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Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as 29 patients in the med/surg wing. The facility census was nine.

Findings included:

1. Observation on 02/27/12 at 3:58 PM showed the entrance doors of rooms 102, 105, 109, 110 and 112, failed to latch when closed into the jamb. Each door was pulled closed several times with varying amounts of force and the latch bolt failed to catch the opening in the jamb.

During an interview on 02/27/12 at 4:00 PM, Staff P, Maintenance Supervisor, stated that there is not a preventive maintenance policy or schedule for doors. He stated that maintenance checks hardware for function when working in the area but rely on work orders or verbal requests to initiate a response. He stated he was not sure when the doors were last checked for alignment and latching.

Based on observation and interview, the facility failed to ensure the integrity of smoke and fire barriers in accordance with 8.3 and 19.3.7.5 to maintain a minimum one half-hour fire resistance rating for one electrical room and four of four smoke/fire barriers dividing the facility. This deficient practice potentially enables the spread of smoke and fire gases to penetrate into separate fire zones and affect visitors, staff and the patient census. The facility census was nine.

Findings included:

1. Observations on 02/27/12 at 4:20 PM showed more than 17 unsealed penetrations in the walls of an electrical room off of the med-surg area. The annular spaces around metal conduit, flex conduit and various types of single wires and bundled communication cables ranged in size from one-quarter inch to one half inch diameter. A vent duct and water flex cable penetrated the largest opening in the wall, which measured 12 inches wide by 14 inches high and exposed metal studs attached to the metal roof deck.

2. Observations on 02/29/12 from 9:30 AM through 10:00 AM showed the following openings and unsealed penetrations in smoke and fire barriers throughout the facility:
-Two foot wide by three foot high hole and a four inch square hole in the smoke wall separating the gift shop and lobby.
-Ten inch wide by seven inch high hole with several communication wires passed through it, a two inch wide by three inch high hole, and a one quarter-inch diameter annular space around two separate communication wires that penetrated the wall above the entrance to the medical surgical unit.
-Annular spaces around seven unsealed one-inch diameter holes for half inch copper pipe penetrations above the entrance to the Obstetrical patient wing.
-Annular spaces around cables passing through three, three-inch diameter holes, a 14 inch wide by 16 inch high hole and a two inch wide by three inch high hole in the wall above the entrance to Radiology.

During an interview on 02/29/12 at 9:50 AM, Staff P, Maintenance Supervisor acknowledged the penetrations and stated they do not have a policy or procedure to cover above ceiling work by contractors.

Based on interview and record review, the facility failed to establish a dedicated communication link with an approved central station fire alarm system to automatically transmit a signal to notify first responders of a fire at the Medical Mall Cardiac Rehabilitation Clinic. The Medical Mall does not have a complete sprinkler system. The facility census was nine.

Findings included:

1. During an interview on 02/28/12 at 9:10 AM, Staff AA, Manager of the Medical Mall, stated that when the fire alarm sounds, she announces it over the intercom, calls the dispatcher for the fire department and is also required to notify the hospital. She stated that the bells only rang inside the building, and if they did not call out of the Medical Mall no one on the outside would be aware or respond to the alarm.

During an interview on 02/28/12 at 11:00 AM, Staff P, Maintenance Supervisor, stated the fire alarm system at the Medical Mall does not automatically transmit a signal anywhere. He stated the Medical Mall staff were expected to contact the local dispatcher for Fire Department, Sheriff or Police Department and to notify the hospital.

Record review on 02/28/12 at 1:00 PM showed ongoing preventive maintenance and monitoring of essential exercise equipment, ventilation and fire extinguishers, however there was no agreement or contract with an alarm company for remote signaling to a fire or police entity.

Based on observation and interview, the facility failed to provide a one hour protected storage space in accordance with 19.3.2.1, for soiled linen or trash collection receptacles that exceed 32 gallon capacity, for seven of seven containers in an unsprinklered closet, potentially hazarding the staff, visitors and inpatients. The facility census was nine.

Findings included:

1. Observation on 02/27/12 at 2:58 PM showed seven large, heavyweight 44 gallon capacity trash barrels in a small closet in the corridor used by housekeeping for holding the empty rubber waste receptacles when not in use on the floor by housekeeping staff. The walls of the room were not finished to the roof deck, the door was a hollow-core wood with open louvers for air circulation.

During an interview on 02/27/12 at 3:00 PM, Staff P stated the room was one of the original housekeeping closet spaces that seemed to remain unchanged through all the renovations. He stated he would like to see the containers moved to the maintenance garage and had been talking with the Housekeeping Director about eliminating the room and re-purposing the space for better use.

