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Based on tests to doors and observations made during the survey for life safety from fire with the facility's Safety Officer (employee #4), it was determined that patient's doors protecting corridors at the upper ward, patient's rooms #2-02, #2-08 and #2-09 on the second floor did not close completely (did not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested on 8/16/11 from 1:00 pm till 3:00 pm with the facility's Safety Officer (employee #4), it was found that the following patient's rooms do not have the capability of latching when the doors are in the closed position, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire:
a. Patient's rooms of the upper ward on the second floor #2-02, #2-08 and #2-09 (all room doors shall be verified for compliance).

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Safety Officer (employee #4), it was determined that the smoke barrier doors on the first floor had a gap between the door leafs greater than 1/8 of an inch when released from their hold open devices which is not in accordance with the requirements of the 2000 edition of the Life Safety Code of the NFPA Sections 19.3.7.3 and 19.3.7.5.

Findings include:

The smoke barrier doors located near the lower ward did not close flush to within 1/8 of an inch to its frame when released from its hold open devices with the facility's Safety Officer (employee #4) on 8/15/11 at 2:45 pm, this can permit smoke, fire and noxious gases to enter the smoke barrier in the event of a fire.

Based on tests to doors, observations made during the survey for life safety from fire with the facility's Safety Officer (employee #4), it was determined that exit components (stairway doors) do not provide protection against fire or smoke from other parts of the building due to the lack of the doors' ability to close completely at the first and second floor as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.1.1 and 19.3.2.1.

Findings include:

During the tour for life safety from fire, exit components (stair enclosures) were inspected and found that the enclosure (door) on the first and second floors of the internal staircase near the nursery and diet department and the stair door near the administration office did not completely close (lacked positive latching) as observed on 8/16/11 at 9:30 am with the facility's Safety Officer (employee #4). These fire doors can be opened with a minimum force and can permit fire and toxic gases to enter this means of egress and these doors shall be fire rated or solid core.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (employee #4), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided at nine emergency exits as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Safety Officer (employee #4) from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm in the following areas:

a. The facility provides services with three shifts and there are nine direct exits used to lead persons to the outside of the building, but no evidence was found of outside emergency lamps at these emergency exits to illuminate the path of travel if municipal electricity is lost and the generator does not activate. (Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Safety Officer (employee #4), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation and lack of exit fire drills which is not in accordance with the requirements of the LSC 2000 section 19.7.1.2 and section 5.5.

Findings include:

1. Written documents about conducted fire drills for the facility were reviewed with the facility's Safety Officer (employee #4) on 8/17/11 at 9:40 am and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

2. Written evidence reviewed of fire drills on 8/17/11 at 10:00 am with the facility's Safety Officer (employee #4) failed to provide evidence that the facility is performing fire exit drills for the proper protection of patients; drills for the purpose of relocating patients to an area of safety.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (employee #4), it was determined that the facility failed to ensure that smoke detectors are available at all required areas, strobe lights are needed in public bathrooms and the fire alarm system lacks annunciation to an approved central station as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Safety Officer (employee #4) from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm:
a. In the dry food storage area of the kitchen (boxes were stacked up to the ceiling on some shelves).
b. In the kitchen storage room located under the stair.
c. In the laboratory's storage room and bacteriological room.
d. In the pantry near the Intensive Care Unit.
e. In the computer room.
f. In the room used to access the roof (this room was found with approximately 100 boxes filled with papers-combustible material in this room shall be removed because it is in the staircase).
g. In the housekeeping closet near the recovery room of the operating department.
h. In the elevator's machine room.

2. Three patient's and visitor's public bathrooms (at the emergency room and out patient waiting room) were visited from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm with the facility's Safety Officer (employee #4) and provided evidence that they do not have strobe lights to alert deaf persons using these bathrooms in the event that the fire alarm is activated.

3. The fire alarm system lacks annunciation to an approved central station as reviewed on 8/17/11 at 9:00 am with the facility's Safety Officer (employee #4). The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Safety Officer (employee #4), it was determined that the facility is not performing visual inspections, sensing chamber tests or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 8/17/11 at 9:35 am with the facility's Safety Officer (employee #4) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response (twice a year).

c. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

d. Location of pull-down stations and tests (monthly).

e. Visible (strobe lights) and audible signal tests (monthly).

