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Based on observation and staff interview it was determined that the facility failed to maintain the self closing doors located in a two hour fire barrier wall. The findings include:

1. A facility tour with the facility engineer on 1/20/2010 at 10:30 AM observed that one leaf of a set of double 90 minute corridor door in a two hour rated wall would not close and positively latch. The first leaf would close and latch, but it appeared that the closer could not overcome the air flow in the corridor to close the last two inches to allow the second door leaf to latch. This double door is in a wall that separates the health care occupancy from the business occupancy. One of four doors in fire rated wall were observed to have this deficiency. The findings were observed and acknowledged by the facility engineer.

The requirement that doors in a rated fire barrier self close and latch. Doors that do not self close and latch in fire barrier wall will allow heat and smoke pass across the barrier placing patients and residents in the hospital are greater risk of injury or death. Ref: 19.1.2.1(2)

Based on observation and staff interview it was determined that the facility failed to maintain corridor doors to provide for positive latching and smoke resistance when the doors were closed. The findings include:

1. A tour of the facility was conducted on 1/20/10 with maintenance staff of the entire facility. The following doors were observed to not latch into their frame - A107, A314, D410, D425, D435, D417, D419, and E260.

2. A tour of the facility was conducted on 1/20/10 with maintenance staff of the entire facility. The door way to room D446 was blocked by a suction machine.

3. A tour of the facility was conducted on 1/20/10 with the maintenance staff of the entire facility. The door to room A135 was observed to have penetrations through the door that made the door non-smoke resistant.

All of the above observations were confirmed by maintenance staff at the time of the observations.

During the tour of the Wanblee Health Care Clinic on 10/21/2010 it was observed that 1 hour fire protection was not provided to protect the stairway located on the South end of the building. The vertical opening was open and failed to protect the basement stairway ,but also the first floor exit landing above. The basement was observed to contain storage items that could ignite and result in heat, smoke and fire to travel from the basement up the stairway and settle onto first floor exit area that would minimize vision and render the area unsafe.

This violation was confirmed by maintenance staff at the time of the observation.

NFPA 101 Chapter 39 Existing Business occupancy 39..3.1.2

Based on observation and staff interview it was determined that the facility failed to maintain exit doors in a condition that assured they were readily accessible at all times in accordance with NFPA 101, 7.2.1.5.4, 2000 edition. The findings include:

1. A tour of the facility was made on 1/21/10 with the facility engineer and the building maintenance staff. Observation was made of a marked exit located from the corridor of the building into a lobby (room 20) and finally to the outside of the building.

a. Observation found the doorway from the corridor into lobby where the outside exit door was located, was secured with a keyed door knob lock. The door was locked at the time of the observation. The facility safety officer and the building maintenance person confirmed that the doorway was locked at the time of the observation and were not aware that the door could not be locked and must be accessible at all times as a marked exit.

b. Observation found that the door from the lobby (room 20) to the outside was equipped with a door knob and a separate dead bolt lock. This created a duel releasing mechanism to open the door rather than the required single releasing operation required by the LSC Code. The facility safety officer and the building maintenance person confirmed the use of a duel operating mechanism at the time of the observation.

2. A tour of the facility was made on 1/21/10 with the facility engineer and the building maintenance staff. Observation was made of the marked exit door from the conference room to the outside. The door was equipped with two latching mechanisms that would require the door to be opened with more than one releasing mechanism. The two components were: (a) a single action push bar latch that was equipped with a audible alarm that sounded when the door bar was pushed to open the doorway and (b) a dead bolt lock.

The push bar was equipped with a sign that clearly identified the push bar as a means of opening the door and that the alarm would sound upon opening the door. The latching mechanism on the side of the door for push bar latch was taped over to prevent the latching mechanism to latch when the door was closed, but appeared to be operational. The dead bolt was used to latch and lock the door.

3. A tour of the facility was made on 1/21/10 with the facility engineer and the building maintenance staff. Observation was made of the main entrance marked exit door from the front vestibule to the outside. The door was equipped with a dead bolt lock and a door knob lock.

This created a duel releasing mechanism to open the door rather than the required single releasing operation required by the LSC Code. The facility engineer and the building maintenance person confirmed the use of a duel operating mechanism at the time of the observation.

Based on observation and staff interview it was determined that the facility failed to maintain emergency lighting as required by the NFPA 101, section 7.9. The findings include:

1. A tour of the facility was made on 1/21/10 with the facility engineer and the building maintenance person. Two battery operated emergency lights were observed located in the corridor at room 20 and room 23. Both of the emergency lights were tested and neither of the lights were found to be working. This was confirmed by the facility engineer and the building maintenance person at the time of the observations.

