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Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 18.1.6.2.

Findings include:

A. At 8:41 AM on March 30, 2011, a steel lintel was observed, above the ceiling immediately east of the Information Desk, which is not fireproofed in accordance with the designated construction type for the building. During an interview held at that time and location, the provider's Plant Operations Manager confirmed that the Emergency Department Addition is of Type I (332) construction. This deficiency could affect all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure of the lintel under fire conditions could result in the partial collapse of the roof.

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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the 25 bed facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke reaching the facility's exit access corridors.

Findings include:

A. At 1:50 PM on March 29, 2011, the Second Floor former OB Nurses' Station, now a staff work area which is not constantly attended, was observed to lack a smoke detector required by Exception 1. [subpart (c)] to 19.3.6.1.

B. At 9:11 AM on March 30, 2011, the First Floor West Entry Vestibule, which constitutes a waiting area open to the corridor and not visible from a constantly attended station because it houses a couch, was observed to lack a smoke detector required by Exception 2. [subpart (b)] to 19.3.6.1.

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. At 1:52 PM on March 29, 2011, the pair of doors to the Second Floor former Delivery Room, now being utilized as a Classroom, was observed to not be positive latching as required by 19.3.6.3.2. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by allowing smoke to pass from the building's exit access corridors to rooms housing them.

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Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by allowing smoke to pass between smoke compartments.

Findings include:

A. At 2:48 PM on March 29, 2011, both leafs of the pair of cross-corridor doors in the Second Floor west smoke barrier were observed to not be self-closing as required by 19.3.7.6.
1. The self-closing device at the north leaf was observed to have been disabled.
2. The south leaf was observed to lack a self-closing device.
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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. These deficiencies could affect all patients in the 25 bed facility, 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. Doors to hazardous rooms were observed that do not carry a minimum 3/4 hour fire resistance rating as required by 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:
1. 1:28 PM March 29, 2011: Second Floor Soiled Utility Room.
2. 9:47 AM March 30, 2011: First Floor Paint Storage Room (adjacent to Dietary Department Serving Line).

B. At 9:25 AM on March 30, 2011, the door to the First Floor Boiler Room was observed to not be self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(1).

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Based on random observation during the survey walk-through, not all exit enclosures are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. At 9:20 AM on march 30, 2011, a set of chairs was observed in the First Floor Exit Passageway, which does not comply with 7.1.3.2.3. because it constitutes a use for the Exit Passageway other than for egress. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

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Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 9:57 AM on March 30, 2011, the door to the First Floor East Exit Stair was observed to not swing in the direction of egress as required by 7.2.1.4.3.

B. At 1:55 PM on March 29, 2011, the following conditions were observed at the pair of cross-corridor doors across the Corridor to the west of the Second Floor Surgical Department, both of which do not comply with 7.2.1.4.4.:
1. The north leaf was observed to protrude more than 7" into the Corridor when in the fully open (180 degree) position.

2. The south leaf was observed to obstruct more than half of the adjacent door to the South Center Exit Stair.

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Based on staff interview, not all exterior egress paths are illuminated as required by 19.2.8.

Findings include:

A. During an interview held at the Loading Dock at 2:16 PM on March 29, 2011, the provider's Plant Operations Manager was not able to verify that exterior egress paths are provided with lighting, on emergency power, as required by 7.9.1.1. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

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Based on staff interview, not all emergency lighting is maintained in accordance with 7.9.

Findings include:

A. During an interview held in the CEO's Office at 10:30 AM on March 30, 2011, the provider's Plant Operations Manager stated that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, because the failure of emergency lights could prevent those occupants from reaching an exit from the building.
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Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include (both Second Floor):

1. 1:47 PM March 29, 2011: No exit sign was observed above the cross-corridor doors immediately east of the former Red Hills Unit, which would direct building occupants toward the south (toward the former OB Unit). Surveyor 14290 notes that the cross-corridor doors to the former Red Hills Unit are locked out of hours, thus creating an apparent dead-end condition without the exit sign.
2. 1:58 PM March 29, 2011: No exit sign was observed above the cross-corridor doors at the north end of the Corridor serving the Surgical Department which would direct building occupants toward the north.

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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 18.3.4. These deficiencies could affect all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the lack of labeling could result in the inadvertent discontinuation of power to the building fire alarm system.

