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Vertical openings between floors are not protected in compliance with 19.3.1.1 and 8.2.5. This deficiency could result in the effects of fire and smoke on one floor tranferring to another floor level compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:
A. On 9/25/14 at 12:00 it was observed that there are unprotected vertical openings in the floor system as observed at the Basement Boiler room which are not sealed in accordance with the minimum 1-hour fire resistance rated construction. Numerous abandoned pipes and other penetrations were observed to be unprotected in accordance with tested design assemblies.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:
A. At 10:30am on 9/25/14 it was observed that the Soiled Utility room (also used for storage) near the CT room did not have a minimum 3/4-hour fire resistance rated door and lacked positive latching to comply with 19.3.2.1, 8.4.1, 8.2.3.2.1.

B. At 10:30am on 9/25/14 it was observed that a former shower room near the CT room used as the Bio-hazard storage room storing greater than 32 gallon capacity bags/containers of waste material was not enclosed with 1-hour rated construction to comply with 19.3.2.1, 8.4.1, and 19.7.5.5 because the self-closing door was not minimum 3/4-hour fire resistance rated.

C. At 10:45am on 9/25/14 it was observed that the Pharmacy/Storage room/Maintenance room area was not enclosed with 1-hour rated construction to comply with 19.3.2.1, 8.4.1 and 8.2.3.2.1 because the fire resistance labeled Maintenance room corridor door was not self-closing and the Pharmacy/Storage room corridor door was not minimum 3/4-hour fire resistance rated and self-closing.

D. At 11:00am on 9/25/14 it was observed that the Chapel/Gift Shop room was not enclosed with 1-hour rated construction to comply with 19.3.2.1, 8.4.1 and 19.3.2.5 because the Chapel side of the non-full height partitioned room corridor door was not minimum 3/4-hour fire resistance rated and positive latching. Surveyor notes that if the Gift Shop was to be separated from the Chapel by 1-hour rated construction, the Chapel corridor door does not comply with 19.3.6.3.2 because the door is not provided with positive latching.

Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.2.3 and 7.2. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching the public way from an exit from the building.

Findings include:
A. At 10:00am on 9/25/14 it was observed that the exterior door identified and marked as an exit from the old CT trailer discharged to a stair which lacked a landing at the door swing to comply with 7.2.1.3 & 7.2.2.3.2 and lacked handrails at the stair to comply with 7.2.2.4.2.

B. At 11:15am on 9/25/14 it was observed that the exterior door identified and marked as an exit from the Administration wing discharged to a stair which lacked handrails at the stair to comply with 7.2.2.4.2. The discharge path to the public way also traversed a grass bank which lacked a stable, maintainable surface to comply with 7.1.6 and 7.1.7.

C. At 12:00pm on 9/25/14 it was observed that the concrete platform at the top of the areaway stair from the Basement Boiler room was deteriorated to the point of presenting a tripping hazard in noncompliance with 7.1.6.3 & 7.1.10.1 for those utilizing the exit discharge path.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1, 19.2.2.2.1 and Chapter 7. This deficiency could affect any staff and visitors present, by preventing those occupants from exiting the building.

Findings include:
A. At 12:00pm on 9/25/14 it was observed that the Basement Boiler room exterior aluminum full-glazed door was observed to have damaged panic hardware which could prevent occupants from operating the door as intended. The panic device hardware lacked the pushbar making the operation of the door hardware unfamiliar in noncompliance with 7.2.1.5.4.

Based on random observation during the survey walk-through on 9/25/14, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:
A. At 10:15am on 9/25/14 it was observed that the 2-bulb fixture provided at the exterior exit door of the CT trailer had only one functional lamp in non-compliance with 7.8.1.4.

Based on random observation during the 9/25/14 survey walk-through and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:
A. During the survey walk-through and document review of the available Life Safety Plans, it was observed that the plans are not sufficiently accurate to comply with 19.7.1.1. The definitive location of the smoke barrier wall in compliance with 19.3.7 and 8.3 was not indicated on the plan or otherwise readily identified by staff at the time of the survey. The Life Safety Management Plan indicated that a floor plan "in the front of the book" was available but the book lacked the referenced plan.

