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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by allowing smoke to pass from the building's exit access corridors to rooms housing them. Locations observed include:

1. 10:20 AM May 25, 2011: The door to the Doctors' Lounge.

2. 10:26 AM May 25, 2011: The glass and aluminum door to the Administration Suite.

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Based on random observation during the survey walk-through and staff interview, not all laboratories employing quantities of flammable, combustible, or hazardous materials are protected in accordance with NFPA 99.

Findings include:

A. Of the 2 doors to the Laboratory, only the east door was observed to carry a 3/4 hour fire resistance rating. During an interview held at the site at 10:55 AM on May 25, 2011, the provider's Director of Facilities was not able to verify that the Laboratory is provided with a 1 hour fire rated enclosure in compliance with NFPA 99 1999 10-3.1.1. and 8.2.3.2.3.1.(2). This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by allowing smoke or fire to pass from the Laboratory to the remainder of the building.

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Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. At 9:54 AM on May 25, 2011, the south leaf of the door from the Medical Office Building to the exit Corridor for the Hospital Nursing Unit was observed to, when in the fully open position, protrude more than 7" into the required clear corridor width as prohibited by 7.2.1.4.4. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by limiting the space available for them to exit the building through this Corridor.

B. Doors were observed that are equipped with thumbturn deadbolt retractors, thus requiring more than 1 door releasing operation as prohibited by 7.2.1.5.4. These deficiencies could affect all outpatients receiving treatment in the Emergency Department, as well as any staff and visitors present, by preventing them from exiting the building under emergency conditions. Locations observed include:
1. 11:10 AM May 25, 2011: The inner set of automatic sliding doors from the Emergency Department to the exterior.
2. 11:16 AM May 25, 2011: The inner set of automatic sliding doors from the Emergency Department Reception Area to the exterior.

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Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. Based on document review conducted in the Basement Classroom at 1:18 PM on May 25, 2011, fire drills are not conducted at least once per quarter per shift as required by 19.7.1.2. During the calendar years 2010 and 2011, fire drill records were not found for the quarters/shifts listed below. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, because staff members may not be trained in the Hospital's fire emergency procedures. Quarters/shifts for which no fire drills were documented include:
1. Second Quarter 2010.
2. Fourth Quarter 2010.

3. First Quarter 2011.

4. Second Quarter 2011.

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A. Based on direct observation during the building tour on the afternoon of May 25 at the lower level fire sprinkler water service room, the surveyor finds conditions that delay and cannot automatically notify all occupants of the building that a fire condition may exist:

1. The sprinkler system flow switch had the tamper proof cover removed and what appeared to be a piece of paper towel rolled up and lodged in the switch inhibiting the switch activation compromising the transmission of the water flow condition to the fire alarm control panel. The Director of Facilities removed the paper towel therefore correcting the condition.

2. Documentation was not provided indicating quarterly flow testing of the fire sprinkler system had been completed as required by NFPA 25, 1998, 9-2.7. Documentation was provided for the yearly sprinkler system inspection conducted by the facilities service contractor on November 15, 2010. The length of time the condition listed in No. 1 above existed could not be confirmed by the Director of Facilities however the inspection log located in the water service room indicated the last time of inspection was January 2011.

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Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed an maintained as fire resistive assemblies.

Findings include:

A. At 10:05 Am on May 25, 2011, the door to the Linen Chute Service Room was observed not to carry a minimum fire resistance rating of 1 hour required by 19.5.4.1. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by allowing smoke and fire from the linen chute to pass into the Corridor.

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Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. At 10:10 AM on May 25, 2011, a bariatric bed was observed being stored in the Corridor adjacent to Patient Room 105, which does not comply with 19.2.3.3. and 7.1.10.2.1. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by obstructing the egress path through the Corridor.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute 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.

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Based on random observation during the survey walk-through, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required by NFPA 99.

Findings include:

A. At 10:00 AM on May 25, 2011, the medical gas alarm was observed to be connected to Panel CL1-2 (Circuit 41), which is served by the critical branch of the building's Type I EES system, and not to an electrical panel served by the life safety branch, as required by NFPA 99 1999 3-4.2.2.2(b)(3)(b) and NFPA 70 1999 517-32(c)(2). This deficiency could affect all inpatients in the 20 bed facility, because the medical gas alarm panel could fail to function properly when emergency power is in use.

.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. At 9:37 AM on May 25, 2011, Electrical Panel EES (located in the Surgery Chiller Room) was observed to not be provided with a panel directory required by NFPA 70 1999 384-13. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, because the lack of a directory could result in the inadvertent shutdown of electrical systems served by the life safety branch of the building's Type I EES system.

