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Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 18.

Findings are:
Observations during the facility tour on 7/23/13, from 10:49 am to 10:53 am revealed:
1. The Clean and Dirty Laundry Room Doors failed to fully close and latch when swung shut. The Dirty Laundry Room Door had a gap that exceeded 1/8 " at the meeting edges of the doors.
2. The Elevator Equipment Room Door failed to fully close and latch when swung shut.
In an interview conducted at the time of observation, (7/23/13, from 10:49 am to 10:53 am), Safety A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 18.

Findings are:
Observations during the facility tour on 7/23/13, from 10:51 am to 3:38 pm revealed:
1. The Classrooms Construction Area failed to have complete smoke resistive separation from occupied spaces. An approved sprinkler system failed to be installed throughout the area.
2. The Old Cafeteria/Administration Construction Area failed to have complete smoke resistive separation from occupied spaces. An approved sprinkler system failed to be installed throughout the area.
3. The Central Energy Plant Stairwell Vestibule Door failed to latch when swung shut.
4. Both Respiratory Therapy Storage Room Doors were propped open by door wedges during the survey. The doors failed to self-close.
5. The provided latch installed in the top leaf of the Lab Dutch Door failed to positively latch when closed swung shut.
6. The Imaging Soiled Utility Door failed to latch when swung shut.
In an interview conducted at the time of observation, (7/23/13, from 10:51 am to 3:38 pm), Safety A acknowledged the findings.

Based on record review and staff interview, the facility failed to maintain battery backup emergency lighting in 3 of 3 Operating Rooms. This condition had the potential to leave occupants in darkness during a loss of power. Facility census was 18.

Findings are:
Record review revealed the facility failed to provide documentation that battery backup emergency lights were tested monthly in all ORs.
In an interview conducted at the time of record review (7/22/13, at 4:03 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. 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 1 ½ hours. Equipment shall be fully operation 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.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills on each shift for 1 of 3 shifts. This condition would not provide the necessary training for staff to respond to a fire emergency. The facility census was 18.

Findings are:
Record review of fire drills revealed:
1. The facility failed to document a fire drill for the 3rd shift in the 1st quarter of 2013.
2. The facility failed to document a fire drill for the 3rd shift in the 2nd quarter of 2013.
In an interview conducted at the time of record review (7/23/13, at 10:01 am), Safety A acknowledged the missing fire drills.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke. Facility census was 18.

Findings are:
Record review of fire alarm inspection reports revealed that documentation failed to be provided to verify that the existing hospital (lower level) had been tested semiannually.
In an interview conducted at the time of record review, (7/22/13, at 3:12 pm), Safety A confirmed the documentation wasn ' t available.

Based on observation and staff interview, the sprinkler riser and aboveground sprinkler piping failed to be sprinkler protected in a hazardous room. This condition would cause sprinkler system failure. Facility census was 18.

Findings are:
Observation during the facility tour on 7/23/13, at 10:33 am revealed that the Hospital Crawlspace failed to be fully sprinkler protected where the sprinkler riser and aboveground piping were located. The crawlspace was used for storage.
In an interview conducted at the time of observation (7/23/13, at 10:33 am), Safety A confirmed that the crawl space failed to be sprinkler protected.

Actual NFPA Standard:
NFPA 13, 1999 ed, 5-14.3.3 Protection of Piping in Hazardous Areas.
Private service main aboveground piping shall not pass through hazardous areas and shall be located so that it is protected from mechanical and fire damage.
Exception: Aboveground piping is permitted to be located in hazardous areas protected by an automatic sprinkler system.

Based on observation and staff interview, the facility failed to maintain exits so they were free of obstructions. This condition had the potential to prevent staff from exiting the Central Energy Plant Electrical Room. Facility census was 18.

Findings are:
Observation during the facility tour on 7/23/13, at 2:03 pm revealed spools of rope were stored in front of CEP Electrical Room Exit Door near the overhead door. A utility vehicle was parked so this same door failed to open a full 90 degrees. The exit door failed to be maintained for instant use.
In an interview conducted at the time of observation, (7/23/13, at 2:03 pm), Safety A acknowledged the findings.

Based on record review and staff interview, the facility failed to provide documentation that the generator had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. Facility census was 18.

Findings are:
Record review of emergency generator maintenance and testing revealed that the facility failed to provide complete documentation of weekly generator testing for both emergency generators.
In an interview conducted at the time of record review (7/22/13, at 3:47 pm), Safety A confirmed that the information was not recorded for every week the past year.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 18.

Findings are:
Observation during the facility tour on 7/23/13, at 3:09 pm revealed the crash cart in the Trauma Room was plugged in by an extension cord. The extension cord failed to be removed prior to the survey.
In an interview conducted at the time of observation (7/23/13, at 3:09 pm), Safety A acknowledged the use of the electrical equipment.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 18.

Findings are:
Observations during the facility tour on 7/23/13, from 10:49 am to 10:53 am revealed:
1. The Clean and Dirty Laundry Room Doors failed to fully close and latch when swung shut. The Dirty Laundry Room Door had a gap that exceeded 1/8 " at the meeting edges of the doors.
2. The Elevator Equipment Room Door failed to fully close and latch when swung shut.
In an interview conducted at the time of observation, (7/23/13, from 10:49 am to 10:53 am), Safety A acknowledged the findings.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for fire to spread into the exit corridors and other use areas. Facility census was 18.

