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Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating .

Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/30/2011 the surveyor noted penetrations in the walls or ceilings of the following locations:
a) Old mechanical room 1 (vents and conduit);
b) Mower room;
c) Basement IT room (cabels);
d) Human Resources;
e) Storage room 34 (conduit) inner and outer walls; and
f) Electrical room near generator room (at base coving).

Based on observation the facility failed to provide doors that would resist the passage of smoke.

Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 8/30/2011 the surveyor noted the following violations related to doors that would not resist the passage of smoke:
a) The corridor door into the the staff lounge (cafeteria) would not close and latch;
b) The corridor door to the scullery would not close and latch;
c) The double doors located near the recycle bins in basement would not close and latch due to a faulty coordinator and one of the doors was held open with a wedge because an electro-magnet door hold was malfunctioning;
d) The clinic stairwell doors had a gap greater than 1/4 inch in width;
e) The double smoke doors by the scope processing room had a gap greater than 1/4 inch in width; and
f) The double smoke doors by Mammography had a gap greater than 1/4 inch in width and failed to completely close when released.

Based on observation the facility failed to maintain exit access in such a manner as to prevent an impediment in the way of travel to exit.

Failure on the part of the facility to maintain an exit access free of impediments puts patients, staff and visitors of the facility at risk from the effects of smoke, fire and other situations requiring emergency exiting.

Reference: NFPA 101, 2000 edition, Chapter 4.5.3.2 states: Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.

Findings include:

1. On 8/30/2011 the surveyor noted that the following kitchen doors were fitted with thumb turn locking mechanisms:
a) Main kitchen door; and
b) Kitchen scullery door.

Based on document review the hospital failed to perform fire drills at the required frequency.

Failure to conduct quarterly fire drills as required puts patients, staff and visitors of the facility at risk of injury and death from fire, and prevents an accurate assessment of the staff's preparedness to manage a fire emergency.

Findings include:

1. On 8/30/2011 the surveyor reviewed available documentation for fire drills held during the period between 2010 and 2011. Documentation was not available indicating that fire drills had been performed during the last quarter of 2010.

A. Based on document review the facility failed to show that the fire alarm system had been installed and tested as required.

Failure on the part of the facility to document the installation and testing of the fire alarm system puts patients, staff and visitors of the facility at risk from the effects of smoke and/or fire.

Findings include:

1. On 8/30/2011 the facility was unable to provide the surveyor with documentation to show that newly installed components of the fire alarm system (related to new construction) had been properly installed and validated by required system testing.



B. Based on observation and interview the facility failed to ensure smoke detectors were installed in staff sleeping rooms.

Failure to install smoke detectors in staff sleeping rooms risks the ability of occupants to safely evacuated in the event of a smoldering fire.

National Fire Protection Association (NFPA) 101, 6.1.14.2 Life Safety Code 2000 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. NFPA 101, 26.3.3.5 requires smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings include:

1. On 8/30/2011 the surveyor noted that the physician sleeping room located in the physician's lounge (main floor old building) lacked smoke detection and a notification appliance.

A. Based on document review the facility failed to show that the automatic sprinkler system had been installed and tested as required.

Failure on the part of the facility to document the installation and testing of the automatic sprinkler system puts patients, staff and visitors of the facility at risk from the effects of smoke and/or fire.

Findings include:

1. On 8/30/2011 the facility was unable to provide the surveyor with documentation to show that newly installed components of the automatic sprinkler system (related to new construction) had been properly installed and validated by required system testing.



B. Based on observation the facility failed to maintain its automatic sprinkler system as required.

Failure on the part of the facility to maintain automatic sprinkler systems puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

1. On 8/30/2011 the survey noted the following deficiencies related to the automatic sprinkler system:
a) Main lobby (new) restrooms lacked sprinkler coverage.
b) Main lobby vestibule lacked sprinkler coverage.

Based on observation and document review the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers that were being inspected as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/302011 the surveyor noted that portable fire extinguishers in the following locations had not been inspected monthly as required:
a) Basement IT room; and
b) Acute care electrical room.

