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Based on observation and staff interview, the facility's practice failed to ensure doors installed in smoke barrier walls were capable of resisting the passage of smoke. It is essential these doors close and seal so in the event of fire, they would prevent the spread of fire and/or smoke to or from other smoke compartments. This deficient practice had the potential to harm staff near room #250. The findings are:

A. On 11/02/11 at 8:15 am, the surveyor observed the smoke barrier doors located near room #250 failed to close properly. The right leaf of the smoke barrier doors appeared to be warped and would not close properly when tested. There was a one (1) inch gap that would allow smoke to spread from one smoke compartment to another.

B. The Administrator/CEO, and the Plant Operations Director acknowledged the finding at the exit conference on 11/02/11 at 05:30 pm .

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.



Based on record review and staff interview, the facility failed to ensure fire drills are conducted at least quarterly on every shift to assure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice had the potential to harm all sixty-six (66) inpatients of the hospital as identified by the Patient Roster List provided by the Plant Operations Director on 11/01/11 at 2:30 pm. The findings are:

A. Review of the facility's Fire Drill records revealed the facility has three (3) shifts:
1. First Shift (6:00 am - 3:00 pm)
2. Second Shift (3:00 pm - 11:00 pm)
3. Third Shift (11:00 pm - 6:00 am)


B. On 11/01/11 at 2:15 pm, review of the fire drill log with the Plant Operations Director revealed no record that fire drills were conducted between November 5th, 2010 and March 24th, 2011 for the third shift (11:00 pm - 6:00 am). This exceeds the 90-day spacing between drills for this shift. No further records were available for review.

C. During interview at this time, the Plant Operations Director stated that the fire drill was missed due to a confusion of what constitutes a quarter.

D. The Administrator/CEO, and the Plant Operations Director acknowledged the above findings at the exit conference on 11/02/11 at 05:30 pm .

NFPA 72 National Fire Alarm Code? 1999 Edition
2-3.5 Heating, Ventilating, and Air-Conditioning (HVAC).
2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.



Based on observation, the facility failed to assure the fire alarm system is installed in accordance with NFPA 72 (National Fire Alarm Code) and that smoke detectors are located where air-handling systems do not prevent operation of the detectors. It is essential that smoke detectors are not placed in areas where airflow would prevent the device from detecting smoke. This deficient practice had the potential to harm all sixty-six (66) inpatients of the hospital as identified by the Patient Roster List provided by the Plant Operations Director on 11/01/11 at 2:30 pm. The findings are:


A. On 11/02/11 at 8:30 am, the smoke detector at the Atrium was within 11" inches of the supply register.

B. On 11/02/11 at 8:40 am, the smoke detector located in the corridor on the first floor near room #201 was 10" inches from the supply register.

C. On 11/02/11 at 9:30 am, the smoke detector located on the first floor near the main entrance was 10" from the supply register.

D. On 11/02/11 at 10:00 am, the smoke detector located in the Cardio Pulmonary corridor near critical care #2 was 10" inches from the supply register.

E. The CEO/Administrator, and the Plant Operations Director acknowledged the findings at the exit conference on 11/02/11 at 5:30 pm.




Based on observation and staff interview, the facility failed to assure notification devices for the fire alarm system are installed in the Physician Sleep Rooms and Materials Management area, in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code). This deficient practice has the potential to harm three (3) staff within the Physicians Sleep Rooms and four (4) staff observed working within the Materials Management area. The findings are:

F. On 11/02/11 at 10:50 am, the Surveyor observed there were no notification devices to alert staff of a potential fire within the Materials Management area.

G. On 11/02/11 at 11:00 am, the Surveyor observed there were no notification devices to alert staff of a potential fire within the three (3) Physician Sleep Rooms.

H. The CEO/Administrator, and the Plant Operations Director acknowledged the findings at the exit conference on 11/02/11 at 5:30 pm.

Actual NFPA Standard: NFPA 101, 9.6.5.1. A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

Actual NFPA Standard: NFPA 101, Ch 7.2.1.6.2 (e). Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Actual NFPA Standard: NFPA 72, 3-9.7.1. Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.

Actual NFPA Standard: NFPA 72, 3-9.7.2. All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.

Actual NFPA Standard: NFPA 72, 3-9.7.3. All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.



Based on observation and staff interview, the facility failed to ensure magnetic locking devices installed on stairwell doors located in the path of emergency egress de-energize (unlock) when the fire alarm system is activated. This deficient practice had the potential to harm all staff working within the Pediatrics Wing. The findings are:

A. On 11/2/11 at 2:30 pm, a fire alarm system test was conducted at the facility to ensure fire alarm system integrity. During this time, the surveyor observed the magnetic locking device installed on the stairwell door located at the Pediatrics Wing failed to unlock with the fire alarm system. The Pediatrics Wing is used by staff only and was not occupied by patients at the time of survey.

B. During interview at 2:45 pm, the Plant Operations Director stated, "The door should unlock with the fire alarm system."

