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Based on observations, the facility failed to assure that smoke detectors for door release are installed in accordance with NFPA #72. Where the depth of the wall section above the door is less than 24 inches Section 2.10.6.2.5.1.1 and Figure 2.10.6.2.5.1.1 require one smoke detector to be placed within 5 feet of the door and not less than 12 inches from the door.

THE FINDINGS INCLUDE:

- During the morning hours of December 2, 2010, in the Bailey Building first floor level Radiology Department, the Stairwell "E" door is held open with a magnetic holder that is connected to the fire alarm system that disconnects upon the activation of the fire alarm, however there is no dedicated door release smoke detector within five feet of the door.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on observations, the facility failed to ensure that doors in the means of egress are in accordance with Section 7.2.1. Section 7.2.1.5.1 requires doors to be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. Section 7.2.1.5.4 requires a latch or other fastening device on a door to be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. Doors shall be operable with not more than one releasing operation.

THE FINDINGS INCLUDE:

- While touring the South Building on the morning of December 1, 2010, the two (2) sets of sliding doors at the main entrance to the Emergency Dept. were found equipped with cylinder type locking devices. The doors are equipped with signs stating "In Emergency Push to Open", however when the doors are locked they cannot be opened in an emergency as stated on the signs.

This was confirmed by the the facility's Director of Facilities and Engineering and maintenance staff.

Based on observations and confirmed by staff, the facility failed to assure that all exit egress routes are properly maintained. Section 7.1.10.1 states 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.

THE FINDINGS INCLUDE:

- During the morning hours of December 2, 2010, it was observed that Stair #5 (from East Bldg): The stairwell egress at Stair #5 (from East Bldg) discharges to an uneven surface which has been dug up to place a drain. There is an uneven edge where the asphalt was chopped off and removed and filled with crushed stone in lieu of a hard surface. The broken edge is approximately 4" in height and poses a trip hazard, the edge is jaggered and not finished like a normal step would be.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on record review and staff interview, the facility failed to assure compliance with chapter 19. Section 19.7.1.1 states the administration of every health care occupancy shall have in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

THE FINDINGS INCLUDE:

- During the morning hours of December 2, 2010, while touring the second floor level of the East Building, four (4) facility nursing staff interviewed were unsure about the location of the medical gas shut off valves. Four of four staff members interviewed did not know the location and the proper procedures to shut off the medical gas. One staff member indicated that facility staff wait for the local fire department to instruct them to shut off medical gas.
According to the hospital's policy and procedures, it states the charge clinician, should have a list of medical gas shut off valve locations, and "the decision to shut off the oxygen valve can only be made by the change clinician or respiratory."

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on record review and confirmed by staff interview, the facility failed to assure that the fire alarm system is maintained and tested as required. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA #72, Section 7.1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.
Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to replace the batteries every four years.

THE FINDING INCLUDE:

- During the afternoon hours of December 1, 2010, it was observed that the Bailey basement FACP batteries are all over four years old, dated March 11, 2004, to the following areas:
- Bailey Building Basement Computer Room,
- LinACC, and
- Cogen and Electric Rooms.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings, Hospital staff indicated that the batteries noted were replaced on December 2, 2010.

Based on record review the facility failed to ensure that the automatic sprinkler system is tested as required by NFPA #25. NFPA #25, Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results and the date. Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.

THE FINDINGS INCLUDE:

- Record review of the quarterly automatic sprinkler system records available on December 3, 2010 revealed that the water flow alarms are tested semi-annually by opening the inspectors test valve. Facility records show that test of the water flow alarms were performed on April 1, 2010 and September 25, 2010.

This was confirmed by the the facility's Director of Facilities and Engineering and maintenance staff.

Based on observations, the facility failed to assure that portable electric heaters are prohibited from the building.

THE FINDINGS INCLUDE:

1. While touring the South Building at 10:30 a.m. on December 1, 2010, a portable electric heater was found in the office of the Clinical Manager - Operating Rooms.

2. While touring the Bailey Building at 2:05 p.m. on December 1, 2010, a portable electric heater was found in the Urgent Care office located next to Emergency Dept. X-Ray room #2.

These were confirmed by the the facility's Director of Facilities and Engineering and maintenance staff.

Based on observations and confirmed by staff, the facility failed to assure that exit corridors are kept free and clear of any obstacles preventing egress.

THE FINDINGS INCLUDE:

1. During the morning hours of December 1, 2010, on the West Building's second floor level corridor a total of five (5) WOW's (workstation on wheels) were observed stored/charging in the corridor.

2. During the afternoon hours of December 1, 2010, on the East Building's third floor level corridor a total of three (3) WOW's (workstation on wheels) were observed stored/charging in the corridor.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on observations and confirmed with staff, the facility failed to assure that mobile trash carts are stored in properly enclosed rated rooms.

THE FINDINGS INCLUDE:

- During the morning hours of December 1, 2010, on the West Building's third floor level nurses' station a 64 gallon paper recycle container is stored and utilized for recycling. Engineering staff removed the receptacle on December 3, 2010.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on observations, the facility failed to to properly store oxygen in accordance with NFPA 99. Sections 16.3.8.1, 8.3.1.11.2(h), and 4.3.5.2.1(b)27 requires freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart.

THE FINDINGS INCLUDE:

- During the afternoon hours of December 1, 2010, on the East Building's third floor level corridor a free standing E-type oxygen cylinder was found in the Clean Utility Room.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on observations, the facility failed to assure that smoke detectors for door release are installed in accordance with NFPA #72. Where the depth of the wall section above the door is less than 24 inches Section 2.10.6.2.5.1.1 and Figure 2.10.6.2.5.1.1 require one smoke detector to be placed within 5 feet of the door and not less than 12 inches from the door.