2. On 8/30/2011 the surveyor noted during a review of available fire life safety documentation that the facility failed to have available documentation regarding the servicing of the portable fire extinguishers. Lacking this documentation the facility was not in a position to determine if and when hydrostatic testing of the devices was or will be required.

Based on document review the facility failed to assure the protection of its cooking facility by maintaining the kitchen suppression system as required.

Failure on the part of the facility to maintain the kitchen suppression system as required puts patients, staff and visitors of the facility at risk from the effects of grease accelerated fire.

Finding include:

1. On 8/30/2011 the facility was unable to provide the surveyor with documentation to show that kitchen suppression system had been properly installed and validated by required system testing.

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/30/2011 the surveyor noted a portable space heating device in the Infection Control office.

Based on observation the facility failed to maintain designated means of egress free of impediments to full instant use in the case of fire or other emergency.

Failure on the part of the facility to keep the means of egress free of impediments puts patients, staff and visitors of the facility at risk in the event of fire or other emergency.

Findings include:

1. On 8/30/2011 the surveyor noted that the hallway near the main nurse's station was partially blocked by a fan, patient monitor and a hat rack.

2. On 8/30/2011 the surveyor noted that the door to the electrical room near the physicians lounge has an outward swing that extends across more than 50 percent of the hallway.

Based on observation the facility failed to prohibit the placement of trash collection receptacles of greater than 32 gallons in the facility.

Failure on the part of the facility to prohibit receptacles of greater than 32 gallons puts patients, staff and visitors of the facility at risk from the effects of fire

Findings include:

1. On 8/30/2011 the surveyor noted two trash containers (shredded paper and recycling) with a combined capacity of greater than 32 gallons in the corridor near the kitchen.

Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99.

Failure on the part of the facility to properly secure oxygen cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death.

Findings include:

1. On 8/30/2011 the surveyor noted that a medical air compressed gas cylinder and a helium compressed gas cylinder in the Oxygen gas storage room were not secured in racks to prevent their toppling over.

Based on observation the facility failed to maintain its emergency electrical system in accordance with NFPA 99 Standard for Health Care Facilities 1999 edition and NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition. More specifically, the facility failed to provide emergency lighting in the space containing the emergency generator.

Failure on the part of the facility to maintain its emergency power system as is required puts patients, staff and visitors of the facility at risk should the emergency power system fail and repairs are required.


References: NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, Chapter 5-3.1 states: "The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch."


Findings include:

1. On 8/30 /2011 the surveyor noted that the compartment containing the emergency generator was not provided with a battery-powered emergency lighting system as is required.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 8/30/2011 the surveyor noted the following violations:
a) An open J-box in mechanical room #1;
b) An extension cord in the basement IT room being used as a permanent source of power for computer servers;
c) An power receptacle in the basement IT room hanging from an open J-box;
d) A multi-plug power strip (daisy chained) in the basement IT room connected to computer equipment;
e) A receptacle box in the kitchen which was connect via an extension cord to a second receptacle box;
f) An open J-box in the old fire riser room (current housekeeping room); and
g) An open J-box in the old elevator mechanical room.

Based on interview and document review the facility failed to set its fire watch in the manner prescribed when the sprinkler system is out of service for periods of more the 4 hours in a 24 hour period.

Failure on the part of the facility to set its fire watch in the manner prescribed puts patients, staff and visitors of the facility at risk from the effects of fire.

Findings include:

1. On 8/30/2011 the surveyor was advised by staff member #1 that those persons serving as the fire watch were not exclusively assigned to fire watch duties and were not specially trained to assume them. The facility's policy regarding individuals to be assigned fire watch duties reflects the requirements of he code regarding exclusivity of duties and training.

Based on observation the facility failed to install an alcohol based hand rub (ABHR) dispenser in an appropriate manner.