Based on observations made for life safety from fire with the facility's Safety Officer (employee #4), it was determined that the facility has central air conditioner units with air handling systems in the corridor that uses return air to cool the facility and the system does not have dampers or smoke detectors to prevent the re-circulation of smoke into the corridor in the event of a fire and is not in compliance with the Code requirements of NFPA-90-A and the 2000 edition of the Life Safety Code of the NFPA Section 9.2.

Findings include:

During the observational tour throughout the facility from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm with the facility's Safety Officer (employee #4), it was found that the main corridors where patients receive treatment and services are used as a plenum. Air is blown into the corridor and returned into these air conditioner machine rooms to re-circulate the cool air into the corridors. These air conditioner machine rooms were not found with smoke detectors to automatically shut down the fan and no evidence was provided that the facility has smoke dampers in their air conditioner vent system to ensure that when smoke is detected by the smoke detectors and it turns off the air conditioner, smoke does not continue to travel through the vent system. The smoke dampers will ensure that smoke and toxic gases do not spread via the air conditioner ventilation system.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (employee #4), it was determined that the facility failed to ensure that the automatic fire suppression system above the stoves are appropriately designed and maintained as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.2.3, 19.3.2.6 and NFPA 96.

Findings include:

1. The automatic fire suppression system above the stoves was observed on 8/15/11 at 10:40 am with the facility's Safety Officer (employee #4) and failed to provide evidence of the following:
a. Fuel source is automatically disconnected when the fire suppression system is activated.
b. Verification that activation of the fire suppression system activates the facility's fire alarm.
c. The kitchen's hood exhaust system six month maintenance was requested, however no evidence was found of the updated required hood/duct exhaust fan inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule. This certification should be posted on the side of the hood system visible for inspection.

Based on observations during the survey for Life safety from fire with the facility's Safety Officer (employee #4), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to oxygen cylinder placement, standpipe maintenance, facility is using mult-outlet adapter, the facility is not using fire rated garbage containers, Ground Fault Interrupter (GFI) receptacles are needed near water sources, no evidence was found of Siamese fire department connection documentation and no evidence was found of the annual carbon dioxide fire extinguisher conductivity inspections (of its hose system).

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm with the facility's Safety Officer (employee #4) type E oxygen tanks were found in areas that do not meet these minimum requirements:
a. In the treatment room of the emergency room (three type E oxygen cylinders).
b. A type E oxygen cylinder was found at the surgery department.
(all cylinders were removed and placed in an appropriate area outside of the facility).

2. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Safety Officer (employee #4) on 8/15/11 from 8:00 am till 3:00 pm and the following was determined:
a. No evidence was found of standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

3. During the observational tour of the entire hospital from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm and it was found that regular electrical receptacles located throughout the hospital have adapters which convert two outlets into six. The six outlets are used to plug in various electrical machines. Multi-outlet adapters are not recommended due to the potential for them to over heat.

4. Regular garbage containers located at offices and work areas were verified from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm and provided evidence that they are not made of fire rated material and tested as such. Rubber or plastic garbage containers that are not made of fire rated material can emit toxic fumes if they catch on fire.

5. Two regular electrical receptacles located within three feet from a water source were observed at the ante-room of the isolation room of the emergency room on 8/15/11 at 9:50 am with the facility's Safety Officer (employee #4) (Ground Fault Interrupter (GFI) receptacles are required near water sources). Also, a GFI is needed near the small steam tray in the kitchen as observed on 8/15/11 at 9:55 am.

6. The Siamese connection to be used by the fire department was verified on 8/16/11 at 10:00 am with the facility's Safety Officer (employee #4) and provided evidence that the coupling treads are worn down. No evidence was found of the fire department connection inspection on a quarterly bases to verify visibility and accessibility and to ensure that coupling and swivels are not damaged and they rotate smoothly.

7. Written evidence about the required annual carbon dioxide fire extinguisher conductivity inspections of the extinguisher's hose system was not provided by the facility on 8/17/11 at 11:30 am when requested of the facility's Safety Officer (employee #4).

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Safety Officer (employee #4), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 8/17/11 at 11:00 am with the facility's Safety Officer (employee #4) about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.