Findings include:

A. At 8:48 AM on March 30, 2011, the Fire Alarm Control Panel, located in the Mechanical Room, was observed to not be labeled as to the Electrical Panel from which it is served, as required by NFPA 72 1999 1-5.2.5.2.

B. At 9:00 AM on March 30, 2011, at Electrical Panel E located in the West Passage, the circuit breaker serving the Fire Alarm Control Panel was observed to not be in compliance with NFPA 72 1999 1-5.2.5.2. because it is not equipped with a mechanical lock-on device, is not labeled, and is not painted red.

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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. At 3:01 PM on March 29, 2011, the Fire Alarm Control Panel, located in the First Floor Corridor adjacent to the Center Exit Stair, was observed to not be labeled as to the Electrical Panel from which it is served, as required by NFPA 72 1999 1-5.2.5.2. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, as well as any staff and visitors present, because the lack of labeling could result in the inadvertent discontinuation of power to the building fire alarm system.

B. At 1:41 PM on march 29, 2011, an access panel was observed to be missing from the ceiling of the Second Floor Supply Closet, which is not in compliance with NFPA 72 1999 2-2.2.1. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, because the lack of the access panel compromises the coverage provided by the heat detector.

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Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. At 8:50 AM on March 30, 2011, a ceiling tile was observed to be missing in the Mechanical Room, which does not comply with NFPA 13 1999 5-6.4.1.1. This deficiency could affect all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the lack of the tile compromises sprinkler coverage.

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Based on random observation and staff interview during the survey walk-through, not all portions of the facility's commercial cooking equipment are installed and maintained in accordance with NFPA 96 and 25 1998.

Findings include:

A. During the survey walk-through of the Dietary Department at 9:45 am on March 30, 2011 the following conditions were observed that do not met the requirements of NFPA 96;

1. The ductwork was not joined by liquid tight continuous welded construction in accordance with 4-5.2.1.

2. The ductwork was observed without access panels in horizontal sections for inspection and cleaning purposes in accordance with 4-3.4.4.

3. The ductwork vertical riser location and access panels in accordance with 4-3.4.3 could not be verified at the time of the survey because of the Surgery schedule.

4. The ductwork vertical riser shaft enclosure rating accordance with 4-7.1
could not be verified at the time of the survey because of the Surgery schedule.

The 4 deficiencies listed above could create the possibility for a fire situation affecting all patients, visitors and staff in the building.

B. During the document review process on the morning of March 30, 2011 the following records for the hood could not be provided by the Facility. These deficiencies can lead to poorly maintained system which can fail when needed causing patient, staff and visitor injuries.

1. Hood suppression system installation and semi-annual suppression system in accordance with NFPA 25 1998 8-2.

2. Records on the semi-annual hood inspection and cleaning in accordance with NFPA 25 1998 Table 8-3.1.

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Based on random observation during the survey walk-through, not all portions of the facility's Piped in medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. The outside medical gas oxygen manifold room by the Emergency Department was observed at 8:45 am on March 30, 2011 with no top or bottom louvers installed for gravity ventilation of the small room in accordance with 4-3.1.1.1 (c).

This deficiency could cause an oxygen rich atmosphere in which a fire or explosion could injure staff or visitors in the area or staff entering the room.

B. The medical vacuum system was observed at 8:50 am with no check or isolation valves installed in the common exhaust manifold lines for isolating a pump for repair in accordance with 4-3.2.1.9.

This deficiency could cause a failure of the piped vacuum system due to not being able to isolate a failed pump causing patient injury due the loss of suction in the Emergency Department.

C. During the manifold room inspection at 8:45 am the source valve on the oxygen manifold was observed without a durable tag attached for identifying it as the oxygen source valve for the Emergency Department in accordance with 4-3.1.2.3 (a).

D. During the vacuum system inspection the source valve on the receiver was observed without a durable tag attached for identifying it as the vacuum source valve for the areas served by the vacuum system in accordance with 4-3.1.2.3 (a).

Deficiency C and D could cause injury to any patient using the oxygen or vacuum systems in the Emergency Department due to someone shutting of a valve not knowing the areas served by the valve.

