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1) Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 Findings include:

a) Smoke wall separating the two zones located at the control joint on the south side of the building by the double egress doors has voids in the sheet rock. Those joints had not been sealed with material capable of maintaining the fire resistance of the fire barrier.

1) Based on observation and interview with staff, the facility failed to provide exit and directional signs that are displayed in accordance with section 7.10 . Findings include:

a) Exit sign over the door to Radiology was not in a continuous path of travel. Magnetic lock was installed over the door preventing traffic from exiting the building at all times. The magnetic lock was not installed in accordance with NFPA 101 CHAPTER 7.2.1.6 Special Locking Arrangements. The door was not installed with an irreversible process that releases the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only. (d) *On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
The facility shall move exit sign or install magnetic door lock to meet code in accordance with 7-2.1.6.

1) Based on observation and interview with staff, the facility failed to provide and maintain a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The annual fire alarm test was conducted in March of 2013. Annual testing was not conducted for 2014 as of May 15, 2014.

1)Based on observation and interview with staff, the facility failed to protect anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) Based on interview with operating room staff, the facility has not adopted rules and regulations or posted rules and regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in anesthetizing locations. Operating room staff had not been thoroughly in-serviced for specific area requirements for anesthetizing locations in accordance with 12-4.1.1 through 12-4.1.2.10. Operating room. physicians, and support staff has not had periodic review of manufacturer's safety guidelines and usage requirements for electrosurgical units and similar appliances. Physicians, nurses, nurse aids, engineers, technicians, and orderlies shall be cognizant of the risks associated with their use and to achieve this end the hospital shall provide appropriate programs of continuing education for its personnel in accordance with NFPA 99 1999 edition chapter 7-6.5. Facility did not provide such a program for all its personnel and could not provide documentation.

b) Staff, including doctors, nurses, physicians assistants, scrub techs, and other staff has not received training for a Cautery tool located and used in the Emergency Room. Staff shall be cognizant of fire hazard associated with the tool in an oxygen enriched atmosphere in conjunction with the use of alcohol.

c) Facility failed to conduct a fire drill in the operating room with doctors, nurses, scrub techs to acquaint staff with their duties in the event of a fire.

1) Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 Findings include:

a) Smoke wall separating the two zones located at the control joint on the south side of the building by the double egress doors has voids in the sheet rock. Those joints had not been sealed with material capable of maintaining the fire resistance of the fire barrier.

1) Based on observation and interview with staff, the facility failed to provide exit and directional signs that are displayed in accordance with section 7.10 . Findings include:

a) Exit sign over the door to Radiology was not in a continuous path of travel. Magnetic lock was installed over the door preventing traffic from exiting the building at all times. The magnetic lock was not installed in accordance with NFPA 101 CHAPTER 7.2.1.6 Special Locking Arrangements. The door was not installed with an irreversible process that releases the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only. (d) *On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
The facility shall move exit sign or install magnetic door lock to meet code in accordance with 7-2.1.6.

1) Based on observation and interview with staff, the facility failed to provide and maintain a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The annual fire alarm test was conducted in March of 2013. Annual testing was not conducted for 2014 as of May 15, 2014.

1)Based on observation and interview with staff, the facility failed to protect anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) Based on interview with operating room staff, the facility has not adopted rules and regulations or posted rules and regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in anesthetizing locations. Operating room staff had not been thoroughly in-serviced for specific area requirements for anesthetizing locations in accordance with 12-4.1.1 through 12-4.1.2.10. Operating room. physicians, and support staff has not had periodic review of manufacturer's safety guidelines and usage requirements for electrosurgical units and similar appliances. Physicians, nurses, nurse aids, engineers, technicians, and orderlies shall be cognizant of the risks associated with their use and to achieve this end the hospital shall provide appropriate programs of continuing education for its personnel in accordance with NFPA 99 1999 edition chapter 7-6.5. Facility did not provide such a program for all its personnel and could not provide documentation.

b) Staff, including doctors, nurses, physicians assistants, scrub techs, and other staff has not received training for a Cautery tool located and used in the Emergency Room. Staff shall be cognizant of fire hazard associated with the tool in an oxygen enriched atmosphere in conjunction with the use of alcohol.

c) Facility failed to conduct a fire drill in the operating room with doctors, nurses, scrub techs to acquaint staff with their duties in the event of a fire.