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Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to patients from smoke, fumes or panic should a fire occur. The facility did not maintain one (1) set of 3 tested cross corridor fire rated doors to prevent impediments to closing them to limit the transfer of smoke / heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings are:

During the general life safety tour of the facility July 8, 2010 with the Chief Executive Officer (CEO) and the Clinical Director, observed that the following doors had an impediment to closing / latching so they would limit the transfer of smoke should a fire occur:

The double automatic closing cross corridor fire doors that separated the north wing from the south wing were tested at 8:40 a.m. They would not close and seal / latch to limit the transfer of smoke / heated gases should a fire occur. These doors did release from the magnetic hold open device; however, the right side door (facing south) would not close and latch. The upper latching mechanism was not working / latching. Interview of the CEO revealed that this item would be repaired.

Interviews of the CEO, the Clinical Director and the Quality Management Director during the closing conference at 11:25 a.m. on July 8, 2010, re-confirmed these findings.

NFPA 101-2000, 19.2.2.2.6, 19.3.6.3, 4.6.12.1; NFPA 90A & NFPA 80
Correction Date: 08/08/2010

Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to patients from smoke, fumes or panic should a fire occur. The facility did not maintain two (2) of 20 plus sampled corridor doors to prevent impediments to closing them to limit the transfer of smoke / heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings are:

During the general life safety tour of the facility on July 8, 2010 with the Chief Executive Officer (CEO) and the Clinical Director, observed that the following doors had impediments to self closing and/or latching:

1. At 8:37 a.m., the self closing corridor door to the clean supply room (1066) was observed to have two 1/2 inch diameter holes running through this door. This condition could affect the classification of this door and could allow smoke and fire gases to quickly spread, in the event of a fire. Interview of the clinical director revealed that these holes were a result of replacing the handle / hardware with smaller ones, thus leaving these holes. "It will be repaired."

2. Direct observation / testing of the self closing corridor door to the equipment storage room (1040) at 8:50 a.m., revealed that it would not self close and latch per requirements. It was equipped with a self closing mechanism as required. Testing revealed that this door's latching / closing mechanism was in need of an adjustment. Thus, it would not allow this door to close and latch. This condition creates an impediment to closing / latching these doors so it works as intended / required (maintains positive latching). Interview of maintenance manager revealed that this condition would be corrected.

Interviews of the CEO, the Clinical Director and the Quality Management Director during the closing conference at 11:25 a.m. on July 8, 2010, re-confirmed these findings.

NFPA 101-2000, 19.2.2.2.6, 19.3.6.3, 7.2.1.8 & 4.6.12.1; NFPA 72; NFPA 90A; NFPA 1, 12.7.5 & NFPA 80
Correction Date: 08/08/2010

Based on record review and interviews, the facility did not evidence that an external and internal disaster drills were performed during the past year pursuant to 400.967 (2) (g), Florida Statutes (A). This annual requirement is necessary so that the county can ensure that the facility's plan is put into practice. This could possibly result in the staff being unprepared to execute their duties during an emergency, endangering the building occupants.

Findings are:

During a review of life safety documentation on July 8, 2010 at 10:40 a.m., the facility did not provide evidence that the disaster drills (internal & external) had been accomplished during the past 15 months. The last documented disaster drill was dated March of 2009.

Upon interview of the clinical director at 10:50 a.m., no current drills could be evidenced / produced. Further interviews with administrative staff (Chief Executive Office and the Quality Director) did not evidence that any emergency drills / training had been conducted since March of 2009.

Interviews of the CEO, the Clinical Director and the Quality Management Director during the closing conference at 11:25 a.m. on July 8, 2010, re-confirmed these findings.

NFPA 101-2000, 18.7.2.1-.3; NFPA 1, 12-2, 20.4; & NFPA 99, 12-3.11, 11-5.3.5
Correction Date: 08/08/2008

Based on observations and interviews while touring the facility, it was determined that not all uses and storage of oxygen / medical air were in accordance with NFPA 99, 8-3.1.11 and 8-2.1.2.4. Per 8-2.1.2.4, ". . . electrical equipment . . . / other equipment . . . can create a source of ignition in oxygen enriched atmospheres. Per 4-3.1.1.2(b) 4.....'for areas of oxygen administration....a source of ignition includes, outlets, smoking material....lighters, etc. ' One (1) of 20 plus observed rooms with fixed oxygen systems was not in compliance. Also, per 12-2.5 ... ... ' The hospital shall establish policies and procedures related to safe use of electrical applications ...in patient care areas. ' This condition could affect the safety of patients within the smoke compartment (safety zone).

Findings include:

While touring the hospital on July 8, 2010 with the Chief Executive Officer (CEO) and the Clinical Director, observed the following:

1. At 8:25 a.m., upon touring the north wing, observed that the fixed oxygen system was turned on (running) inside of patient care room 133. No one was present inside this room at this time. Due to posted precautions, the clinical director had to gown up so closer observations could be made. Upon exiting, the clinical director revealed that the oxygen mask (point of expulsion) was hanging down from the panel and was positioned close to an electrical outlet. This panel contained the oxygen shutoff terminal, the suctioning terminal and electrical outlets. It was placed in a vertical position beside the bed. Due to the positioning of the panel, hanging an oxygen mask on or near this panel would allow it to be located / positioned near electrical outlets. Further checking revealed that the patient had left the building at 8:05 a.m.. Note: Neither combustible items nor appliances that were not rated for oxygen enriched environments were observed near this mask.

Interview of the clinical director revealed that the standard of practice is to turn off the oxygen when not in use. Upon reviewing policies and procedures (P&Ps) at 10:35 a.m., did not find any that related to safe usage of medical gas by nursing staff. A final interview with the clinical director revealed that they would adopt relevant P & Ps and train nursing staff on implementing them.

2. At 8:52 a.m., upon entering the equipment storage room 1077, observed that twelve (12) small oxygen cylinders (E-tanks) were stored inside. They were positioned within 12 inches of a bank of electrical outlets. These outlets were positioned on the wall approximately 12 inches from the floor. There was sign identifying that these 12 tanks were full. In addition, inside this storage room were numerous stored items. Per NFPA 99, 4-3.1.1.2 (a) 7 .....storage requirements.....combustible materials shall not be stored or kept near (5 feet away) such cylinders. Interview of the CEO revealed that the electrical outlets nearest this bank of Oxygen tanks will be either removed or repositioned.

Interviews of the CEO, the Clinical Director and the Quality Management Director during the closing conference at 11:25 a.m. on July 8, 2010, re-confirmed these findings.

NFPA 99 (99), 12-2.5, 7-6.2.4.1, 8-2.1.2.4(d), 8-3.1.11, 4-3; NFPA 101-2000, 19.7.4
Correction Date: 08/08/2010