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by allowing smoke to pass from the building's exit access corridors to rooms housing them. Locations observed include:

1. 10:20 AM May 25, 2011: The door to the Doctors' Lounge.

2. 10:26 AM May 25, 2011: The glass and aluminum door to the Administration Suite.

.

Based on random observation during the survey walk-through and staff interview, not all laboratories employing quantities of flammable, combustible, or hazardous materials are protected in accordance with NFPA 99.

Findings include:

A. Of the 2 doors to the Laboratory, only the east door was observed to carry a 3/4 hour fire resistance rating. During an interview held at the site at 10:55 AM on May 25, 2011, the provider's Director of Facilities was not able to verify that the Laboratory is provided with a 1 hour fire rated enclosure in compliance with NFPA 99 1999 10-3.1.1. and 8.2.3.2.3.1.(2). This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by allowing smoke or fire to pass from the Laboratory to the remainder of the building.

.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. At 9:54 AM on May 25, 2011, the south leaf of the door from the Medical Office Building to the exit Corridor for the Hospital Nursing Unit was observed to, when in the fully open position, protrude more than 7" into the required clear corridor width as prohibited by 7.2.1.4.4. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by limiting the space available for them to exit the building through this Corridor.

B. Doors were observed that are equipped with thumbturn deadbolt retractors, thus requiring more than 1 door releasing operation as prohibited by 7.2.1.5.4. These deficiencies could affect all outpatients receiving treatment in the Emergency Department, as well as any staff and visitors present, by preventing them from exiting the building under emergency conditions. Locations observed include:
1. 11:10 AM May 25, 2011: The inner set of automatic sliding doors from the Emergency Department to the exterior.
2. 11:16 AM May 25, 2011: The inner set of automatic sliding doors from the Emergency Department Reception Area to the exterior.

.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. Based on document review conducted in the Basement Classroom at 1:18 PM on May 25, 2011, fire drills are not conducted at least once per quarter per shift as required by 19.7.1.2. During the calendar years 2010 and 2011, fire drill records were not found for the quarters/shifts listed below. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, because staff members may not be trained in the Hospital's fire emergency procedures. Quarters/shifts for which no fire drills were documented include:
1. Second Quarter 2010.
2. Fourth Quarter 2010.

3. First Quarter 2011.

4. Second Quarter 2011.

.

A. Based on direct observation during the building tour on the afternoon of May 25 at the lower level fire sprinkler water service room, the surveyor finds conditions that delay and cannot automatically notify all occupants of the building that a fire condition may exist:

1. The sprinkler system flow switch had the tamper proof cover removed and what appeared to be a piece of paper towel rolled up and lodged in the switch inhibiting the switch activation compromising the transmission of the water flow condition to the fire alarm control panel. The Director of Facilities removed the paper towel therefore correcting the condition.

2. Documentation was not provided indicating quarterly flow testing of the fire sprinkler system had been completed as required by NFPA 25, 1998, 9-2.7. Documentation was provided for the yearly sprinkler system inspection conducted by the facilities service contractor on November 15, 2010. The length of time the condition listed in No. 1 above existed could not be confirmed by the Director of Facilities however the inspection log located in the water service room indicated the last time of inspection was January 2011.

.

Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed an maintained as fire resistive assemblies.

Findings include:

A. At 10:05 Am on May 25, 2011, the door to the Linen Chute Service Room was observed not to carry a minimum fire resistance rating of 1 hour required by 19.5.4.1. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by allowing smoke and fire from the linen chute to pass into the Corridor.

.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. At 10:10 AM on May 25, 2011, a bariatric bed was observed being stored in the Corridor adjacent to Patient Room 105, which does not comply with 19.2.3.3. and 7.1.10.2.1. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by obstructing the egress path through the Corridor.

.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute 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 random observation during the survey walk-through, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required by NFPA 99.

Findings include:

A. At 10:00 AM on May 25, 2011, the medical gas alarm was observed to be connected to Panel CL1-2 (Circuit 41), which is served by the critical branch of the building's Type I EES system, and not to an electrical panel served by the life safety branch, as required by NFPA 99 1999 3-4.2.2.2(b)(3)(b) and NFPA 70 1999 517-32(c)(2). This deficiency could affect all inpatients in the 20 bed facility, because the medical gas alarm panel could fail to function properly when emergency power is in use.

.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. At 9:37 AM on May 25, 2011, Electrical Panel EES (located in the Surgery Chiller Room) was observed to not be provided with a panel directory required by NFPA 70 1999 384-13. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, because the lack of a directory could result in the inadvertent shutdown of electrical systems served by the life safety branch of the building's Type I EES system.

.