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as 29 patients in the med/surg wing. The facility census was nine.

Findings included:

1. Observation on 02/27/12 at 3:58 PM showed the entrance doors of rooms 102, 105, 109, 110 and 112, failed to latch when closed into the jamb. Each door was pulled closed several times with varying amounts of force and the latch bolt failed to catch the opening in the jamb.

During an interview on 02/27/12 at 4:00 PM, Staff P, Maintenance Supervisor, stated that there is not a preventive maintenance policy or schedule for doors. He stated that maintenance checks hardware for function when working in the area but rely on work orders or verbal requests to initiate a response. He stated he was not sure when the doors were last checked for alignment and latching.

Based on observation and interview, the facility failed to ensure the integrity of smoke and fire barriers in accordance with 8.3 and 19.3.7.5 to maintain a minimum one half-hour fire resistance rating for one electrical room and four of four smoke/fire barriers dividing the facility. This deficient practice potentially enables the spread of smoke and fire gases to penetrate into separate fire zones and affect visitors, staff and the patient census. The facility census was nine.

Findings included:

1. Observations on 02/27/12 at 4:20 PM showed more than 17 unsealed penetrations in the walls of an electrical room off of the med-surg area. The annular spaces around metal conduit, flex conduit and various types of single wires and bundled communication cables ranged in size from one-quarter inch to one half inch diameter. A vent duct and water flex cable penetrated the largest opening in the wall, which measured 12 inches wide by 14 inches high and exposed metal studs attached to the metal roof deck.

2. Observations on 02/29/12 from 9:30 AM through 10:00 AM showed the following openings and unsealed penetrations in smoke and fire barriers throughout the facility:
-Two foot wide by three foot high hole and a four inch square hole in the smoke wall separating the gift shop and lobby.
-Ten inch wide by seven inch high hole with several communication wires passed through it, a two inch wide by three inch high hole, and a one quarter-inch diameter annular space around two separate communication wires that penetrated the wall above the entrance to the medical surgical unit.
-Annular spaces around seven unsealed one-inch diameter holes for half inch copper pipe penetrations above the entrance to the Obstetrical patient wing.
-Annular spaces around cables passing through three, three-inch diameter holes, a 14 inch wide by 16 inch high hole and a two inch wide by three inch high hole in the wall above the entrance to Radiology.

During an interview on 02/29/12 at 9:50 AM, Staff P, Maintenance Supervisor acknowledged the penetrations and stated they do not have a policy or procedure to cover above ceiling work by contractors.

Based on interview and record review, the facility failed to establish a dedicated communication link with an approved central station fire alarm system to automatically transmit a signal to notify first responders of a fire at the Medical Mall Cardiac Rehabilitation Clinic. The Medical Mall does not have a complete sprinkler system. The facility census was nine.

Findings included:

1. During an interview on 02/28/12 at 9:10 AM, Staff AA, Manager of the Medical Mall, stated that when the fire alarm sounds, she announces it over the intercom, calls the dispatcher for the fire department and is also required to notify the hospital. She stated that the bells only rang inside the building, and if they did not call out of the Medical Mall no one on the outside would be aware or respond to the alarm.

During an interview on 02/28/12 at 11:00 AM, Staff P, Maintenance Supervisor, stated the fire alarm system at the Medical Mall does not automatically transmit a signal anywhere. He stated the Medical Mall staff were expected to contact the local dispatcher for Fire Department, Sheriff or Police Department and to notify the hospital.

Record review on 02/28/12 at 1:00 PM showed ongoing preventive maintenance and monitoring of essential exercise equipment, ventilation and fire extinguishers, however there was no agreement or contract with an alarm company for remote signaling to a fire or police entity.

Based on observation and interview, the facility failed to provide a one hour protected storage space in accordance with 19.3.2.1, for soiled linen or trash collection receptacles that exceed 32 gallon capacity, for seven of seven containers in an unsprinklered closet, potentially hazarding the staff, visitors and inpatients. The facility census was nine.

Findings included:

1. Observation on 02/27/12 at 2:58 PM showed seven large, heavyweight 44 gallon capacity trash barrels in a small closet in the corridor used by housekeeping for holding the empty rubber waste receptacles when not in use on the floor by housekeeping staff. The walls of the room were not finished to the roof deck, the door was a hollow-core wood with open louvers for air circulation.

During an interview on 02/27/12 at 3:00 PM, Staff P stated the room was one of the original housekeeping closet spaces that seemed to remain unchanged through all the renovations. He stated he would like to see the containers moved to the maintenance garage and had been talking with the Housekeeping Director about eliminating the room and re-purposing the space for better use.