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Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 18.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke detectors leaves the exit access corridors unprotected against early and prompt notification of a fire event that could render the exit access corridors unusable.

Findings include:

A. On the morning of 7/29/14 at approximately 11:45am it was observed that waiting areas open to the corridor were not provided with smoke detection to comply with 18.3.6.1 Exception No.2 (b). The areas were not otherwise located to allow direct supervision by facility staff from a nursing station or similar space staffed on a 24/7 basis. Locations observed include:

1. A sub-waiting area along the corridor wall near Vending 1101.

2. The Main Lobby Waiting area and the Admission/Registration areas not separated from the corridor.

3. A sub-waiting chair stationed in the corner of the corridor near Lab door 1901.

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3.2 and 18.2.2.2.9. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. At 12:40pm on 7/29/14 it was observed that the Emergency Department Trauma room horizontal sliding door did not close and latch to comply with 18.2.2.2.9. A review of the facility's Life Safety Reference Plan did not indicate the Trauma room to be within an Emergency Department suite.

Based on observation during the survey walk-through on the morning of 7/29/14, self-closing doors are not maintained in accordance with NFPA 101-2000, 18.2.2.2.6. Failure to maintain required separation of hazardous areas can expose facility occupants to fire and smoke conditions.

Findings include:

A. At 11:50am on 7/29/14 it was observed that the Gift Shop corridor door was provided with a closer to comply with 18.3.2.5. The door was observed to be held open with a door stop not in compliance with 18.2.2.2.6.

B. At 12:00pm on 7/29/14 it was observed that the PT suite Clean Holding room 1804 door was provided with a closer to comply with 18.3.2.1. The door was observed to be held open with a wooden wedge door stop not in compliance with 18.2.2.2.6.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 18.7.1.2. 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 3rd shift employees include the following dates and times:

6/30/14 at 5:00am
3/29/14 at 5:30am
12/6/13 at 5:15am
9/15/13 at 5:45am
6/1/13 at 5:00am

The fire drills conducted for the 3rd shift employees had all of the last 5 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.

Based on random observation during the survey walk-through on the morning of 7/29/14, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99. Failure to install and/or maintain the medical gas system can result in failure of the system by accidental disruption of piping systems during maintenance operations. A complete review of the medical gas piping system labeling is required throughout the facility based upon the following two observations.

Findings include:

A. At 11:20am on 7/29/14 the "Instrument air" manifold system piping (which was noted by staff as not currently in use) was observed within the manifold room and the adjacent vestibule and corridor where the piping runs to not be labeled in accordance with NFPA 99-1999, 4-3.1.2.13 and 4-3.1.2.14. Labeling could not be readily located on both sides of the partition penetrated, at least once in each room, and at intervals not exceeding 20 ft.

B. At 11:40am on 7/29/14 the copper piping observed above the ceiling near the smoke barrier cross corridor doors near the Kitchen corridor door believed to be medical gas piping was observed not be labeled in accordance with NFPA 99-1999, 4-3.1.2.13 and 4-3.1.2.14. Labeling could not be readily located on both sides of the partition penetrated, at least once in each room, and at intervals not exceeding 20 ft.

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 observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 18.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke detectors leaves the exit access corridors unprotected against early and prompt notification of a fire event that could render the exit access corridors unusable.

Findings include:

A. On the morning of 7/29/14 at approximately 11:45am it was observed that waiting areas open to the corridor were not provided with smoke detection to comply with 18.3.6.1 Exception No.2 (b). The areas were not otherwise located to allow direct supervision by facility staff from a nursing station or similar space staffed on a 24/7 basis. Locations observed include:

1. A sub-waiting area along the corridor wall near Vending 1101.

2. The Main Lobby Waiting area and the Admission/Registration areas not separated from the corridor.

3. A sub-waiting chair stationed in the corner of the corridor near Lab door 1901.

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3.2 and 18.2.2.2.9. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. At 12:40pm on 7/29/14 it was observed that the Emergency Department Trauma room horizontal sliding door did not close and latch to comply with 18.2.2.2.9. A review of the facility's Life Safety Reference Plan did not indicate the Trauma room to be within an Emergency Department suite.

Based on observation during the survey walk-through on the morning of 7/29/14, self-closing doors are not maintained in accordance with NFPA 101-2000, 18.2.2.2.6. Failure to maintain required separation of hazardous areas can expose facility occupants to fire and smoke conditions.

Findings include:

A. At 11:50am on 7/29/14 it was observed that the Gift Shop corridor door was provided with a closer to comply with 18.3.2.5. The door was observed to be held open with a door stop not in compliance with 18.2.2.2.6.

B. At 12:00pm on 7/29/14 it was observed that the PT suite Clean Holding room 1804 door was provided with a closer to comply with 18.3.2.1. The door was observed to be held open with a wooden wedge door stop not in compliance with 18.2.2.2.6.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 18.7.1.2. 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 3rd shift employees include the following dates and times:

6/30/14 at 5:00am
3/29/14 at 5:30am
12/6/13 at 5:15am
9/15/13 at 5:45am
6/1/13 at 5:00am

The fire drills conducted for the 3rd shift employees had all of the last 5 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.

Based on random observation during the survey walk-through on the morning of 7/29/14, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99. Failure to install and/or maintain the medical gas system can result in failure of the system by accidental disruption of piping systems during maintenance operations. A complete review of the medical gas piping system labeling is required throughout the facility based upon the following two observations.

Findings include:

A. At 11:20am on 7/29/14 the "Instrument air" manifold system piping (which was noted by staff as not currently in use) was observed within the manifold room and the adjacent vestibule and corridor where the piping runs to not be labeled in accordance with NFPA 99-1999, 4-3.1.2.13 and 4-3.1.2.14. Labeling could not be readily located on both sides of the partition penetrated, at least once in each room, and at intervals not exceeding 20 ft.

B. At 11:40am on 7/29/14 the copper piping observed above the ceiling near the smoke barrier cross corridor doors near the Kitchen corridor door believed to be medical gas piping was observed not be labeled in accordance with NFPA 99-1999, 4-3.1.2.13 and 4-3.1.2.14. Labeling could not be readily located on both sides of the partition penetrated, at least once in each room, and at intervals not exceeding 20 ft.

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.