

2. The smoke barrier wall above the examination room on E wing had two unsealed penetrations, one being around a blue cable and one measuring 2 inches by 3 inches in the sheetrock on 8/30/10 at 11:25 a.m.

3. The smoke barrier access door (fire rated with self closure hardware) was tied open to a railing above the B wing nurses' station. Staff Member A removed the tie and closed the door when he observed the same issue. The sign on the door indicated "Fire Door Keep Closed".

Based on observations made during the survey, not all doors in a smoke barrier are a pair of opposed swing doors provided with wire glass vision panels.

Findings include:

The door in the smoke barrier between the C wing and D wing is a horizontal sliding door instead of a pair of opposed swing doors. In addition, the vision panel in the door was polycarbonate bullet proof panel, not wired glass panel as required.

Based on observations, the facility failed to maintain or establish the fire rated protection for hazardous areas.

Findings include:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

On 8/30/10 at 10:55 a.m., the main oxygen storage room door was examined. The door was metal with a self closure hardware. After 3 tries, the door would not close to positive latching.

Based on observations and review of plan review documents, the facility failed to maintain horizontal exits in accordance with the requirements of the Life Safety Code.

Finding include:

The 90-minute door leafs in the horizontal exit between A wing and B wing are not provided with a vision panel as required by Sections 7.2.4 and 19.2.2.5 of the Code.

Based on review of battery powered emergency light fixture testing logs, the facility did not ensure that the required 90-minute annual tests were conducted on all battery powered emergency light fixtures in the facility.

Findings include:

Section 7.9.3 of NFPA 101 states that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

1. The battery powered emergency lighting test logs were reviewed during the survey on 8/30/10. The logs lacked documentation that an annual test had been conducted for minimum of 90 minutes for the battery powered lights found in the generator room as well as the one found in the C wing fan deck staircase for 2009.

2. Additionally, there were no records of the monthly 30-second tests conducted on the battery powered emergency light fixture located in the C wing fan deck staircase.

Based on observations, the facility failed to maintain the continuous illumination for all exit signs.

Findings include:

Exit signs in accordance with sections 19.2.10.1 and 7.10.5.2 of NFPA 101, 2000 edition, shall be continuously illuminated. Exit signs that are internally illuminated must meet UL 924 standards and are listed for use only with all bulbs evenly and uniformly illuminating the letters.

On 8/30/10, two exit signs were observed to not be illuminating on E wing.

Based on review of the fire drill reports and records, the facility did not ensure that fire drills were conducted on all shifts at least quarterly.

Findings include:

In accordance with Life Safety Code 101 section 19.7.1.2, fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

The fire drill reports and records were reviewed at the facility on 8/30/10. There were no drill records showing drills were conducted in the main hospital for the April-June quarter for 2010.

Based on review of the fire drill reports and records, the facility did not ensure that fire drills were conducted on all shifts at least quarterly.

Findings include:

In accordance with Life Safety Code 101 section 19.7.1.2, fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

The fire drill reports and records were reviewed at the facility on 8/30/10. There were no records revealing that drills were conducted in the Spratt building for the afternoon and night shifts during the January-March 2010 quarter. Additionally, there were no drill records showing that drills were conducted for the October-December 2009 quarter.

Based on observations, the facility failed to maintain the fire alarm system in accordance with the standards of NFPA 72, 1999 edition.

Findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72, 1999 edition.

1. A Simplex Model 4020-8001 Fire Alarm Control Panel (FACP) was located in the Communication room on C wing was observed at 11:05 a.m. on 8/30/10. The disconnect means for the normal power serving this FACP was not identified at the panel.

2. The electrical panel board located in the mechanical room on E wing was examined at 5:15 p.m. on 8/30/10. Breaker number 19 in electrical panel CBC was listed as the power source for the FACP. This breaker did not have a red marking at it for identification purposes.

Based on observations, the facility failed to maintain the fire alarm system in accordance with the standards of NFPA 72, 1999 edition.

Findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72, 1999 edition.

Fire Alarm Control Panel (FACP) located on the corridor wall adjacent to the nurses' station was observed at 4:05 p.m. on 8/30/10. The disconnect means for the normal power serving this FACP was not identified at the panel.

Based on observations, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 13 and 25, 1999 edition.

Findings include:

1. Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

On 8/30/10 at 4:01 p.m., a sprinkler head had a missing escutcheon ring in storage room S22.

2. On 8/30/10 at 4:27 p.m., there was an annular space between the sprinkler escutcheon ring and the solid ceiling surface in S42.

3. In accordance with Section 5-6.6 of NFPA 13, the clearance between the deflector of standard pendent and upright spray sprinklers and the top of storage or obstruction shall be 18 inches or greater.