Findings are:
Observations during the facility tour on 7/23/13, from 10:51 am to 3:38 pm revealed:
1. The Classrooms Construction Area failed to have complete smoke resistive separation from occupied spaces. An approved sprinkler system failed to be installed throughout the area.
2. The Old Cafeteria/Administration Construction Area failed to have complete smoke resistive separation from occupied spaces. An approved sprinkler system failed to be installed throughout the area.
3. The Central Energy Plant Stairwell Vestibule Door failed to latch when swung shut.
4. Both Respiratory Therapy Storage Room Doors were propped open by door wedges during the survey. The doors failed to self-close.
5. The provided latch installed in the top leaf of the Lab Dutch Door failed to positively latch when closed swung shut.
6. The Imaging Soiled Utility Door failed to latch when swung shut.
In an interview conducted at the time of observation, (7/23/13, from 10:51 am to 3:38 pm), Safety A acknowledged the findings.

Based on record review and staff interview, the facility failed to maintain battery backup emergency lighting in 3 of 3 Operating Rooms. This condition had the potential to leave occupants in darkness during a loss of power. Facility census was 18.

Findings are:
Record review revealed the facility failed to provide documentation that battery backup emergency lights were tested monthly in all ORs.
In an interview conducted at the time of record review (7/22/13, at 4:03 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. 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 1 ½ hours. Equipment shall be fully operation 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.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills on each shift for 1 of 3 shifts. This condition would not provide the necessary training for staff to respond to a fire emergency. The facility census was 18.

Findings are:
Record review of fire drills revealed:
1. The facility failed to document a fire drill for the 3rd shift in the 1st quarter of 2013.
2. The facility failed to document a fire drill for the 3rd shift in the 2nd quarter of 2013.
In an interview conducted at the time of record review (7/23/13, at 10:01 am), Safety A acknowledged the missing fire drills.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke. Facility census was 18.

Findings are:
Record review of fire alarm inspection reports revealed that documentation failed to be provided to verify that the existing hospital (lower level) had been tested semiannually.
In an interview conducted at the time of record review, (7/22/13, at 3:12 pm), Safety A confirmed the documentation wasn ' t available.

Based on observation and staff interview, the sprinkler riser and aboveground sprinkler piping failed to be sprinkler protected in a hazardous room. This condition would cause sprinkler system failure. Facility census was 18.

Findings are:
Observation during the facility tour on 7/23/13, at 10:33 am revealed that the Hospital Crawlspace failed to be fully sprinkler protected where the sprinkler riser and aboveground piping were located. The crawlspace was used for storage.
In an interview conducted at the time of observation (7/23/13, at 10:33 am), Safety A confirmed that the crawl space failed to be sprinkler protected.

Actual NFPA Standard:
NFPA 13, 1999 ed, 5-14.3.3 Protection of Piping in Hazardous Areas.
Private service main aboveground piping shall not pass through hazardous areas and shall be located so that it is protected from mechanical and fire damage.
Exception: Aboveground piping is permitted to be located in hazardous areas protected by an automatic sprinkler system.

Based on record review and staff interview, the facility failed to have the sprinkler system inspected quarterly in accordance with the National Fire Protection Association 25. This condition increased the potential that the sprinkler system flow switch would fail to activate. Facility census was 18.

Findings are:
Record review revealed that quarterly flow testing of the sprinkler system failed to be documented.
In an interview conducted at the time of record review, (7/22/13, at 3:38 pm), Safety A confirmed that the testing was not being conducted.

Actual NFPA Standard:
5.3.3* Alarm Devices.
5.3.3.1 Water-flow devices including, but not limited to, mechanical water motor gongs and pressure switch type shall be tested quarterly.

Based on observation and staff interview, the facility failed to maintain exits so they were free of obstructions. This condition had the potential to prevent staff from exiting the Central Energy Plant Electrical Room. Facility census was 18.

Findings are:
Observation during the facility tour on 7/23/13, at 2:03 pm revealed spools of rope were stored in front of CEP Electrical Room Exit Door near the overhead door. A utility vehicle was parked so this same door failed to open a full 90 degrees. The exit door failed to be maintained for instant use.
In an interview conducted at the time of observation, (7/23/13, at 2:03 pm), Safety A acknowledged the findings.

Based on record review and staff interview, the facility failed to provide documentation that the generator had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. Facility census was 18.

Findings are:
Record review of emergency generator maintenance and testing revealed that the facility failed to provide complete documentation of weekly generator testing for both emergency generators.
In an interview conducted at the time of record review (7/22/13, at 3:47 pm), Safety A confirmed that the information was not recorded for every week the past year.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 18.

Findings are:
Observation during the facility tour on 7/23/13, at 3:09 pm revealed the crash cart in the Trauma Room was plugged in by an extension cord. The extension cord failed to be removed prior to the survey.
In an interview conducted at the time of observation (7/23/13, at 3:09 pm), Safety A acknowledged the use of the electrical equipment.