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Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. The medical gas tank storage room located at the loading dock at 9:20am on March 30, 2011 was observed with a grill installed in the upper portion of the exterior wall and without a grill in the lower portion for natural ventilation in accordance with 4-3.1.1.2 (b) 4. This deficiency could provide for an accumulation of mixed gasses with an abnormal oxygen concentration for staff breathing. This deficiency could affect staff entering the tank storage room due to an oxygen rich or an oxygen deficient atmosphere which could cause a fire or suffocation.

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Based on staff interview, the building's emergency generator is not installed and maintained in accordance with NFPA 99. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing hospital staff from being aware that the emergency generator is not able to function.


Findings include:

A. During an interview held in the CEO's Office at 3:01 PM on March 29, 2011, the provider's Plant Operations Manager stated that the emergency generator is not provided with a remote audible alarm annunciator, located at a readily observable site, required by NFPA 99 1999 3-4.1.1.15. and NFPA 110 1999 3-5.6.1.

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A. Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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.

B. Based on document review and staff interview, the facility's Halon system is not inspected, tested, and maintained in accordance with NFPA 12A. These deficiencies could affect all patients in the 25 bed facility, as well as any staff and visitors present, because the failure to maintain the Halon system could result in the failure of the system to function in an emergency condition.

Findings include:

Through document review, it was determined that the facility does not inspect and test the Halon system,.located in the First Floor Radiology Storage Room, on a semi-annual basis as required by NFPA 12A 1997 4-1.1. During an interview held in the CEO's Office at 10:00 AM on March 30, 2011, the provider's Plant Operations Manager confirmed this finding.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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.

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Based on random observation during the survey walk-through, the facility's electrical system is not divided into the critical branch, life safety branch, and the equipment system as required by NFPA 99.

Findings include:

A. At 9:00 AM on March 30, 2011, The Emergency Department Addition's electrical system was observed to not be divided into the Emergency and and Equipment Systems as required by NFPA 99 1999 3-4.2.2.1. and NFPA 70 1999 517-30(b)(1), with the Emergency System not being further broken down into the Life Safety and Critical Branches as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-30(b)(2). At the stated time and date, Panel E, located in the Emergency Department West Passage, was observed to serve both the Life Safety Branch and Critical electrical loads. This deficiency could affect all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the power sources for building life safety components such as exit signs and the fire alarm system are not protected.

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Based on random observation during the survey walk-through, not all portions of the facility's electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. During them walk-through of the Emergency Department at 9:05 on March 30, 2011 patient exam rooms 4 and 5 were observed to have only emergency outlets installed and no circuit from the normal electric system in accordance with 517-19 (a).

This deficiency could cause injury to any patients in any of the exam rooms due to equipment shutting off due a generator failure with no other possible source of electric in the exam room.

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Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 18.1.6.2.

Findings include:

A. At 8:41 AM on March 30, 2011, a steel lintel was observed, above the ceiling immediately east of the Information Desk, which is not fireproofed in accordance with the designated construction type for the building. During an interview held at that time and location, the provider's Plant Operations Manager confirmed that the Emergency Department Addition is of Type I (332) construction. This deficiency could affect all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure of the lintel under fire conditions could result in the partial collapse of the roof.

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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the 25 bed facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke reaching the facility's exit access corridors.

Findings include:

A. At 1:50 PM on March 29, 2011, the Second Floor former OB Nurses' Station, now a staff work area which is not constantly attended, was observed to lack a smoke detector required by Exception 1. [subpart (c)] to 19.3.6.1.

B. At 9:11 AM on March 30, 2011, the First Floor West Entry Vestibule, which constitutes a waiting area open to the corridor and not visible from a constantly attended station because it houses a couch, was observed to lack a smoke detector required by Exception 2. [subpart (b)] to 19.3.6.1.

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. At 1:52 PM on March 29, 2011, the pair of doors to the Second Floor former Delivery Room, now being utilized as a Classroom, was observed to not be positive latching as required by 19.3.6.3.2. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by allowing smoke to pass from the building's exit access corridors to rooms housing them.

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Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by allowing smoke to pass between smoke compartments.