C. The CEO/Administrator, and the Plant Operations Director acknowledged the above findings at the exit conference on 11/02/11 at 5:30 pm,

Actual Standard NFPA 99
Standard for Health Care Facilities
1999 Edition

5-4.1.1*
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

A-5-4.1.1
Advantages claimed for humidity include avoidance of hypothermia in patients, especially during long operative procedures; the fact that floating particulate matter increases in conditions of low relative humidity; and the fact that the incidence of wound infections can be minimized following procedures performed in those operating rooms in which the relative humidity is maintained at the level of 50 to 55 percent.




Based on observation and staff interview, the facility failed to ensure relative humidity is maintained equal to or greater than 35% in areas where anesthesia is administered. This deficient practice had the potential to harm all patients requiring anesthesia. The findings are:

A. On 11/02/11 between the times of 6:00 am and 7:00 am, during a tour of the operating room suite with the Plant Operations Director, the surveyor observed the following Operating Rooms had a relative humidity of less than 35%.
1. Operating Room #3 had a relative humidity of 22%.
2. Operating Room #5 had a relative humidity of 22%.
3. Operating Room #6 had a relative humidity of 27%.

B. On 11/02/11 at 7:10 am, during a tour of the Labor and Delivery Operating Room on the first floor, the surveyor observed the relative humidity was 22%.

C. During interview with the Plant Operations Director at 7:30 am, it was stated, "Humidity levels should be at least 35% and they will be monitored."

D. The CEO/Administrator, and the Plant Operations Director acknowledged the findings at the exit conference on 11/02/11 at 5:30 pm.

NFPA 99:
3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.



Based on observation and staff interview, the facility failed to ensure the emergency generator's main annunciator panel was maintained as required by NFPA 110 (Standard for Emergency and Standby Power Systems). It is essential this panel is maintained and inspected to ensure trouble alarms are addressed as to prevent equipment malfunction of the emergency generator and emergency power system. This deficient practice had the potential to harm all sixty-six (66) inpatients of the hospital as identified by the Patient Roster List provided by the Plant Operations Director on 11/01/11 at 2:30 pm. The findings are:


A. On 11/02/11 at 10:30 am, the surveyor observed the generator's main annunciator panel located at the PBX indicated a trouble alarm which read, "Battery Charge Malfunction."

B. During interview at this time, the PBX operator was asked how long the annunciator panel showed a trouble alarm, and the response was, "That has been there for a while. I am not sure."

C. The Administrator/CEO, and the Plant Operations Director acknowledged the above findings at the exit conference on 11/02/11 at 05:30 pm .

Based on observation and staff interview, the facility's practice failed to ensure doors installed in smoke barrier walls were capable of resisting the passage of smoke. It is essential these doors close and seal so in the event of fire, they would prevent the spread of fire and/or smoke to or from other smoke compartments. This deficient practice had the potential to harm staff near room #250. The findings are:

A. On 11/02/11 at 8:15 am, the surveyor observed the smoke barrier doors located near room #250 failed to close properly. The right leaf of the smoke barrier doors appeared to be warped and would not close properly when tested. There was a one (1) inch gap that would allow smoke to spread from one smoke compartment to another.

B. The Administrator/CEO, and the Plant Operations Director acknowledged the finding at the exit conference on 11/02/11 at 05:30 pm .

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.



Based on record review and staff interview, the facility failed to ensure fire drills are conducted at least quarterly on every shift to assure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice had the potential to harm all sixty-six (66) inpatients of the hospital as identified by the Patient Roster List provided by the Plant Operations Director on 11/01/11 at 2:30 pm. The findings are:

A. Review of the facility's Fire Drill records revealed the facility has three (3) shifts:
1. First Shift (6:00 am - 3:00 pm)
2. Second Shift (3:00 pm - 11:00 pm)
3. Third Shift (11:00 pm - 6:00 am)


B. On 11/01/11 at 2:15 pm, review of the fire drill log with the Plant Operations Director revealed no record that fire drills were conducted between November 5th, 2010 and March 24th, 2011 for the third shift (11:00 pm - 6:00 am). This exceeds the 90-day spacing between drills for this shift. No further records were available for review.

C. During interview at this time, the Plant Operations Director stated that the fire drill was missed due to a confusion of what constitutes a quarter.

D. The Administrator/CEO, and the Plant Operations Director acknowledged the above findings at the exit conference on 11/02/11 at 05:30 pm .

NFPA 72 National Fire Alarm Code? 1999 Edition
2-3.5 Heating, Ventilating, and Air-Conditioning (HVAC).
2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.



Based on observation, the facility failed to assure the fire alarm system is installed in accordance with NFPA 72 (National Fire Alarm Code) and that smoke detectors are located where air-handling systems do not prevent operation of the detectors. It is essential that smoke detectors are not placed in areas where airflow would prevent the device from detecting smoke. This deficient practice had the potential to harm all sixty-six (66) inpatients of the hospital as identified by the Patient Roster List provided by the Plant Operations Director on 11/01/11 at 2:30 pm. The findings are:


A. On 11/02/11 at 8:30 am, the smoke detector at the Atrium was within 11" inches of the supply register.

B. On 11/02/11 at 8:40 am, the smoke detector located in the corridor on the first floor near room #201 was 10" inches from the supply register.