Failure to install ABHR dispensers appropriately puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

1. On 8/30/2011 the surveyor noted Alcohol Based Hand Rub (ABHR) dispenser mounted directly above a light switch in the basement conference room.

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating .

Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/30/2011 the surveyor noted penetrations in the walls or ceilings of the following locations:
a) Old mechanical room 1 (vents and conduit);
b) Mower room;
c) Basement IT room (cabels);
d) Human Resources;
e) Storage room 34 (conduit) inner and outer walls; and
f) Electrical room near generator room (at base coving).

Based on observation the facility failed to provide doors that would resist the passage of smoke.

Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 8/30/2011 the surveyor noted the following violations related to doors that would not resist the passage of smoke:
a) The corridor door into the the staff lounge (cafeteria) would not close and latch;
b) The corridor door to the scullery would not close and latch;
c) The double doors located near the recycle bins in basement would not close and latch due to a faulty coordinator and one of the doors was held open with a wedge because an electro-magnet door hold was malfunctioning;
d) The clinic stairwell doors had a gap greater than 1/4 inch in width;
e) The double smoke doors by the scope processing room had a gap greater than 1/4 inch in width; and
f) The double smoke doors by Mammography had a gap greater than 1/4 inch in width and failed to completely close when released.

Based on observation the facility failed to maintain exit access in such a manner as to prevent an impediment in the way of travel to exit.

Failure on the part of the facility to maintain an exit access free of impediments puts patients, staff and visitors of the facility at risk from the effects of smoke, fire and other situations requiring emergency exiting.

Reference: NFPA 101, 2000 edition, Chapter 4.5.3.2 states: Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.

Findings include:

1. On 8/30/2011 the surveyor noted that the following kitchen doors were fitted with thumb turn locking mechanisms:
a) Main kitchen door; and
b) Kitchen scullery door.

Based on document review the hospital failed to perform fire drills at the required frequency.

Failure to conduct quarterly fire drills as required puts patients, staff and visitors of the facility at risk of injury and death from fire, and prevents an accurate assessment of the staff's preparedness to manage a fire emergency.

Findings include:

1. On 8/30/2011 the surveyor reviewed available documentation for fire drills held during the period between 2010 and 2011. Documentation was not available indicating that fire drills had been performed during the last quarter of 2010.

A. Based on document review the facility failed to show that the fire alarm system had been installed and tested as required.

Failure on the part of the facility to document the installation and testing of the fire alarm system puts patients, staff and visitors of the facility at risk from the effects of smoke and/or fire.

Findings include:

1. On 8/30/2011 the facility was unable to provide the surveyor with documentation to show that newly installed components of the fire alarm system (related to new construction) had been properly installed and validated by required system testing.



B. Based on observation and interview the facility failed to ensure smoke detectors were installed in staff sleeping rooms.

Failure to install smoke detectors in staff sleeping rooms risks the ability of occupants to safely evacuated in the event of a smoldering fire.

National Fire Protection Association (NFPA) 101, 6.1.14.2 Life Safety Code 2000 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. NFPA 101, 26.3.3.5 requires smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings include:

1. On 8/30/2011 the surveyor noted that the physician sleeping room located in the physician's lounge (main floor old building) lacked smoke detection and a notification appliance.

A. Based on document review the facility failed to show that the automatic sprinkler system had been installed and tested as required.

Failure on the part of the facility to document the installation and testing of the automatic sprinkler system puts patients, staff and visitors of the facility at risk from the effects of smoke and/or fire.

Findings include:

1. On 8/30/2011 the facility was unable to provide the surveyor with documentation to show that newly installed components of the automatic sprinkler system (related to new construction) had been properly installed and validated by required system testing.



B. Based on observation the facility failed to maintain its automatic sprinkler system as required.

Failure on the part of the facility to maintain automatic sprinkler systems puts patients, staff and visitors of the facility at risk from the effects of fire and smoke.

Findings include:

1. On 8/30/2011 the survey noted the following deficiencies related to the automatic sprinkler system:
a) Main lobby (new) restrooms lacked sprinkler coverage.
b) Main lobby vestibule lacked sprinkler coverage.

