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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18. 18.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On November 5, 2013, the surveyor, accompanied Engineering Staff, observed that the following rated corridor doors would not tightly close when tested or had gaps greater than approximately 1/8 inch around the door frame assemblies and will not resist the passage of smoke;

1. Third floor Skill Lab corridor door held open with a filing cabinet.
2. First floor Surgery soiled utility room door will not close and latch.
3. First floor OB 3/8 inch gap between doors at OBT 1.
4. First floor Birth Center 90 min. doors had a gap of 1/2 inch between the doors when closed.
5. First floor Continual Care Nursery North Side rated UL double smoke doors gap between doors 3/8
inch when closed.
6. First floor door C1301A from OR to OB torn astragal.

During the exit conference on November 5, 2013, the above findings were again acknowledged by the CEO, Director of Nursing, Director of Maintenance and Engineering Staff.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to provide self-closing hardware on combustible storage room doors.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 18.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings Include:

On November 5, 2013, the surveyor accompanied by Engineering Staff, observed the corridor doors, in the following rooms, were without self closing hardware or the self closing hardware was removed.

1. Second floor, Nurse Work Station, door B2244 with flammable and combustible
storage had the self-closing hardware removed.
2. First floor Surgery EVS Storage room with combustibles and chemical storage, no self-
closing hardware on the door.
3. First floor EVS closet, Sterile Processing, with combustibles and chemical storage, no
self-closing hardware on the door.

During the exit conference on November 5, 2013, the above findings were again acknowledged by the CEO, Director of Nursing, Director of Maintenance, and Engineering Staff.

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to residents in time of a fire.

Baaed on observation and a review of building plans the facility has an Emergency Department suite which exceeds the 10,000 square foot maximum floor area.

NFPA 101, Life Safety Code, 2000 edition, Chapter 18, Section 18.2.5 "Arrangement of Means of Egress."
and Section 18.2.5.7, "Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 square feet."

Findings Include:

On November 5, 2013, the surveyor accompanied by the Director of Maintenance observed the new addition to the Emergency Department suite. The addition was in use at the time of the survey. There are two eight foot corridors and one 44 inch corridor entering into the new addition from the existing E.D suite. None of the corridors are provide with doors at the exterior wall, into the new addition. The addition of doors in the corridors will limit the spread of smoke and reduce the size of the suites to under 10,000 square feet. which is the maximum allowable by the Life Safety Code.
The review of the building plans indicated that the existing emergency department suite and the new addition was approximately 18,000 square feet.
The facility Architect has provide plans and information to the State Architects to add doors to the three open corridors. The work should take approximately 4 to 6 weeks.

During the exit conference on November 5, 2013, the above findings were again acknowledged by the CEO, Director of Nursing, Director of Maintenance and Engineering Staff.

Failing to limit the size of suites will exceed allowable travel distances to exits and will cause harm to patients and staff during a fire.

The facility failed to provide a medical gas cylinder storage rooms free of combustible materials and install outlets and switches 5 feet above the floor.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, "Health Care Facilities", Chapter 8, Section 8-3.1.11 "Storage Requirements, Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic, feet. " (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...."Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic fee. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2(a) 11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. above the floor to avoid physical damage."

Findings Include:

On November 5, 2013, the surveyors accompanied by the Director of Maintenance and Engineering Staff observed the following medical gases stored in combustible storage rooms:

1. Third floor Repertory closet, Door B3260 , had 6 oxygen cylinders stored next to combustibles.
2. Second floor, Door 2267, RT Storage room, seven oxygen cylinders stored next to combustibles.
3. Second floor, Equipment Storage room, by PT room, four oxygen cylinders stored below wall
mounted power strip, a light switch at 48 inches in height and combustibles were stored within
five feet.
4. First floor A/T room oxygen cylinders stored within five feet of combustibles.

During the exit conference on November 5, 2013, the above findings were again acknowledged by the CEO, Director of Nursing, Director of Maintenance and Engineering Staff.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, and receptacles and switches could be damaged by cylinders if less than five feet above the floor, which will cause harm to the patients and staff.

K136

Baaed on policy review the facility failed to have a written copy of equipment shut down procedures.

NFPA 101, Life Safety Code, 2000 edition, Chapter 18, Section 18.3.2.2 "Laboratories." "Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities."
NFPA 99, Chapter 10, Section 10-2.1.3, "Emergency Procedures" Section 10-2.1.3.1 "Procedures for laboratory emergencies shall be developed. Such procedures shall include ...Equipment Shutdown Procedures,...

Findings Include:

On November 5, 2013, the surveyor accompanied by the Laboratory Supervisor and Engineering Staff asked to review the emergency procedures for the laboratory. No written procedures or on-line procedures were found for the shutdown procedures of equipment during and emergency

During the exit conference on November 5, 2013, the above findings were again acknowledged by the CEO, Director of Nursing, Director of Maintenance, and Engineering Staff.

Failing to shut down equipment during and emergency could injure staff and damage laboratory equipment.

Based on Observation the facility allowed the use of a power strip and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On November 5, 2013, the surveyor, accompanied by Engineering Staff, observed the Engineering Storage room located on the second floor. The door was marked B2268. Two of three refrigerators were plugged into a power strip and not plugged directly into a electrical receptacles.

During the exit conference on November 5, 2013, the above findings were again acknowledged by the CEO, Director of Nursing, Director of Maintenance, and Engineering Staff.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.