B. During the document review of the facility's Life Safety Management Plan, Fire Policy #201, it was observed that the written plan lacked concise instructions to ensure the safety of patients, staff and visitors within the facility in accordance with 19.7.1.1. The written plan states "Leave the building through the nearest exit without going through the fire area or fire barrier doors." These instructions appear to indicate that the primary response to fire alarm activation is to evacuate the building rather than first movng to an adjacent smoke compartment or fire area as an area of refuge. The evacuation of patients from the building could further compromise the patients safety due to inclement weather or separation from needed services within the building. The evacuation of the building is considered a secondary response after movement to an area of refuge within the building is prevented by incident location or severity of fire/smoke conditions. The Life Safety Management Plan was indicated to be currently under review for revisions.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. Fire Drills conducted for the 2nd shift (7pm-7am) employees include the following dates and times:

1st Quarter: 1/8/14 at 5:30am
4th Quarter: 12/14/13 at 5:00am
4th Quarter: 11/14/13 at 6:00am
3rd Quarter: 9/11/13 at 5:50am
2nd Quarter: No documented drill

The fire drills conducted for the 2nd shift (7pm-7am) employees had all of the last 4 drills occurring within the same hour of the day at approximately the end of the shift and not at varying times during the normal shift. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. Fire Drills conducted for the 1st shift (7am-7pm) employees include the following dates and times:

2nd Quarter: 6/10/14 at 10:45am
2nd Quarter: 5/11/14 at 8:20am
2nd Quarter: 4/8/14 at 12:15pm
1st Quarter: 2/28/14 at 7:15am
4th Quarter: No documented drill
3rd Quarter: 8/2/13 at 12:45pm
3rd Quarter: 7/23/13 at 6:15pm

A fire drill was not documented for the 1st shift employees during the 4th quarter of the previous year. Therefore, not meeting the requirement of being held at least once per quarter per shift as required by 19.7.1.2.

Based on observation during the survey walk-through, not all Medical Gas storage locations comply with NFPA 99-1999, and NFPA 101-2000. This deficiency could affect all persons within the ER department by creating an undue hazard by improperly storing or separating oxidizing gases from combustibles.

Findings include:
A. At 10:15am on 9/25/14 it was observed that oxygen tank storage of less than 3000 cu.ft. consisting of six "E"-size tanks was located in a storage alcove area within the ER adjacent to combustibles in non-compliance with NFPA 99-1999, 8-3.1.11.2(b) which requires a minimum separation of 20' from combustibles or storage within an enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2-hour (or an approved flammable liquid storage cabinet).

The Hospital generator system is not in compliance with NFPA 110-1999, 5-3.1. Failure to provide required safety lighting at the generator during failure of normal power and emergency generator power could prevent prompt repair and/or resolution of generator failure during an emergency.

Findings include:
A. At 12:10pm on 9/25/14 it was observed that the exterior mounted generator enclosure is not provided with battery powered lighting to comply with NFPA 110-1999, 5-3.1.

B. At 9:30am on 9/25/14 during document review of the emergency generator logs it was observed that the 120/208 3 phase 400KW deisel generator was not being tested in accordance with NFPA 110-1999, 6-4.2. Recorded loads during the monthly load testing did not meet the minimum 30% of capacity to comply with 6-4.2(a). Minimum exhaust gas temperatures as recommended by the manufacturer were not otherwise recorded during the monthly tests to otherwise comply with 6-4.2(b). Surveyor notes that a load bank test was performed on 8/22/13 to satisfy 6-4.2.2 but was indicated by the provider's Quality Director not to be scheduled to be repeated annually as required when either 6-4.2(a) or 6-4.2(b) are not met.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk through, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:
A. The surveyor observed that the panel identification and panel schedules were not accurate or were not updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13. The room identifiers posted at the rooms did not match the designations in the panel directories at the panels observed in the patient room corridor.