Based on observation and document review the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers that were being inspected as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/302011 the surveyor noted that portable fire extinguishers in the following locations had not been inspected monthly as required:
a) Basement IT room; and
b) Acute care electrical room.

2. On 8/30/2011 the surveyor noted during a review of available fire life safety documentation that the facility failed to have available documentation regarding the servicing of the portable fire extinguishers. Lacking this documentation the facility was not in a position to determine if and when hydrostatic testing of the devices was or will be required.

Based on document review the facility failed to assure the protection of its cooking facility by maintaining the kitchen suppression system as required.

Failure on the part of the facility to maintain the kitchen suppression system as required puts patients, staff and visitors of the facility at risk from the effects of grease accelerated fire.

Finding include:

1. On 8/30/2011 the facility was unable to provide the surveyor with documentation to show that kitchen suppression system had been properly installed and validated by required system testing.

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/30/2011 the surveyor noted a portable space heating device in the Infection Control office.

Based on observation the facility failed to maintain designated means of egress free of impediments to full instant use in the case of fire or other emergency.

Failure on the part of the facility to keep the means of egress free of impediments puts patients, staff and visitors of the facility at risk in the event of fire or other emergency.

Findings include:

1. On 8/30/2011 the surveyor noted that the hallway near the main nurse's station was partially blocked by a fan, patient monitor and a hat rack.

2. On 8/30/2011 the surveyor noted that the door to the electrical room near the physicians lounge has an outward swing that extends across more than 50 percent of the hallway.

Based on observation the facility failed to prohibit the placement of trash collection receptacles of greater than 32 gallons in the facility.

Failure on the part of the facility to prohibit receptacles of greater than 32 gallons puts patients, staff and visitors of the facility at risk from the effects of fire

Findings include:

1. On 8/30/2011 the surveyor noted two trash containers (shredded paper and recycling) with a combined capacity of greater than 32 gallons in the corridor near the kitchen.

Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99.

Failure on the part of the facility to properly secure oxygen cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death.

Findings include:

1. On 8/30/2011 the surveyor noted that a medical air compressed gas cylinder and a helium compressed gas cylinder in the Oxygen gas storage room were not secured in racks to prevent their toppling over.

Based on observation the facility failed to maintain its emergency electrical system in accordance with NFPA 99 Standard for Health Care Facilities 1999 edition and NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition. More specifically, the facility failed to provide emergency lighting in the space containing the emergency generator.

Failure on the part of the facility to maintain its emergency power system as is required puts patients, staff and visitors of the facility at risk should the emergency power system fail and repairs are required.


References: NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, Chapter 5-3.1 states: "The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch."


Findings include:

1. On 8/30 /2011 the surveyor noted that the compartment containing the emergency generator was not provided with a battery-powered emergency lighting system as is required.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 8/30/2011 the surveyor noted the following violations:
a) An open J-box in mechanical room #1;
b) An extension cord in the basement IT room being used as a permanent source of power for computer servers;
c) An power receptacle in the basement IT room hanging from an open J-box;
d) A multi-plug power strip (daisy chained) in the basement IT room connected to computer equipment;
e) A receptacle box in the kitchen which was connect via an extension cord to a second receptacle box;
f) An open J-box in the old fire riser room (current housekeeping room); and
g) An open J-box in the old elevator mechanical room.

Based on interview and document review the facility failed to set its fire watch in the manner prescribed when the sprinkler system is out of service for periods of more the 4 hours in a 24 hour period.

Failure on the part of the facility to set its fire watch in the manner prescribed puts patients, staff and visitors of the facility at risk from the effects of fire.

Findings include:

1. On 8/30/2011 the surveyor was advised by staff member #1 that those persons serving as the fire watch were not exclusively assigned to fire watch duties and were not specially trained to assume them. The facility's policy regarding individuals to be assigned fire watch duties reflects the requirements of he code regarding exclusivity of duties and training.