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Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating .

Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted barrier penetrations in the following areas of the facility:

? Second floor cleaning closet;
? OR sink room closet (light and wire installation); and
? Basement crawl space.

Based on observation the facility failed to provide doors with hold open devices that would permit the doors to automatically close upon activation of the fire alarm and/or sprinkler system or the detection of smoke.

Failure on the part of the facility to provide doors that will automatically close upon activation of the fire alarm and/or sprinkler system or upon the detection of smoke puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted that the following doors were fitted with kick-stops that would prevent the doors to automatically close with activation of the above noted systems:

? Surgery to Emergency Department doors; and
? Surgery to Acute Care doors.

Based on observation the facility failed to maintain smoke barriers so as to prevent the migration of smoke from one area to another.

Failure on the part of the facility to maintain smoke barriers puts patients, staff and visitors of the facility at risk from migrating smoke.

Findings include:

1. On 3/15/2011 the surveyor noted that cross corridor doors by the Nurse's stock room and the soiled utility had a faulty coordinator/sequencer creating a situation in which the doors would not latch. These doors served as part of a rated barrier.

2. On 3/15/2011 the surveyor noted that double doors (Surgery to Emergency Department) had a faulty coordinator/sequencer which created a situation were the doors failed to completely close and prevent the passage of smoke.

Based on observation the facility failed to provide emergency lighting in that portion of the means of egress leading from an exit to the public way.

Failure on the part of the facility to provide required lighting in the means of egress puts patients, staff and visitors of the facility at risk should an emergency occur requiring building evacuation.

Findings include:

1. On 3/15/2011 the surveyor noted that outside emergency lighting was not provided at the medical records exit door and the south stairway exit door. Said doors allowed for travel to the public way.

Based on observation the facility failed to provide exit and/or directional signs that were provided with sufficient illumination.

Failure to ensure that exit signs are displayed with continuous illumination risks inability of staff and patients to rapidly locate exits in a fire.

Findings include:

On 3/15/2011 the surveyor noted that the exit sign on the 2nd floor near the Information Technology (IT) office was only partially illuminated due to what appeared to be a burned out light source.

Based on document review the hospital failed to perform fire drills at the required frequency.

Failure to conduct quarterly fire drills as required puts patients, staff and visitors of the facility at risk of injury and death from fire, and prevents an accurate assessment of the staff's preparedness to manage a fire emergency.

Findings include:

1. On 3/15/2011 during a review of available documentation the surveyor noted that a fire drill was not performed by the day shift during the first quarter of 2010.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25 and Chapter 19.3.5 NFPA 101 Life Safety Code 2000 edition.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted missing escutcheons in the following areas:

? Dictation room;
? Acute care dirty utility; and
? Nurse manager's office.

Based on observation, the hospital failed to maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted that sprinkler heads in the following areas had been subjected to paint overspray:

? Restroom of Cardiac Rehab/Physical Therapy;
? Acute Care dirty utility; and
? Record Archives.

2. On 3/15/2011 the surveyor noted that an overhead light fixture was creating an obstruction to sprinkler heads in the clean area of Sterile Processing/Supply.

Notations made on the sprinkler system annual service report dated 7/6/2010 indicated: "Some sprinklers are partially obstructed".

3. On 3/15/2011 the surveyor noted that a sewer line in the "crawl space" was hung from a sprinkler line.

4. On 3/15/2011 the surveyor noted a sprinkler head in the kitchen (intermediate temperature classification) that did not match the temperature classification of all the other heads in the compartment (ordinary).

5. On 3/15/2011 the surveyor noted that the stock of spare sprinklers located at the riser was less than needed for the various types found in the facility. It was further noted that a sprinkler wrench was not available in the spare sprinkler cabinet.

Based on observation the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers that were being inspected as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted that a portable fire extinguisher located in the Clean Linen room has not been inspected monthly as required. The last inspection as indicated on the the tag was performed in 2008.

Based on observation the facility failed to maintain the means of egress free of impediments to egress.

Failure on the part of the facility to keep the means of egress free of impediments puts patients, staff and visitors of the facility at risk of the effects of smoke and fire.

Finds include:

1. On 3/15/2011 the surveyor noted that the Emergency Department door to the lobby triage area was partially blocked by the improper storage of wheel chairs.