Findings include:

A. At 2:48 PM on March 29, 2011, both leafs of the pair of cross-corridor doors in the Second Floor west smoke barrier were observed to not be self-closing as required by 19.3.7.6.
1. The self-closing device at the north leaf was observed to have been disabled.
2. The south leaf was observed to lack a self-closing device.
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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. These deficiencies could affect all patients in the 25 bed facility, 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. Doors to hazardous rooms were observed that do not carry a minimum 3/4 hour fire resistance rating as required by 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:
1. 1:28 PM March 29, 2011: Second Floor Soiled Utility Room.
2. 9:47 AM March 30, 2011: First Floor Paint Storage Room (adjacent to Dietary Department Serving Line).

B. At 9:25 AM on March 30, 2011, the door to the First Floor Boiler Room was observed to not be self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(1).

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Based on random observation during the survey walk-through, not all exit enclosures are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. At 9:20 AM on march 30, 2011, a set of chairs was observed in the First Floor Exit Passageway, which does not comply with 7.1.3.2.3. because it constitutes a use for the Exit Passageway other than for egress. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

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Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 9:57 AM on March 30, 2011, the door to the First Floor East Exit Stair was observed to not swing in the direction of egress as required by 7.2.1.4.3.

B. At 1:55 PM on March 29, 2011, the following conditions were observed at the pair of cross-corridor doors across the Corridor to the west of the Second Floor Surgical Department, both of which do not comply with 7.2.1.4.4.:
1. The north leaf was observed to protrude more than 7" into the Corridor when in the fully open (180 degree) position.

2. The south leaf was observed to obstruct more than half of the adjacent door to the South Center Exit Stair.

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Based on staff interview, not all exterior egress paths are illuminated as required by 19.2.8.

Findings include:

A. During an interview held at the Loading Dock at 2:16 PM on March 29, 2011, the provider's Plant Operations Manager was not able to verify that exterior egress paths are provided with lighting, on emergency power, as required by 7.9.1.1. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

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Based on staff interview, not all emergency lighting is maintained in accordance with 7.9.

Findings include:

A. During an interview held in the CEO's Office at 10:30 AM on March 30, 2011, the provider's Plant Operations Manager stated that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, because the failure of emergency lights could prevent those occupants from reaching an exit from the building.
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Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include (both Second Floor):

1. 1:47 PM March 29, 2011: No exit sign was observed above the cross-corridor doors immediately east of the former Red Hills Unit, which would direct building occupants toward the south (toward the former OB Unit). Surveyor 14290 notes that the cross-corridor doors to the former Red Hills Unit are locked out of hours, thus creating an apparent dead-end condition without the exit sign.
2. 1:58 PM March 29, 2011: No exit sign was observed above the cross-corridor doors at the north end of the Corridor serving the Surgical Department which would direct building occupants toward the north.

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Based on document review and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. This deficiency could affect all patients in the 25 bed facility and all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure to maintain any of those components could result in smoke or fire passing from one part of the building to another.

Findings include:

A. During an interview held in the CEO's Office at 11:00 AM on March 29, 2011, the provider's Plant Operations Manager was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. During that interview, the Plant Operations Manager confirmed that no records of the locations of those life safety components were available. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. Building construction types.

2. Occupancy classifications.

3. Portions of the building covered by an automatic sprinkler system.

4. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, building separations, and separations between disparate construction types.

5. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, or ventilation shafts. Surveyor 14290 notes that this includes the shaft for the Kitchen exhaust duct as it passes through the Second Floor.

6. Smoke barrier walls and areas (in square feet) of smoke compartments.

7. Exit access corridors and designated corridor walls.

8. The limits and areas (in square feet) of all suites.

9. Hazardous areas and their fire resistance ratings.

10. Exits.

11. Other special fire protection features such as areas of the building covered by a smoke evacuation system.

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Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. This deficiency could affect all patients in the 25 bed facility and all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure to prepare to react in emergency conditions could result in the failure to execute the facility's fire plan.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2010 and 2011, fire drills for the following quarters/shifts were conducted at the similar times listed (all roughly between the hours of 1:00 PM and 3:30 PM, regardless of the shift involved):

1. First Shift:

a. First Quarter 2010: none performed.

b. Second Quarter 2010: April 5, 2010, 1:20 PM.

c. Third Quarter 2010: July 2, 2010, 3:17 PM.

d. Fourth Quarter 2010: October 12, 2010, 1:30 PM.

e. First Quarter 2011: January 10, 2011, 1:27 PM.

