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Based on documentation review and tour of the main hospital building which included the D & T building and three offsite locations on 05/06/13 thru 05/09/13, it was determined this facility was not maintained in a manner safe from fire. These life safety deficiencies included holes in or missing ceiling tiles (K-15), exit accesses lacking exit signs (K-22), penetrations in smoke barriers (K-25), doors in hazardous areas lacking self closing devices (K-29), storage located near sprinkler heads (K-62), portable fire extinguishers not checked annually or monthly or access to them blocked by equipment (K-64), medical gas components not inspected annually (K-77) and smoke detectors located by air flow devices (K-130). This had the potential to affect all patients, visitors, and staff members. This facility census at the beginning of the survey was 201. The cumulative effect of this failure to ensure all life safety measures were in place resulted in the facility's inability to provide a safe environment to all patients, visitors and staff members.

Based on the life safety code inspection conducted on 05/06/13 thru 05/09/13, it was determined this facility was not maintained in a manner safe from fire. This had the potential to affect patients, visitors, and staff members. This facility census at the beginning of the survey was 202.

Findings include:

Building # 1

Observation during facility tour and staff verification, this facility failed to ensure the interior finish for rooms in regards to the ceiling tiles were constructed to provide at least a class A fire resistance rating.

Please refer to K-15


During facility tour with staff members A, B, C and D on 05/06/13 through 05/07/13 observation was made of a ceiling tile that was missing in the following location:

Third floor:
*Within the education conference room an approximate three inch by five inch ceiling tile was missing in the northwest corner of the room.



Observations on facility tour and staff verification determined this facility failed to ensure all exit accesses were marked by approved, readily visible signs to ensure occupants are able to reach the exit discharge in the event of an emergency.
During facility tour with staff members A, B, C and D on 05/06/13 through 05/07/13 observation was made of two exit accesses at the north corridor of the emergency department. From the south corridor of the emergency department looking to the north, it was observed that no exit signs were displayed at either of the corridor entrances to direct occupant flow into the corridor exit access.

Please refer to K-22.


During facility tour with staff members A, B, C and D on 05/06/13 through 05/07/13 observation was made of penetrations in the one hour smoke barrier in the following locations:

Ground floor:
*From within the clinical nurse manager's office identified as H-G-62, one open end conduit was observed which was also not sealed around the annular space.

Third floor:
*Within the soiled utility room identified as T3028 was observed to have one unsealed flex conduit around the annular space.
*From within the nurse manager's office identified as H-381 was observed to have one open end flex conduit with green and white wires passing through.

Please refer to K-25.


During facility tour with staff members A, B, C and D on 05/06/13 through 05/07/13 observation was made of hazardous areas which had doors that lacked a self-closing device in the following locations:

Ground floor:
*Door within the plant operations department at the south end identified as FED # 0499708.

First floor:
*Door within the materials management office separating rooms H-EG-126 from H-EG-129.

Please refer to K-29.


During facility tour with staff members A, B, C and D on 05/06/13 through 05/07/13 observation was made of storage located within 18 inches of a sprinkler head in the following location:

Fifth floor:
*Within storage closet T5022, observation was made of packets of paper towels stacked within a few inches from the only sprinkler head within the closet.

Please refer to K-62.


During facility tour with staff members A, B, C and D on 05/06/13 through 05/07/13 observation was made of one fire extinguisher located in the west mechanical room on the ground floor which lacked the inspection for the month of April 2013. Upon review of the computerized fire extinguisher monitoring system it was discovered this portable fire extinguisher had been left off the inspection log.
Additionally, observation was made of one fire extinguisher mounted behind a coat rack within the ground floor cardiac therapy room.

Please refer to K-64.


During facility tour with staff members A, B, C and D on 05/07/13 observation was made of smoke detectors located by air flow devices in the following locations:

Fourth floor:
*Within the nurse specialist room identified as H-439.
*Within a small alcove housing an ice machine located on the north wing.
Please refer to K-130.


Building # 2

Please refer to K-15


During facility tour with staff members A, B, C and D on 05/06/13 through 05/07/13 observation was made of ceiling tiles that had a hole in the following location:

First floor:
*Within the kitchen area an approximate three inch hole was observed in the ceiling tile in the southeast corner of the room.

Please refer to K-77.


Medical gas documentation review took place on 05/07/13 with staff members A, B, C and D and also with a staff member from a contracted medical gas inspection company. During documentation review this writer noticed the MRI unit was documented as "unavailable" for the annual medical gas inspections for the years 2011 and 2012. This writer questioned why it was documented this way and the contracted medical gas staff member stated they were not able to get their equipment into the MRI room during the times of the inspections since it was probably occupied. This writer questioned all staff members present why this was not completed and if an attempt was made to reschedule this inspection when the MRI would be available. The answer received was that it takes special equipment in the MRI room to inspect the medical gas components and "no" an attempt was not made to reschedule.

During facility tour with staff members A, B, C and D on 05/07/13 observation was made of smoke detectors located by air flow devices in the following locations:

First floor:
*Within the general radiology control room.

Second floor:
*Within the corridor by the blood bank.

Please refer to K-130.


Building # 3

During facility tour with staff members A, B, C and D on 05/08/13 observation was made of one portable fire extinguisher located at the east wall within the emergency department which was obstructed with medical equipment.

During tour of the lab observation was made of one smoke detector which was located near an air flow device.

Please refer to K-130

Building # 5

During facility tour with staff members A, B, C, D and H on 05/08/13 observation was made of one portable fire extinguisher which had an annual inspection tag dated for March 2011. It was verified through interview with staff H in the afternoon hours of 05/08/13 that this portable fire extinguisher had not been annually inspected since March 2011.

Please refer to K-130.