Although NFPA 101, chapter 39 does not require the use of emergency lighting in this type of building, NFPA 101, chapter 4, section 4.6.12.2 does require that safety features obvious to the public must be maintained or removed.

Based on observation and staff interview it was determined that the facility failed to maintain exit lighting as required. The findings include:

1. A tour of the facility was conducted on 1/21/10 with the facility engineer and the building maintenance foreman. Observation was made of an exit sign in the emergency room area. The sign was not illuminated. This was confirmed by the building maintenance foreman at the time of the observation.

Based on observation, record review , and staff interview it was determined that the facility failed to maintain the building fire alarm system as required. The findings include:

1. The fire alarm system did not meet the requirement that the fire department be automatically notified by the fire alarm system through one of four methods prescribed by the Life Safety Code. Ref: 9.6.4. Fire alarm systems that do not automatically notify an entity outside of the building risk delayed emergency forces response to fires if assigned staff are unavailable or become incapacitated due to the fire. This places patients and staff at a higher risk of injury or death.

An interview with the facility safety officer on 1/21/2010 at 3:30pm revealed that the fire alarm system was not programmed to contact anyone automatically when the fire alarm was activated. The Safety Officer stated that when the fire alarm was activated, staff stood by to call the fire department if necessary. The facility engineer advised the survey team that the fire alarm equipment had the capability but was not programmed to automatically contact the fire department through one of the means prescribed by the code.

2. The facility failed to maintain all occupant notification devices in functional condition by reparing three occupant notification devices.

A review of the fire alarm inspection report dated 6/9/08 on 1/19/2010 found that 3 occupant notification devices were defective. No records could be produced that indicated that the devices had been repaired. An interview with the facility engineer confirmed that the devices had not been repaired or replaced.

The alarm system performs the following functions: signal initiation, detection, occupant notification, emergency forces notification, emergency control and annunciation. The emergency forces notification function was fully non functional and 2% of the occupant notification devices were not functional. As such, one of six function of the fire alarm system did not function, and one of six functions had a minor impairment. The findings were observed and acknowledged by the facility engineer.






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Based on observation and staff interview it was determined that the facility failed to install and maintain the automatic fire alarm system in working order. The findings include:

1. A tour of the facility was made on 1/21/10 with the facility engineer and the building maintenance person. Upon entry into the facility observation was made of the fire pull station located at the main entrance. The pull station appeared to be in the pulled position.

The building maintenance person confirmed that the fire alarm system was deactivated and not working. The building maintenance person stated that the smoke alarms activated the alarm system whenever smudging ceremonies were performed in the building periodically and that the alarms were just shut off to prevent the system from activating.

2. A tour of the facility was made on 1/21/10 with the facility engineer and the building maintenance person. The facility fire alarm system included the use of smoke detectors. Smoke detectors were obseved in the corridors. Observation was made that in the corridor portion of the facility there were eight sky lights.

Although NFPA 101, chapter 39 does not require a fire alarm system for this particular type of building, NFPA 101, chapter 4, section 4.6.12.2 does require that safety features obvious to the public must be maintained or removed.

Based on observation and staff interview it was determined that the facility failed to install and maintain smoke alarms as required under the 2000 edition of NFPA 101, Chapter 9. The finding include:

1. A tour of the facility was made on 1/21/10 with the facility engineer and the building maintenance person. Observation found that numerous ceiling tile were missing in the laboratory area, emergency area, and the WIC Program area. This was confirmed by the building maintenance person at the time of the observations.
The missing ceiling tiles could allow smoke to escape above the ceiling tiles resulting in delayed operation of the smoke alarms. Delayed operation of smoke alarms places the patients and staff in the facility at greater risk of larger undetected fires causing injury or death.

2. A tour of the facility was made on 1/21/10 with the facility engineer and the building maintenance person. Observation of smoke detector placement in the main corridors of the building found the potential for delayed detection by the fire alarm system because of inadequate placement of smoke detectors. In the corridor area near the sky lights there were portions of the corridor that would not be protected by smoke detection because the intervening sky lights. No smoke detection was observed in the sky lights or directly on either side of the sky light.

Although NFPA 101, chapter 39 does not require a fire alarm system with smoke detection for this particular type of building, NFPA 101, chapter 4, section 4.6.12.2 does require that safety features obvious to the public must be maintained or removed.

