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Based on observations and confirmed by staff, the facility failed to assure that egress routes are readably accessible at all times. Section 19.2.2.2.4. Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

THE FINDINGS INCLUDE:

- During the afternoon hours of 6/26/12 while touring the facility, the rear stairwell exit # 9 from the In-patient Psychiatry unit has a non-delayed mag lock on the door. A keypad type device is used to release the mag lock. When the staff was question about the release code four out of five staff did not know the code.


This was acknowledged by the Hospital Administrator staff during the exit interview process.

Based on document review , the facility failed to provide a detailed written fire plan in accordance with the requirements and failed to properly train staff. Section 19.7.2.3 requires all health care occupancy personnel to be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

THE FINDINGS INCLUDE:

- Review of the facility's fire plan (last revised during May 2010) on 6/27/12 revealed the following:

1. The fire emergency preparedness plan does not direct staff to call out a code phrase before going to the aid of an endangered person.

2. The fire safety plan does not include information regarding procedures to follow in the event that the fire alarm system is not functioning.

This was reviewed during the summary of survey findings at which time, facility staff presented the most recently revised fire emergency preparedness plan (May 2010), however, the staff were unable to provide documentation refuting the findings noted above.

Based on observations and confirmed by staff, the facility failed to ensure that non-sprinklered electrical rooms/closets are properly separated. NFPA 13 section 5.13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.
Section 5.6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).
Section 19.3.5.1 states where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. This facility is required to be fully sprinklered to meet the numerous exceptions which are utilized by installation of the automatic sprinkler system.

THE FINDINGS INCLUDE:

- During the morning hours of 6/25/12 while performing the facility tour, the following items were observed regarding the sprinkler system installation:

1) The two electrical rooms near the two hour fire barrier are not sprinklered, the corridor wall does not extend above the lay-in ceiling tile.

2) The ground level of the facility has mesh ceiling type tiles, open to the interstitial space above the ceiling tiles. The space above the ceiling tiles to the deck above is approximately two feet (2') in distance.

This was acknowledged by the Hospital Administrator staff during the exit interview process.

Based on record review and confirmed by staff, the facility failed to ensure that the generator is run monthly under a load condition for the required 30-minutes. NFPA 110 section 6-4.1 states level 1 and level 2 Emergency Power Supply Systems (EPSSs), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.
NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

- During the morning hours of 6/27/12 while performing the record review process, it was noted that the generator is not maintained as required. After reviewing the generator log book, it was observed that the generator is not run under a load condition monthly. The generator is only exercised monthly.

This was acknowledged by the Hospital Administrator staff during the exit interview process.