2. Second Shift:

a. First Quarter 2010: February 10, 2010, 3:28 PM.

b. Second Quarter 2010: May 4, 2010, 1:15 PM.

c. Third Quarter 2010: August 13, 2010, 2:00 PM.

d. Fourth Quarter 2010: November 5, 2010, 2:30 PM.

e. First Quarter 2011: February 4, 2011, 1:06 PM.

3. Third Shift:

a. First Quarter 2010: March 1, 2010, 2:57 PM.

b. Second Quarter 2010: June 2, 2010, 2:10 PM.

c. Third Quarter 2010: September 21, 2010, 2:00 PM.

d. Fourth Quarter 2010: December 7, 2010, 2:00 PM.

e. First Quarter 2011: March 7, 2011, 2:05 PM.

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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 18.3.4. These deficiencies could affect all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the lack of labeling could result in the inadvertent discontinuation of power to the building fire alarm system.

Findings include:

A. At 8:48 AM on March 30, 2011, the Fire Alarm Control Panel, located in the Mechanical Room, was observed to not be labeled as to the Electrical Panel from which it is served, as required by NFPA 72 1999 1-5.2.5.2.

B. At 9:00 AM on March 30, 2011, at Electrical Panel E located in the West Passage, the circuit breaker serving the Fire Alarm Control Panel was observed to not be in compliance with NFPA 72 1999 1-5.2.5.2. because it is not equipped with a mechanical lock-on device, is not labeled, and is not painted red.

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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. At 3:01 PM on March 29, 2011, the Fire Alarm Control Panel, located in the First Floor Corridor adjacent to the Center Exit Stair, was observed to not be labeled as to the Electrical Panel from which it is served, as required by NFPA 72 1999 1-5.2.5.2. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, as well as any staff and visitors present, because the lack of labeling could result in the inadvertent discontinuation of power to the building fire alarm system.

B. At 1:41 PM on march 29, 2011, an access panel was observed to be missing from the ceiling of the Second Floor Supply Closet, which is not in compliance with NFPA 72 1999 2-2.2.1. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, because the lack of the access panel compromises the coverage provided by the heat detector.

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Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. These deficiencies could affect all patients in the 25 bed facility and all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure to maintain the building fire alarm could result in the failure of the system to function in an emergency condition.

Findings include:

A. Through document review, it was determined that the facility does not visually inspect fire alarm system components on a periodic basis as required by NFPA 72 1999 Table 7-3.1. During an interview held in the CEO's Office at 11:05 AM on March 30, 2011, the provider's Plant Operations Manager confirmed this finding.

B. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 Table 7-3.2. During an interview held in the CEO's Office at 11:05 AM on March 30, 2011, the provider's Plant Operations Manager confirmed this finding.

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Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. At 8:50 AM on March 30, 2011, a ceiling tile was observed to be missing in the Mechanical Room, which does not comply with NFPA 13 1999 5-6.4.1.1. This deficiency could affect all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the lack of the tile compromises sprinkler coverage.

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Based on random observation and staff interview during the survey walk-through, not all portions of the facility's commercial cooking equipment are installed and maintained in accordance with NFPA 96 and 25 1998.

Findings include:

A. During the survey walk-through of the Dietary Department at 9:45 am on March 30, 2011 the following conditions were observed that do not met the requirements of NFPA 96;

1. The ductwork was not joined by liquid tight continuous welded construction in accordance with 4-5.2.1.

2. The ductwork was observed without access panels in horizontal sections for inspection and cleaning purposes in accordance with 4-3.4.4.

3. The ductwork vertical riser location and access panels in accordance with 4-3.4.3 could not be verified at the time of the survey because of the Surgery schedule.

4. The ductwork vertical riser shaft enclosure rating accordance with 4-7.1
could not be verified at the time of the survey because of the Surgery schedule.

The 4 deficiencies listed above could create the possibility for a fire situation affecting all patients, visitors and staff in the building.

B. During the document review process on the morning of March 30, 2011 the following records for the hood could not be provided by the Facility. These deficiencies can lead to poorly maintained system which can fail when needed causing patient, staff and visitor injuries.