Based on observation, record review, and staff interview it was determined that the facility failed to maintain and inspect the integrity of the automatic sprinkler system to operate effectively. The findings include:

1. A facility tour with the facility engineer and maintenance foreman on 1/20/2010 at various times between 8:00 AM and 4:00 PM observed that ceiling tiles were missing at or near these room locations: J713, A138B, A200, Ambulance entry, screening room behind patient registration, C602.

2. A hatch was left open in room C602. The findings were observed and acknowledged by the facility engineer or the facilities maintenance foreman.

The need for ceiling tiles to be in place for sprinklers to operate as intended. Missing ceiling tiles and open hatches allow heat to escape above the ceiling tiles resulting in delayed operation of sprinklers. Delayed operation of sprinklers places the patients and staff in the facility at greater risk of larger unsuppressed fires causing injury or death.

3. A tour of the facility was made on 1/20/10 with facility maintenance staff. During the tour several escutcheon rings were missing in room 210 and in the laboratory blood draw area. This was confirmed by maintenance staff at the time of the observations.

4. A record review was made of the automatic sprinkler system inspection reports for 2009. The reports did not contain any evidence that a sprinkler test had been done for the 4th quarter of 2009. This was confirmed by the facility safety officer at the time of the record review. The safety officer stated that the contract had expired with the company that did the annual and quarterly testing prior to the 4th quarter and that no test had been done for the 4th quarter of 2009.

Based on record review and staff interview it was determined that the facility failed to have the kitchen hood suppression system inspected every six months as required. The findings include:

1. Record review of the kitchen hood suppression system inspection reports were made on 1/18/10. The inspection records showed that an inspection of the kitchen hood suppression system had last been conducted on 8/24/09. There were no other inspection reports for the kitchen hood suppression system showing that it had been inspected in the prior six month period. This was confirmed by the facility maintenance at the time of the record review.

Based on observation and staff interview it was determined that the facility failed to maintain the piped medical gas system in accordance with NFPA 99 (Ref: NFPA 99 sections: 4-3.1.1.8(a), 4-3.1.2.3(b), 4-3.1.2.2). The findings include:

1. A facility tour with the facility engineer on 1/20/2010 at 8:45 am where it was observed that one- E sized oxygen cylinders outside of established multicylinder rack in full cylinder storage room, one E size oxygen cylinder outside of multicylinder rack in empty cylinder storage room, and 3-J size cylinders chained loosely so that they could fall over in empty cylinder storage room. 3 of approximately 70 bottles in storage were unsecured.

Unsecured gas cylinders place the facility at greater risk to damaging cylinders causing unintended discharge of gas resulting in a life safety hazard.

The findings were observed and acknowledged by the facility engineer.

2. At 9:00 AM it was observed that the main shutoff valve located above the ceiling was not properly marked. One of 14 valve locations inspected this one valve was not properly identified.

Unidentified gas shut off valves place the residents and staff at greater risk of injury in the event of an uncontrolled breach in an oxygen line within the facility.

The findings were observed and acknowledged by the facility engineer.

3. At 9:15 AM local alarm panels located serving pediatrics acute care, Adult Acute Care and Pre op Recover were either partially or fully non functional. Three of 13 panels inspected did not function as required.

Malfunctioning medical gas warning systems place patients depending on medical gasses at greater risk to injury should unknown loss of medical gasses occur.

The findings were observed and acknowledged by the facility engineer.

Based on observation and staff interview it was determined that the facility failed to maintain electrical wiring and equipment as required. The findings include:

1. A tour of the facility was made on 1/21/10 with the facility engineer and the building maintenance foreman. Observation was made of the sink area in the maintenance shop. No Ground Fault Circuit Interrupter (GFCI) was found for the outlet located next to the sink. This maintenance foreman confirmed that the circuit the outlet used was not protected by a GFCI.

Based on record review and staff interview it was determined that the facility did not have a policy that would include a fire watch or evacuation of the building, and notification of the authority having jurisdiction in the event that the AUTOMATIC SPRINKLER SYSTEM was out of service for more than four hours. The findings include:

1. Record review was conducted of the facility fire safety policy on 1/19/10. The policy did not contain any information related to outages of greater than four hours that would include notification of all authorities having jurisdiction. The facility safety officer stated at the time of review that he was not able to provide such a policy.

Based on record review and staff interview it was determined that the facility did not have a policy that would include a fire watch or evacuation of the building, and notification of the authority having jurisdiction in the event that the AUTOMATIC FIRE ALARM SYSTEM was out of service for more than four hours. The findings include:

1. Record review was conducted of the facility fire safety policy on 1/19/10. The policy did not contain any information related to outages of greater than four hours that would include notification of all authorities having jurisdiction. The facility safety officer stated at the time of review that he was not able to provide such a policy.