2. On 3/15/2011 the surveyor noted that at the point of exit discharge from the south stairway exit door the stairs to the left (looking out) were effectively blocked by the exit door which swung open to the left. This would require users to go right and step off an elevated pad to a surface not considered to be all weather before reaching a suitable surface leading to the public way.

Based on observation the facility failed to prohibit the placement of trash collection receptacles of greater than 32 gallons in the facility. Failure on the part of the facility to prohibit receptacles of greater than 32 gallons puts patients, staff and visitors of the facility at risk from the effects of fire

Findings include:

1. On 3/15/2011 the surveyor noted four (4) trash receptacles having a capacity of greater than 32 gallons located in Archives. Containers observed held 64 gallons.

Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99.

Failure on the part of the facility to properly secure oxygen cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death.

Findings include:

1. On 3/15/2011 the surveyor noted compressed gas cylinders in the tank farm which were secured in such a manor (loose chain) that cylinders could topple. Other cylinders were stored in modified milk crates.

It was noted by the surveyor subsequent to this finding that steps were in process to better secure compressed gas cylinders.

Based on observation and interview the facility failed to have systems in place that would allow for controlling the relative humidity of the operating rooms (anesthetizing location) at a level of 35% or greater.

Failure on the part of the facility to be able to control the relative humidity in locations where anesthetics are being used puts patients and staff at risk from fire or static electricity discharge.

Findings include:

On 3/15/2011 the surveyor noted that the facility was monitoring both the temperature and relative humidity of the operating rooms via devices installed for that purpose. Upon questioning a member of the plant maintenance staff indicated that it was not known if the HVAC system was capable of controlling or altering the relative humidity in the OR's. It was later leaned through an assessment of the computer control system that the HVAC system was incapable of controlling or altering the relative humidity in the OR's.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 3/15/2011 the surveyor noted that a an electrical J-box (junction box) in the Archives storage area had wires exposed because of a missing cover plate.

Based on observation the facility failed to install an alcohol based hand rub (ABHR) dispenser in an appropriate manner.

Failure to install ABHR dispensers appropriately puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

1. On 3/15/2011 the surveyor noted in Conference Room C an ABHR dispenser that was installed above an electrical receptacle.

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating .

Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted barrier penetrations in the following areas of the facility:

? Second floor cleaning closet;
? OR sink room closet (light and wire installation); and
? Basement crawl space.

Based on observation the facility failed to provide doors with hold open devices that would permit the doors to automatically close upon activation of the fire alarm and/or sprinkler system or the detection of smoke.

Failure on the part of the facility to provide doors that will automatically close upon activation of the fire alarm and/or sprinkler system or upon the detection of smoke puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted that the following doors were fitted with kick-stops that would prevent the doors to automatically close with activation of the above noted systems:

? Surgery to Emergency Department doors; and
? Surgery to Acute Care doors.

Based on observation the facility failed to maintain smoke barriers so as to prevent the migration of smoke from one area to another.

Failure on the part of the facility to maintain smoke barriers puts patients, staff and visitors of the facility at risk from migrating smoke.

Findings include:

1. On 3/15/2011 the surveyor noted that cross corridor doors by the Nurse's stock room and the soiled utility had a faulty coordinator/sequencer creating a situation in which the doors would not latch. These doors served as part of a rated barrier.

2. On 3/15/2011 the surveyor noted that double doors (Surgery to Emergency Department) had a faulty coordinator/sequencer which created a situation were the doors failed to completely close and prevent the passage of smoke.

Based on observation the facility failed to provide emergency lighting in that portion of the means of egress leading from an exit to the public way.

Failure on the part of the facility to provide required lighting in the means of egress puts patients, staff and visitors of the facility at risk should an emergency occur requiring building evacuation.

Findings include:

1. On 3/15/2011 the surveyor noted that outside emergency lighting was not provided at the medical records exit door and the south stairway exit door. Said doors allowed for travel to the public way.

Based on observation the facility failed to provide exit and/or directional signs that were provided with sufficient illumination.

Failure to ensure that exit signs are displayed with continuous illumination risks inability of staff and patients to rapidly locate exits in a fire.

