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Based upon an Emergency Preparedness Program (EPP) survey performed on 08/08/2024 from 1:30 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to track the location of on-duty staff and sheltered patients in the hospitals facility's care during an emergency.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #) on 08/08/2024 at 1:30 PM it was noted that the EP failed to have written procedures to document the specific name and location of the receiving facility or other location.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/08/2024 from 1:30 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #) on 08/08/2024 from 1:30 PM through 3:30 PM it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the Hospital during and after an emergency.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/08/2024 at 1:30 PM to 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #) on 08/08/2024 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §482.15(b)(6).

Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility's Safety Officer (Employee #22) and Engineering Sub-director from 9:00 AM to 4:00 PM, it was determined that the smoke barrier doors on the fourth and fifth floor failed to close flush when released as required by the 2012 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2.

Findings include:

1. The smoke barrier doors on the fourth and fifth floor were observed on 08/22/2024 approximately al 10:30 AM
did not close flush to its frame, this can permit smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility's Safety Officer (Employee #22) and Engineering Sub-director( employee #23) and Engineering Director (employee #24) from 9:00 AM to 4:00 PM, it was determined that the facility failed to have emergency lighting in accordance with 7.9.

Findings include:

1. Emergency light on Operation Room #3 was found inoperable.

2. No emergency light to iluminate the exit pathway on the outside of ambulance entrance on first floor.

Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility's Safety Officer (Employee #22) and Engineering Sub-director( employee #23) and Engineering Director (employee #24) from 9:00 AM to 4:00 PM, it was determined that the facility failed to provide exit and directional signs displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1

Findings include:

1. On the Pharmacy Department it was noted that no exit sign directed from entry through the hospital to working area and exteirior of the buiilding.

2. On some floors it was noticed that exit signs were missing directing to all available exits on the floor

Based on a recertification survey, observations made during the life safety from fire, it was determined that the facility failed to ensure that cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

Findings include:

During observational tour for Life Safety from Fire on 08/20/2024 at approximately 9:05 AM with the facilty's Engineering Director (employee #24) and the Safety Officer (employee #22) the following was noticed in the Diet Department.

1. Grease Baffles not properly installed leaving approximately 2" gap into the exhaust hood system.

2. Rubber Blow Off Caps Fire Suppression Nozzles were missing on 8 of the ANSUL nozzles of the system.

Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility's Safety Officer (Employee #22) and Engineering Sub-director (employee #23) and Engineering Director from 9:00 AM to 4:00 PM, it was determined that the facility failed to efectively maintain initiation of the fire alarm system by manual means and by detection device, or detection system as required in (NFPA101) 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5. This deficiency could affect 71 patients out of 154 patient census.

Findings include:

At approximately 11:45 AM on 08/22/2024, the activation of the manual activation device (pull station) located at the emergency exit was requested. The Safety Officer proceeded to activate the device and it did not turn on the emergency alarm. We then proceeded to the second device available on the floor located in the second emergency exit and proceeded to activate it and the emergency alarm did not activate either. Upon further investigation it was indicated that the deficiency in the manual alarm ignition system replicated on the fifth, fourth, third, second, first and ground floors. In addition, it was reported that the deficiency in the system also affected the operation of the smoke detectors in the same areas.

Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility's Safety Officer (Employee #22) and Engineering Sub-director from 9:00 AM to 4:00 PM, it was determined that the facility failed to have a fire alarm system that is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code.

Findings include:

1) Fire alarm annunciator reported 223 trouble signals that were not restored to normal within 200 seconds.
Trouble detected on screen: NO ANSWER BMC 3RD FLR FARMACIA COUNTER

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #22) and Engineering sub-director (employee #23), it was determined that the facility failed to protect corridors at clinical floors ( doors do not latch) as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

During the tour for life safety from fire on 08/21/2024 through 08/22/2024 from 8:30 AM through 4:00 PM, patient's sleeping room doors were tested it was found that patient's sleeping rooms #503, #505, #516, #518 do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #22) and Engineering sub-director (employee #23), it was determined that the facility failed to certify that window curtains and room dividing curtains are up to standard with NFPA 701 in accordance with 10.3.1.

Findings include:

During observational tour on faclity's eighth, seventh, fifth and fourth floors were verified, as well as the emergency room area. No tag with flame retardant or fire resistant in accordance with an equivalent standard to NFPA 701 was observed on curtains.

Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility's Safety Officer (Employee #22) and Engineering Sub-director( employee #23) and Engineering Director (employee #24) from 9:00 AM to 4:00 PM, it was determined that the facility failed inspect daily to ensure its ability to be used instantly in case of emergency and compliance with NFPA 241. 8.7.9, 19.7.9, 4.6.10, 7.1.10.1

Findings include:

During observational tour on faclity's third floor construction site it was noticed that:

1. One (1) out of three (3) fire extinguisher was with expired inspection
2. One (1) out of three (3) fire extinguisher did not have monthly inspection since April 2024

Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility's Safety Officer (Employee #22) and Engineering Sub-director from 9:00 AM to 4:00 PM, it was determined that the facility failed to observe that electrical system complies with NFPA 99 Chapter 6.

Findings include:

1. On 08/20/2024 approximately at 9:00 AM the Electrical Panel SF-B01 located in the Diet Department area was observed unlocked not guarding of electrical live parts.

2. On 08/20/2024 approximately at 9:00 AM the Electrical Panel KP-2 and KP located in the Diet Department was observed unlocked not guarding of electrical live parts.

3.On 08/21/2024 approximately at 11:00 AM the Electrical Electrical Panel located in the patient care area was observed unlocked not guarding of electrical live parts in the Imaging area.

4. On 08/20/2024 approximately at 11:30 AM the Electrical Electrical Room was found unlocked on the fifth floor

Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility's Safety Officer (Employee #22) and Engineering Sub-director from 9:00 AM to 4:00 PM, it was determined that the facility failed to handle cylinders with precautions as specified in (NFPA 99) 11.7.3.

Findings include:


1. On 08/20/2024 approximately at 9:45 AM a type H oxygen tank was observed on LDR 1 room.

2. On 08/21/2024 approximately at 8:35 AM a type CL helium tank was observed on top of a equipment cart not secured.

3. On 08/21/2024 approximately at 8:35 AM three type H oxygen tanks were observed without protection cap on tank bank cage.

4. On 08/22/2024 approximately at 2:00 PM a type H oxygen tank was observed on the in-patient waiting area of the Imaging Center.

5. On 08/22/2024 approximately at 2:15 PM a type E oxygen tank was observed un secured on the machine room of the MRI area.