Vertical openings between floors are not protected in compliance with 19.3.1.1 and 8.2.5. This deficiency could result in the effects of fire and smoke on one floor tranferring to another floor level compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:
A. On 9/25/14 at 12:00 it was observed that there are unprotected vertical openings in the floor system as observed at the Basement Boiler room which are not sealed in accordance with the minimum 1-hour fire resistance rated construction. Numerous abandoned pipes and other penetrations were observed to be unprotected in accordance with tested design assemblies.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:
A. At 10:30am on 9/25/14 it was observed that the Soiled Utility room (also used for storage) near the CT room did not have a minimum 3/4-hour fire resistance rated door and lacked positive latching to comply with 19.3.2.1, 8.4.1, 8.2.3.2.1.

B. At 10:30am on 9/25/14 it was observed that a former shower room near the CT room used as the Bio-hazard storage room storing greater than 32 gallon capacity bags/containers of waste material was not enclosed with 1-hour rated construction to comply with 19.3.2.1, 8.4.1, and 19.7.5.5 because the self-closing door was not minimum 3/4-hour fire resistance rated.

C. At 10:45am on 9/25/14 it was observed that the Pharmacy/Storage room/Maintenance room area was not enclosed with 1-hour rated construction to comply with 19.3.2.1, 8.4.1 and 8.2.3.2.1 because the fire resistance labeled Maintenance room corridor door was not self-closing and the Pharmacy/Storage room corridor door was not minimum 3/4-hour fire resistance rated and self-closing.

D. At 11:00am on 9/25/14 it was observed that the Chapel/Gift Shop room was not enclosed with 1-hour rated construction to comply with 19.3.2.1, 8.4.1 and 19.3.2.5 because the Chapel side of the non-full height partitioned room corridor door was not minimum 3/4-hour fire resistance rated and positive latching. Surveyor notes that if the Gift Shop was to be separated from the Chapel by 1-hour rated construction, the Chapel corridor door does not comply with 19.3.6.3.2 because the door is not provided with positive latching.

Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.2.3 and 7.2. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching the public way from an exit from the building.

Findings include:
A. At 10:00am on 9/25/14 it was observed that the exterior door identified and marked as an exit from the old CT trailer discharged to a stair which lacked a landing at the door swing to comply with 7.2.1.3 & 7.2.2.3.2 and lacked handrails at the stair to comply with 7.2.2.4.2.

B. At 11:15am on 9/25/14 it was observed that the exterior door identified and marked as an exit from the Administration wing discharged to a stair which lacked handrails at the stair to comply with 7.2.2.4.2. The discharge path to the public way also traversed a grass bank which lacked a stable, maintainable surface to comply with 7.1.6 and 7.1.7.

C. At 12:00pm on 9/25/14 it was observed that the concrete platform at the top of the areaway stair from the Basement Boiler room was deteriorated to the point of presenting a tripping hazard in noncompliance with 7.1.6.3 & 7.1.10.1 for those utilizing the exit discharge path.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1, 19.2.2.2.1 and Chapter 7. This deficiency could affect any staff and visitors present, by preventing those occupants from exiting the building.

Findings include:
A. At 12:00pm on 9/25/14 it was observed that the Basement Boiler room exterior aluminum full-glazed door was observed to have damaged panic hardware which could prevent occupants from operating the door as intended. The panic device hardware lacked the pushbar making the operation of the door hardware unfamiliar in noncompliance with 7.2.1.5.4.

Based on random observation during the survey walk-through on 9/25/14, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:
A. At 10:15am on 9/25/14 it was observed that the 2-bulb fixture provided at the exterior exit door of the CT trailer had only one functional lamp in non-compliance with 7.8.1.4.

Based on random observation during the 9/25/14 survey walk-through and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:
A. During the survey walk-through and document review of the available Life Safety Plans, it was observed that the plans are not sufficiently accurate to comply with 19.7.1.1. The definitive location of the smoke barrier wall in compliance with 19.3.7 and 8.3 was not indicated on the plan or otherwise readily identified by staff at the time of the survey. The Life Safety Management Plan indicated that a floor plan "in the front of the book" was available but the book lacked the referenced plan.

