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Based on observation and staff interview the facility fails to maintain one of four smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting 3 of 10 smoke zones. This facility has a capacity of 82 and census of 41 at the time of this survey.

Findings Include:

During the survey on 11/14/2011 between 10:00 AM and 4:30 PM the following is observed:

1. There is an unsealed penetration around a communication wire above the smoke barrier doors between the T-2 and the Cath Lab.

2. There is an unsealed penetration around two communication wires above the smoke barrier doors between the ICU and the Operating Room corridor.

3. There are two cables running through a smoke damper above the smoke barrier doors between the ICU and the Operating Room corridor.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects 10 of 10 smoke zones. The facility has a capacity of 82 with a census of 41 at the time of survey.

Findings Include:

During the survey on 11/14/2011 between 10:00 AM and 4:30 PM it is observed that the facility did not conduct a fire drill during the 2nd shift of the 2nd quarter of 2011

Maintenance Staff A and B and Security Staff A were present and acknowledged the finding.

NFPA Standard: 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 to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede all occupants from exiting in the event of a fire or other emergency situation, affecting 3 of 10 smoke zones. This facility has a capacity of 82 and a census of 41 at the time of the survey.

Findings Include:

During the survey on 11/14/2011 between 10:00 AM and 4:30 PM the following is observed:

1. Wheelchairs are blocking the public exit from the Emergency Room.

2. A housekeeping cart and an EKG monitor are stationary in the corridor between T-3 and T-4 for more than 30 minutes.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1.