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Based on observation, the critical access hospital failed to ensure that all doors protecting corridor openings closed without impediment, and had a functional means of ensuring that the doors remained closed.

Failure to ensure the secure closing of doors protecting corridor openings risks spread of smoke and heat into the exit corridors in the hospital, potentially impeding safe egress from the area where a fire exists.

Findings include:

During a tour of the hospital on 08/10/10, it was observed that doors in the following locations did not close securely:

Clean utility room adjacent to room 105
Soiled utility room adjacent to room 105
Soiled linen room adjacent to room 112

Based on observation, the critical access hospital failed to ensure that the fire alarm system could notify all occupants in all areas of the hospital.

Failure to ensure that the fire alarm system is capable of notifying all occupants in all areas of the hospital risks inability of occupants to take appropriate actions in the event of a fire emergency.

Findings include:

During a tour of the hospital on 08/10/10, the fire alarm system was accidentally triggered by the removal of a smoke detector plastic protective cover in the boiler room. The fire alarm was not audible in the boiler room, and the overhead page could not be clearly heard in the boiler room. There was no visual fire alarm signal in this area.


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Based upon observation, the facility has failed to maintain the automatic sprinkler system in a reliable operating condition.

Failure to maintain the automatic sprinkler system in a reliable operating condition risks failure of the sprinkler system to operate in the event of a fire, and could allow the fire to grow and endanger patients, staff and visitors.

Findings include but are not limited to:

During a tour of the critical access hospital on 08/10/10, it was observed that a sprinkler head in the materials management basement storage room was obstructed by protective plastic catchment sheeting that had been suspended from the ceiling near the sprinkler head, and the sprinkler head in room 193 within the storage room was located below the level of storage that was placed on shelves against the walls.


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Based upon observation, the facility failed to maintain trash collection or recycling paper bin of a capacity exceeding 32 gallons in a room protected as a
hazardous area.

Failure to keep large trash and paper bins in protected rooms risks spread of fire outside a protected environment, endangering patients, staff and visitors.

Findings include but are not limited to:

During a tour of the critical access hospital on 08/10/10, it was observed that a large wheeled recycle paper bin exceeding 32 gallons capacity was located in the acute care nurses' lounge, and seven large wheeled recycle paper bins exceeding 32 gallons capacity were located in the basement housekeeping storage room.

Neither of the two rooms were protected as a hazardous area.

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Based upon observation, the facility failed to maintain the relative humidity equal to or greater than 35% in anesthetizing locations.

Humidity levels below 35% are conducive to the production of static electrical discharges that could ignite a fire and endanger patients and staff in these locations.

Findings include but are not limited to:

During a tour of the critical access hospital on 08/10/10, it was stated by surgery management and by hospital maintenance staff that the hospital does not have the ability to adjust humidity levels. Review of humidity monitoring records kept by the surgery department found that from November 5, 2009 until May 25, 2010, the humidity in the operating room was measured below 35% on at least 107 days.

Based on observation, the critical access hospital failed to ensure that all doors protecting corridor openings closed without impediment, and had a functional means of ensuring that the doors remained closed.

Failure to ensure the secure closing of doors protecting corridor openings risks spread of smoke and heat into the exit corridors in the hospital, potentially impeding safe egress from the area where a fire exists.

Findings include:

During a tour of the hospital on 08/10/10, it was observed that doors in the following locations did not close securely:

Clean utility room adjacent to room 105
Soiled utility room adjacent to room 105
Soiled linen room adjacent to room 112

Based on observation, the critical access hospital failed to ensure that the fire alarm system could notify all occupants in all areas of the hospital.

Failure to ensure that the fire alarm system is capable of notifying all occupants in all areas of the hospital risks inability of occupants to take appropriate actions in the event of a fire emergency.

Findings include:

During a tour of the hospital on 08/10/10, the fire alarm system was accidentally triggered by the removal of a smoke detector plastic protective cover in the boiler room. The fire alarm was not audible in the boiler room, and the overhead page could not be clearly heard in the boiler room. There was no visual fire alarm signal in this area.


.

Based upon observation, the facility has failed to maintain the automatic sprinkler system in a reliable operating condition.

Failure to maintain the automatic sprinkler system in a reliable operating condition risks failure of the sprinkler system to operate in the event of a fire, and could allow the fire to grow and endanger patients, staff and visitors.

Findings include but are not limited to:

During a tour of the critical access hospital on 08/10/10, it was observed that a sprinkler head in the materials management basement storage room was obstructed by protective plastic catchment sheeting that had been suspended from the ceiling near the sprinkler head, and the sprinkler head in room 193 within the storage room was located below the level of storage that was placed on shelves against the walls.


.

Based upon observation, the facility failed to maintain trash collection or recycling paper bin of a capacity exceeding 32 gallons in a room protected as a
hazardous area.

Failure to keep large trash and paper bins in protected rooms risks spread of fire outside a protected environment, endangering patients, staff and visitors.

Findings include but are not limited to:

During a tour of the critical access hospital on 08/10/10, it was observed that a large wheeled recycle paper bin exceeding 32 gallons capacity was located in the acute care nurses' lounge, and seven large wheeled recycle paper bins exceeding 32 gallons capacity were located in the basement housekeeping storage room.

Neither of the two rooms were protected as a hazardous area.

.

Based upon observation, the facility failed to maintain the relative humidity equal to or greater than 35% in anesthetizing locations.

Humidity levels below 35% are conducive to the production of static electrical discharges that could ignite a fire and endanger patients and staff in these locations.

Findings include but are not limited to:

During a tour of the critical access hospital on 08/10/10, it was stated by surgery management and by hospital maintenance staff that the hospital does not have the ability to adjust humidity levels. Review of humidity monitoring records kept by the surgery department found that from November 5, 2009 until May 25, 2010, the humidity in the operating room was measured below 35% on at least 107 days.