C. On 11/02/11 at 9:30 am, the smoke detector located on the first floor near the main entrance was 10" from the supply register.

D. On 11/02/11 at 10:00 am, the smoke detector located in the Cardio Pulmonary corridor near critical care #2 was 10" inches from the supply register.

E. The CEO/Administrator, and the Plant Operations Director acknowledged the findings at the exit conference on 11/02/11 at 5:30 pm.




Based on observation and staff interview, the facility failed to assure notification devices for the fire alarm system are installed in the Physician Sleep Rooms and Materials Management area, in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code). This deficient practice has the potential to harm three (3) staff within the Physicians Sleep Rooms and four (4) staff observed working within the Materials Management area. The findings are:

F. On 11/02/11 at 10:50 am, the Surveyor observed there were no notification devices to alert staff of a potential fire within the Materials Management area.

G. On 11/02/11 at 11:00 am, the Surveyor observed there were no notification devices to alert staff of a potential fire within the three (3) Physician Sleep Rooms.

H. The CEO/Administrator, and the Plant Operations Director acknowledged the findings at the exit conference on 11/02/11 at 5:30 pm.

Actual NFPA Standard: NFPA 101, 9.6.5.1. A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

Actual NFPA Standard: NFPA 101, Ch 7.2.1.6.2 (e). Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Actual NFPA Standard: NFPA 72, 3-9.7.1. Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.

Actual NFPA Standard: NFPA 72, 3-9.7.2. All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.

Actual NFPA Standard: NFPA 72, 3-9.7.3. All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.



Based on observation and staff interview, the facility failed to ensure magnetic locking devices installed on stairwell doors located in the path of emergency egress de-energize (unlock) when the fire alarm system is activated. This deficient practice had the potential to harm all staff working within the Pediatrics Wing. The findings are:

A. On 11/2/11 at 2:30 pm, a fire alarm system test was conducted at the facility to ensure fire alarm system integrity. During this time, the surveyor observed the magnetic locking device installed on the stairwell door located at the Pediatrics Wing failed to unlock with the fire alarm system. The Pediatrics Wing is used by staff only and was not occupied by patients at the time of survey.

B. During interview at 2:45 pm, the Plant Operations Director stated, "The door should unlock with the fire alarm system."

C. The CEO/Administrator, and the Plant Operations Director acknowledged the above findings at the exit conference on 11/02/11 at 5:30 pm,

Actual Standard NFPA 99
Standard for Health Care Facilities
1999 Edition

5-4.1.1*
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

A-5-4.1.1
Advantages claimed for humidity include avoidance of hypothermia in patients, especially during long operative procedures; the fact that floating particulate matter increases in conditions of low relative humidity; and the fact that the incidence of wound infections can be minimized following procedures performed in those operating rooms in which the relative humidity is maintained at the level of 50 to 55 percent.




Based on observation and staff interview, the facility failed to ensure relative humidity is maintained equal to or greater than 35% in areas where anesthesia is administered. This deficient practice had the potential to harm all patients requiring anesthesia. The findings are:

A. On 11/02/11 between the times of 6:00 am and 7:00 am, during a tour of the operating room suite with the Plant Operations Director, the surveyor observed the following Operating Rooms had a relative humidity of less than 35%.
1. Operating Room #3 had a relative humidity of 22%.
2. Operating Room #5 had a relative humidity of 22%.
3. Operating Room #6 had a relative humidity of 27%.

B. On 11/02/11 at 7:10 am, during a tour of the Labor and Delivery Operating Room on the first floor, the surveyor observed the relative humidity was 22%.

C. During interview with the Plant Operations Director at 7:30 am, it was stated, "Humidity levels should be at least 35% and they will be monitored."

D. The CEO/Administrator, and the Plant Operations Director acknowledged the findings at the exit conference on 11/02/11 at 5:30 pm.

NFPA 99:
3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.



Based on observation and staff interview, the facility failed to ensure the emergency generator's main annunciator panel was maintained as required by NFPA 110 (Standard for Emergency and Standby Power Systems). It is essential this panel is maintained and inspected to ensure trouble alarms are addressed as to prevent equipment malfunction of the emergency generator and emergency power system. This deficient practice had the potential to harm all sixty-six (66) inpatients of the hospital as identified by the Patient Roster List provided by the Plant Operations Director on 11/01/11 at 2:30 pm. The findings are:


A. On 11/02/11 at 10:30 am, the surveyor observed the generator's main annunciator panel located at the PBX indicated a trouble alarm which read, "Battery Charge Malfunction."

B. During interview at this time, the PBX operator was asked how long the annunciator panel showed a trouble alarm, and the response was, "That has been there for a while. I am not sure."

C. The Administrator/CEO, and the Plant Operations Director acknowledged the above findings at the exit conference on 11/02/11 at 05:30 pm .