THE FINDINGS INCLUDE:

- During the morning hours of December 2, 2010, in the Bailey Building first floor level Radiology Department, the Stairwell "E" door is held open with a magnetic holder that is connected to the fire alarm system that disconnects upon the activation of the fire alarm, however there is no dedicated door release smoke detector within five feet of the door.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on observations, the facility failed to ensure that doors in the means of egress are in accordance with Section 7.2.1. Section 7.2.1.5.1 requires doors to be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. Section 7.2.1.5.4 requires a latch or other fastening device on a door to be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. Doors shall be operable with not more than one releasing operation.

THE FINDINGS INCLUDE:

- While touring the South Building on the morning of December 1, 2010, the two (2) sets of sliding doors at the main entrance to the Emergency Dept. were found equipped with cylinder type locking devices. The doors are equipped with signs stating "In Emergency Push to Open", however when the doors are locked they cannot be opened in an emergency as stated on the signs.

This was confirmed by the the facility's Director of Facilities and Engineering and maintenance staff.

Based on observations and confirmed by staff, the facility failed to assure that all exit egress routes are properly maintained. Section 7.1.10.1 states 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.

THE FINDINGS INCLUDE:

- During the morning hours of December 2, 2010, it was observed that Stair #5 (from East Bldg): The stairwell egress at Stair #5 (from East Bldg) discharges to an uneven surface which has been dug up to place a drain. There is an uneven edge where the asphalt was chopped off and removed and filled with crushed stone in lieu of a hard surface. The broken edge is approximately 4" in height and poses a trip hazard, the edge is jaggered and not finished like a normal step would be.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on record review and staff interview, the facility failed to assure compliance with chapter 19. Section 19.7.1.1 states the administration of every health care occupancy shall have in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

THE FINDINGS INCLUDE:

- During the morning hours of December 2, 2010, while touring the second floor level of the East Building, four (4) facility nursing staff interviewed were unsure about the location of the medical gas shut off valves. Four of four staff members interviewed did not know the location and the proper procedures to shut off the medical gas. One staff member indicated that facility staff wait for the local fire department to instruct them to shut off medical gas.
According to the hospital's policy and procedures, it states the charge clinician, should have a list of medical gas shut off valve locations, and "the decision to shut off the oxygen valve can only be made by the change clinician or respiratory."

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on record review and confirmed by staff interview, the facility failed to assure that the fire alarm system is maintained and tested as required. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA #72, Section 7.1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.
Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to replace the batteries every four years.

THE FINDING INCLUDE:

- During the afternoon hours of December 1, 2010, it was observed that the Bailey basement FACP batteries are all over four years old, dated March 11, 2004, to the following areas:
- Bailey Building Basement Computer Room,
- LinACC, and
- Cogen and Electric Rooms.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings, Hospital staff indicated that the batteries noted were replaced on December 2, 2010.

Based on record review the facility failed to ensure that the automatic sprinkler system is tested as required by NFPA #25. NFPA #25, Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results and the date. Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.

THE FINDINGS INCLUDE:

- Record review of the quarterly automatic sprinkler system records available on December 3, 2010 revealed that the water flow alarms are tested semi-annually by opening the inspectors test valve. Facility records show that test of the water flow alarms were performed on April 1, 2010 and September 25, 2010.

This was confirmed by the the facility's Director of Facilities and Engineering and maintenance staff.

Based on observations, the facility failed to assure that portable electric heaters are prohibited from the building.

THE FINDINGS INCLUDE:

1. While touring the South Building at 10:30 a.m. on December 1, 2010, a portable electric heater was found in the office of the Clinical Manager - Operating Rooms.

2. While touring the Bailey Building at 2:05 p.m. on December 1, 2010, a portable electric heater was found in the Urgent Care office located next to Emergency Dept. X-Ray room #2.

These were confirmed by the the facility's Director of Facilities and Engineering and maintenance staff.

Based on observations and confirmed by staff, the facility failed to assure that exit corridors are kept free and clear of any obstacles preventing egress.

THE FINDINGS INCLUDE:

1. During the morning hours of December 1, 2010, on the West Building's second floor level corridor a total of five (5) WOW's (workstation on wheels) were observed stored/charging in the corridor.

2. During the afternoon hours of December 1, 2010, on the East Building's third floor level corridor a total of three (3) WOW's (workstation on wheels) were observed stored/charging in the corridor.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on observations and confirmed with staff, the facility failed to assure that mobile trash carts are stored in properly enclosed rated rooms.

THE FINDINGS INCLUDE:

- During the morning hours of December 1, 2010, on the West Building's third floor level nurses' station a 64 gallon paper recycle container is stored and utilized for recycling. Engineering staff removed the receptacle on December 3, 2010.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.

Based on observations, the facility failed to to properly store oxygen in accordance with NFPA 99. Sections 16.3.8.1, 8.3.1.11.2(h), and 4.3.5.2.1(b)27 requires freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart.

THE FINDINGS INCLUDE:

- During the afternoon hours of December 1, 2010, on the East Building's third floor level corridor a free standing E-type oxygen cylinder was found in the Clean Utility Room.

This was observed by facility staff during the building tour and reviewed with the facility's Director of Facilities and Engineering and maintenance staff during a summary of survey findings.