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Based on observation during facility tour and staff verification, this facility failed to ensure that the interior finish for rooms in regards to the ceiling tiles were constructed to provide at least a class A fire resistance rating. This had to potential to affect all persons utilizing these areas of the facility. The census was 202 patients at the time of the survey.

Findings included:

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.

This finding was verified by all staff members present during tour.

Based on observation during facility tour and staff verification, this facility failed to ensure that the interior finish for rooms in regards to the ceiling tiles were constructed to provide at least a class A fire resistance rating. This had to potential to affect all persons utilizing these areas of the facility. The census was 202 patients at the time of the survey.

Findings included:

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.

This finding was verified by all staff members present during tour.

Based on facility tour and staff verification it was 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. This had the potential to affect all occupants utilizing this area of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

This finding was verified by all staff present during tour and re-verified by staff I upon review of the emergency department floor plans in the afternoon of 05/08/13.

Based on observation during facility tour and staff verification, this facility failed to ensure that smoke/fire barriers were constructed to provide at least a half hour fire resistance rating. This had to potential to affect all persons utilizing the facility. The census was 202 patients at the time of the survey.

Findings included:

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.

These findings were verified by staff F during tour.

Based on facility tour, specifically in the hazardous areas, it was determined this facility failed to ensure all doors were equipped with self closing devices. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 202.

Findings include:

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.

These findings were verified by all staff members present during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition in regards to storage located within 18 inches from the sprinkler head. This had the potential to affect all occupants located within this area of the facility. The patient census at the beginning of the survey was 202.

Findings include:

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.

This finding was verified by staff A and the items were then removed.

Based on facility tour, fire extinguisher documentation review and staff verification it was determined this facility failed to ensure all portable fire extinguishers were inspected monthly and failed to ensure all portable fire extinguishers were accessible at all times according to the National Fire Protection Association (NFPA) 10. This had the potential to affect all those who were utilizing these areas of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

These findings were verified by all staff present during the documentation review and facility tour.

Based on medical gas inspection reports and staff verification it was determined this facility failed to ensure all medical gas outlets were inspected annually according to the National Fire Protection Association (NFPA) 99 Chapter 4. This had the potential to affect all those utilizing this area of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke detectors were placed in areas which would not be affected by air flow devices according to NFPA 72 Chapter 2-3.5.1. This had the potential to affect all those utilizing these areas of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

These findings were verified by all staff members during tour of the facility.

Based on facility tour and staff verification this facility failed to ensure all smoke detectors were placed in areas which would not be affected by air flow devices according to NFPA 72 Chapter 2-3.5.1. This had the potential to affect all those utilizing these areas of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

These findings were verified by all staff members during tour of the facility.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were accessible at all times according to the National Fire Protection Association (NFPA) 10. Additionally, this facility failed to ensure all smoke detectors were not placed near any air flow device according to NFPA 72. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 31.

Findings include:

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.

These findings were verified by all staff members present during facility tour on 05/08/13.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were inspected annually according to the National Fire Protection Association (NFPA) 10. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 17.

Findings include:

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.

Based on observation during facility tour and staff verification, this facility failed to ensure that the interior finish for rooms in regards to the ceiling tiles were constructed to provide at least a class A fire resistance rating. This had to potential to affect all persons utilizing these areas of the facility. The census was 202 patients at the time of the survey.

Findings included:

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.

This finding was verified by all staff members present during tour.

Based on observation during facility tour and staff verification, this facility failed to ensure that the interior finish for rooms in regards to the ceiling tiles were constructed to provide at least a class A fire resistance rating. This had to potential to affect all persons utilizing these areas of the facility. The census was 202 patients at the time of the survey.

Findings included:

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.

This finding was verified by all staff members present during tour.

Based on facility tour and staff verification it was 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. This had the potential to affect all occupants utilizing this area of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

This finding was verified by all staff present during tour and re-verified by staff I upon review of the emergency department floor plans in the afternoon of 05/08/13.

Based on observation during facility tour and staff verification, this facility failed to ensure that smoke/fire barriers were constructed to provide at least a half hour fire resistance rating. This had to potential to affect all persons utilizing the facility. The census was 202 patients at the time of the survey.

Findings included:

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.

These findings were verified by staff F during tour.

Based on facility tour, specifically in the hazardous areas, it was determined this facility failed to ensure all doors were equipped with self closing devices. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 202.

Findings include:

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.

These findings were verified by all staff members present during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition in regards to storage located within 18 inches from the sprinkler head. This had the potential to affect all occupants located within this area of the facility. The patient census at the beginning of the survey was 202.

Findings include:

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.

This finding was verified by staff A and the items were then removed.

Based on facility tour, fire extinguisher documentation review and staff verification it was determined this facility failed to ensure all portable fire extinguishers were inspected monthly and failed to ensure all portable fire extinguishers were accessible at all times according to the National Fire Protection Association (NFPA) 10. This had the potential to affect all those who were utilizing these areas of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

These findings were verified by all staff present during the documentation review and facility tour.

Based on medical gas inspection reports and staff verification it was determined this facility failed to ensure all medical gas outlets were inspected annually according to the National Fire Protection Association (NFPA) 99 Chapter 4. This had the potential to affect all those utilizing this area of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

Based on facility tour and staff verification it was determined this facility failed to ensure all smoke detectors were placed in areas which would not be affected by air flow devices according to NFPA 72 Chapter 2-3.5.1. This had the potential to affect all those utilizing these areas of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

These findings were verified by all staff members during tour of the facility.

Based on facility tour and staff verification this facility failed to ensure all smoke detectors were placed in areas which would not be affected by air flow devices according to NFPA 72 Chapter 2-3.5.1. This had the potential to affect all those utilizing these areas of the facility. The patient census was 202 at the beginning of the survey.

Findings include:

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.

These findings were verified by all staff members during tour of the facility.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were accessible at all times according to the National Fire Protection Association (NFPA) 10. Additionally, this facility failed to ensure all smoke detectors were not placed near any air flow device according to NFPA 72. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 31.

Findings include:

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.

These findings were verified by all staff members present during facility tour on 05/08/13.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were inspected annually according to the National Fire Protection Association (NFPA) 10. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 17.

Findings include:

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.