On 8/30/10 at 4:34 p.m., a florescent light fixture was installed approximately 7 inches below the sprinkler head in S37.

4. The facility could not provide copies of the quarterly sprinkler maintenance records for 1/3/10 and 5/17/10 for review.

Based on observations, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 13 and 25, 1999 edition.

Findings include:

1. Sprinklers shall be free of corrosion, foreign material, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall) per section 2-2.1.1 of NFPA 25.

On 8/30/10 at 1:43 p.m., the sprinkler head in room B158 had a heavy accumulation of dust.

2. On 8/30/10, the facility could not provide copies of the quarterly automatic sprinkler maintenance reports for 2/3/10 and 5/17/10 to the surveyor for review.

Based on observations, the facility did not ensure that portable fire extinguishers are always maintained in accordance with all the standards of NFPA 10.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

On 8/30/10 at 4:20 p.m., a fire extinguisher was in upright freestanding position in the south end nurses' station. When notified, Staff Member A placed the extinguisher in its proper hanging location.

Based on observation, the facility did not ensure ventilation met the standards of NFPA 90A.
Findings include:
On 8/30/10 at 4:31 p.m., the vent cover in S38, (the men's bathroom) had a very heavy accumulation of lint and dust and needed to be cleaned.

Based on observations and record review, the facility failed to maintain the fire suppression systems in the kitchen area in accordance with the standards of NFPA 96.

In accordance with 7-2.1.1 of NFPA 96 (1998 edition) a placard identifying the use of the "K" extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each "K" portable fire extinguisher in the cooking area.

Findings include:

On 8/30/10 at 2:20 p.m., there was no placard posted above the K type portable extinguisher in the kitchen in the main hospital. The hood suppression system was a wet chemical system.

Based on observation and staff interview, the facility failed to ensure that nonflammable gas cylinders were stored in accordance with the standards of NFPA 99.

Findings include:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99 (1999 edition) freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

1. On 8/30/10 at 1:48 p.m., an "E" size cylinder of oxygen was observed to be unsecured and in upright freestanding position in the nurses' station on A wing.

2. On 8/30/10 at 2:18 p.m., two cylinders of carbon dioxide were observed unsecured and in upright freestanding position in the kitchen.

Based on observations, the facility did not appropriately label a medical gas shut off valve as to its use.

Findings include:

In accordance with 4-3.5.4.2 of NFPA 99 (1999 edition) shutoff valves for medical gases shall be labeled to reflect the rooms that are controlled by such valves.

On 8/30/10 at 1:45 p.m., the oxygen shutoff valve located in the corridor wall on B wing lacked labeling to address the rooms that it served.

Based on discussions with staff and observations during the survey of the main hospital building on 8/30/10, facility did not ensure that all requirements of Chapter 4, Gas and Vacuum Systems, of NFPA 99 Health Care Facilities (1999 Edition) were adapted.

Findings include:

Upon review of the State agency records for waivers, it was found that Montana State Hospital of Warm Springs has on file an approved waiver signed by Francis Reuer of the Denver Regional Office. The waiver is approved for a time period of two years from the date of the letter (November 20, 2006) or until the next Life Safety Code Survey conducted by the Montana State Survey Agency.

At the time of the initial survey in 2000, the facility was advised that two master alarms were required. The B.C. Wing was 24-hour patient care and was considered Level 1 which required an alarm panel. The other panel should be in the engineering office where it can be monitored by the persons(s) responsible for maintaining equipment and responding to activating alarms. NFPA 99, 1996 4-3.1.1.21(b)2." This same requirement is found under NFPA 99, 1999 Edition, Section 4-3.1.2.2(b)2.

At the time of the survey conducted on 8/30/10, there still was no master alarm panel in the engineering office. The surveyor observed an audible alarm and strobe light that supposedly had been installed adjacent to the fire alarm control panel in the engineering area of the boiler plant but there was no master panel per NFPA 99 and there was no apparent way to even test the alarms signals that had been installed.

Based on observations, the facility did not maintain the electrical system or its components in accordance with the standards of NFPA 70, 1999 edition and NFPA 99, 1999 edition.

Findings include:

1. Faceplates on receptacles shall be installed so as to completely cover the opening and seat against the mounting surface per Article 410-56(d) of NFPA 70.

The E wing nurses' station was observed on 8/30/10 at 11:15 a.m. There was an faceplate missing on one receptacle in this room located under the desk.

2. In accordance with Section 370.28(c) of NFPA 70 (1999 edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110.

On 8/30/10 at 1:21 p.m. a junction box cover plate was left open near the cat walk over A wing. When notified, Staff Member A fastened the cover plate on to the junction box.