1. Hood suppression system installation and semi-annual suppression system in accordance with NFPA 25 1998 8-2.

2. Records on the semi-annual hood inspection and cleaning in accordance with NFPA 25 1998 Table 8-3.1.

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Based on random observation during the survey walk-through, not all portions of the facility's Piped in medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. The outside medical gas oxygen manifold room by the Emergency Department was observed at 8:45 am on March 30, 2011 with no top or bottom louvers installed for gravity ventilation of the small room in accordance with 4-3.1.1.1 (c).

This deficiency could cause an oxygen rich atmosphere in which a fire or explosion could injure staff or visitors in the area or staff entering the room.

B. The medical vacuum system was observed at 8:50 am with no check or isolation valves installed in the common exhaust manifold lines for isolating a pump for repair in accordance with 4-3.2.1.9.

This deficiency could cause a failure of the piped vacuum system due to not being able to isolate a failed pump causing patient injury due the loss of suction in the Emergency Department.

C. During the manifold room inspection at 8:45 am the source valve on the oxygen manifold was observed without a durable tag attached for identifying it as the oxygen source valve for the Emergency Department in accordance with 4-3.1.2.3 (a).

D. During the vacuum system inspection the source valve on the receiver was observed without a durable tag attached for identifying it as the vacuum source valve for the areas served by the vacuum system in accordance with 4-3.1.2.3 (a).

Deficiency C and D could cause injury to any patient using the oxygen or vacuum systems in the Emergency Department due to someone shutting of a valve not knowing the areas served by the valve.

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Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. The medical gas tank storage room located at the loading dock at 9:20am on March 30, 2011 was observed with a grill installed in the upper portion of the exterior wall and without a grill in the lower portion for natural ventilation in accordance with 4-3.1.1.2 (b) 4. This deficiency could provide for an accumulation of mixed gasses with an abnormal oxygen concentration for staff breathing. This deficiency could affect staff entering the tank storage room due to an oxygen rich or an oxygen deficient atmosphere which could cause a fire or suffocation.

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Based on staff interview, the building's emergency generator is not installed and maintained in accordance with NFPA 99. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, by preventing hospital staff from being aware that the emergency generator is not able to function.


Findings include:

A. During an interview held in the CEO's Office at 3:01 PM on March 29, 2011, the provider's Plant Operations Manager stated that the emergency generator is not provided with a remote audible alarm annunciator, located at a readily observable site, required by NFPA 99 1999 3-4.1.1.15. and NFPA 110 1999 3-5.6.1.

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A. Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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.

B. Based on document review and staff interview, the facility's Halon system is not inspected, tested, and maintained in accordance with NFPA 12A. These deficiencies could affect all patients in the 25 bed facility, as well as any staff and visitors present, because the failure to maintain the Halon system could result in the failure of the system to function in an emergency condition.

Findings include:

Through document review, it was determined that the facility does not inspect and test the Halon system,.located in the First Floor Radiology Storage Room, on a semi-annual basis as required by NFPA 12A 1997 4-1.1. During an interview held in the CEO's Office at 10:00 AM on March 30, 2011, the provider's Plant Operations Manager confirmed this finding.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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.

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Based on random observation during the survey walk-through, the facility's electrical system is not divided into the critical branch, life safety branch, and the equipment system as required by NFPA 99.

Findings include:

A. At 9:00 AM on March 30, 2011, The Emergency Department Addition's electrical system was observed to not be divided into the Emergency and and Equipment Systems as required by NFPA 99 1999 3-4.2.2.1. and NFPA 70 1999 517-30(b)(1), with the Emergency System not being further broken down into the Life Safety and Critical Branches as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-30(b)(2). At the stated time and date, Panel E, located in the Emergency Department West Passage, was observed to serve both the Life Safety Branch and Critical electrical loads. This deficiency could affect all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the power sources for building life safety components such as exit signs and the fire alarm system are not protected.

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Based on random observation during the survey walk-through, not all portions of the facility's electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. During them walk-through of the Emergency Department at 9:05 on March 30, 2011 patient exam rooms 4 and 5 were observed to have only emergency outlets installed and no circuit from the normal electric system in accordance with 517-19 (a).

This deficiency could cause injury to any patients in any of the exam rooms due to equipment shutting off due a generator failure with no other possible source of electric in the exam room.

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