Findings include:

On 3/15/2011 the surveyor noted that the exit sign on the 2nd floor near the Information Technology (IT) office was only partially illuminated due to what appeared to be a burned out light source.

Based on document review the hospital failed to perform fire drills at the required frequency.

Failure to conduct quarterly fire drills as required puts patients, staff and visitors of the facility at risk of injury and death from fire, and prevents an accurate assessment of the staff's preparedness to manage a fire emergency.

Findings include:

1. On 3/15/2011 during a review of available documentation the surveyor noted that a fire drill was not performed by the day shift during the first quarter of 2010.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25 and Chapter 19.3.5 NFPA 101 Life Safety Code 2000 edition.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted missing escutcheons in the following areas:

? Dictation room;
? Acute care dirty utility; and
? Nurse manager's office.

Based on observation, the hospital failed to maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted that sprinkler heads in the following areas had been subjected to paint overspray:

? Restroom of Cardiac Rehab/Physical Therapy;
? Acute Care dirty utility; and
? Record Archives.

2. On 3/15/2011 the surveyor noted that an overhead light fixture was creating an obstruction to sprinkler heads in the clean area of Sterile Processing/Supply.

Notations made on the sprinkler system annual service report dated 7/6/2010 indicated: "Some sprinklers are partially obstructed".

3. On 3/15/2011 the surveyor noted that a sewer line in the "crawl space" was hung from a sprinkler line.

4. On 3/15/2011 the surveyor noted a sprinkler head in the kitchen (intermediate temperature classification) that did not match the temperature classification of all the other heads in the compartment (ordinary).

5. On 3/15/2011 the surveyor noted that the stock of spare sprinklers located at the riser was less than needed for the various types found in the facility. It was further noted that a sprinkler wrench was not available in the spare sprinkler cabinet.

Based on observation the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers that were being inspected as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 3/15/2011 the surveyor noted that a portable fire extinguisher located in the Clean Linen room has not been inspected monthly as required. The last inspection as indicated on the the tag was performed in 2008.

Based on observation the facility failed to maintain the means of egress free of impediments to egress.

Failure on the part of the facility to keep the means of egress free of impediments puts patients, staff and visitors of the facility at risk of the effects of smoke and fire.

Finds include:

1. On 3/15/2011 the surveyor noted that the Emergency Department door to the lobby triage area was partially blocked by the improper storage of wheel chairs.

2. On 3/15/2011 the surveyor noted that at the point of exit discharge from the south stairway exit door the stairs to the left (looking out) were effectively blocked by the exit door which swung open to the left. This would require users to go right and step off an elevated pad to a surface not considered to be all weather before reaching a suitable surface leading to the public way.

Based on observation the facility failed to prohibit the placement of trash collection receptacles of greater than 32 gallons in the facility. Failure on the part of the facility to prohibit receptacles of greater than 32 gallons puts patients, staff and visitors of the facility at risk from the effects of fire

Findings include:

1. On 3/15/2011 the surveyor noted four (4) trash receptacles having a capacity of greater than 32 gallons located in Archives. Containers observed held 64 gallons.

Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99.

Failure on the part of the facility to properly secure oxygen cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death.

Findings include:

1. On 3/15/2011 the surveyor noted compressed gas cylinders in the tank farm which were secured in such a manor (loose chain) that cylinders could topple. Other cylinders were stored in modified milk crates.

It was noted by the surveyor subsequent to this finding that steps were in process to better secure compressed gas cylinders.

Based on observation and interview the facility failed to have systems in place that would allow for controlling the relative humidity of the operating rooms (anesthetizing location) at a level of 35% or greater.

Failure on the part of the facility to be able to control the relative humidity in locations where anesthetics are being used puts patients and staff at risk from fire or static electricity discharge.

Findings include:

On 3/15/2011 the surveyor noted that the facility was monitoring both the temperature and relative humidity of the operating rooms via devices installed for that purpose. Upon questioning a member of the plant maintenance staff indicated that it was not known if the HVAC system was capable of controlling or altering the relative humidity in the OR's. It was later leaned through an assessment of the computer control system that the HVAC system was incapable of controlling or altering the relative humidity in the OR's.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 3/15/2011 the surveyor noted that a an electrical J-box (junction box) in the Archives storage area had wires exposed because of a missing cover plate.