B. During the document review of the facility's Life Safety Management Plan, Fire Policy #201, it was observed that the written plan lacked concise instructions to ensure the safety of patients, staff and visitors within the facility in accordance with 19.7.1.1. The written plan states "Leave the building through the nearest exit without going through the fire area or fire barrier doors." These instructions appear to indicate that the primary response to fire alarm activation is to evacuate the building rather than first movng to an adjacent smoke compartment or fire area as an area of refuge. The evacuation of patients from the building could further compromise the patients safety due to inclement weather or separation from needed services within the building. The evacuation of the building is considered a secondary response after movement to an area of refuge within the building is prevented by incident location or severity of fire/smoke conditions. The Life Safety Management Plan was indicated to be currently under review for revisions.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. Fire Drills conducted for the 2nd shift (7pm-7am) employees include the following dates and times:

1st Quarter: 1/8/14 at 5:30am
4th Quarter: 12/14/13 at 5:00am
4th Quarter: 11/14/13 at 6:00am
3rd Quarter: 9/11/13 at 5:50am
2nd Quarter: No documented drill

The fire drills conducted for the 2nd shift (7pm-7am) employees had all of the last 4 drills occurring within the same hour of the day at approximately the end of the shift and not at varying times during the normal shift. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. Fire Drills conducted for the 1st shift (7am-7pm) employees include the following dates and times:

2nd Quarter: 6/10/14 at 10:45am
2nd Quarter: 5/11/14 at 8:20am
2nd Quarter: 4/8/14 at 12:15pm
1st Quarter: 2/28/14 at 7:15am
4th Quarter: No documented drill
3rd Quarter: 8/2/13 at 12:45pm
3rd Quarter: 7/23/13 at 6:15pm

A fire drill was not documented for the 1st shift employees during the 4th quarter of the previous year. Therefore, not meeting the requirement of being held at least once per quarter per shift as required by 19.7.1.2.

Based on observation during the survey walk-through, not all Medical Gas storage locations comply with NFPA 99-1999, and NFPA 101-2000. This deficiency could affect all persons within the ER department by creating an undue hazard by improperly storing or separating oxidizing gases from combustibles.

Findings include:
A. At 10:15am on 9/25/14 it was observed that oxygen tank storage of less than 3000 cu.ft. consisting of six "E"-size tanks was located in a storage alcove area within the ER adjacent to combustibles in non-compliance with NFPA 99-1999, 8-3.1.11.2(b) which requires a minimum separation of 20' from combustibles or storage within an enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2-hour (or an approved flammable liquid storage cabinet).

The Hospital generator system is not in compliance with NFPA 110-1999, 5-3.1. Failure to provide required safety lighting at the generator during failure of normal power and emergency generator power could prevent prompt repair and/or resolution of generator failure during an emergency.

Findings include:
A. At 12:10pm on 9/25/14 it was observed that the exterior mounted generator enclosure is not provided with battery powered lighting to comply with NFPA 110-1999, 5-3.1.

B. At 9:30am on 9/25/14 during document review of the emergency generator logs it was observed that the 120/208 3 phase 400KW deisel generator was not being tested in accordance with NFPA 110-1999, 6-4.2. Recorded loads during the monthly load testing did not meet the minimum 30% of capacity to comply with 6-4.2(a). Minimum exhaust gas temperatures as recommended by the manufacturer were not otherwise recorded during the monthly tests to otherwise comply with 6-4.2(b). Surveyor notes that a load bank test was performed on 8/22/13 to satisfy 6-4.2.2 but was indicated by the provider's Quality Director not to be scheduled to be repeated annually as required when either 6-4.2(a) or 6-4.2(b) are not met.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk through, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:
A. The surveyor observed that the panel identification and panel schedules were not accurate or were not updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13. The room identifiers posted at the rooms did not match the designations in the panel directories at the panels observed in the patient room corridor.