HospitalInspections.org

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that patient's doors protecting corridors at rooms #267 and #268 do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

During the tour for life safety from fire on 7/8/10 at 2:40 pm, patient's sleeping room doors were tested with the facility's Engineer (employee #17) and it was found that patient's sleeping rooms #267 and #268 do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the smoke barrier near the nursing station on the second floor could not close flush to it frame because a piece of wood was holding it open (the hold open device did not work) which is not in accordance with the requirements of the 2000 edition of the Life Safety Code of the NFPA Sections 7.2.1.8.2.

Findings include:

The smoke barrier doors (with hold open devices) located on the second floor near the nursing station was observed with the facility's Engineer (employee #17) on 7/8/10 at 3:15 pm with a piece of wood placed under one side of the door leaf holding it in the open position because the hold open device did not work, this can permit smoke, fire and noxious gases to enter the smoke barrier compartment in the event of a fire.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that smoke barriers near nursing stations located at the different wards were found with crash carts that limit the space near these doors which is not in accordance with the requirements of the 2000 edition of the Life Safety Code of the NFPA Sections 19.3.7.4.

Findings include:

During the observational tour of the facility's wards from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm with the facility's Engineer (employee #17), it was found that crash carts are placed within a few feet from the smoke barrier doors located near the nursing stations. Space is needed on each side of the smoke barriers to adequately accommodate those occupants that are within these compartments.

Based on tests and observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in the hallway of the nursery department, hallway ambulatory procedure department, in the physical therapy department, the emergency lamp in operating suite #5 did not work, no evidence was found of the three year battery changes and no evidence was found of the 90 minute annual tests for all emergency lamps as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Engineer (employee #17) from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm in the following areas:
a. In the hallway of the nursery department.
b. In the hallway of the ambulatory procedure department.
c. In the physical therapy department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

2. The EBOL located at operating suite #5 was tested on 7/7/10 at 2:00 pm and provided evidence that it did not work

3. Documentation about tests to emergency lighting reviewed on 7/9/10 at 9:45 am from the hospital provided evidence that the facility is not performing the annual 90 minute tests to all of the emergency battery operated lamps at the facility.

4. No evidence was found on 7/9/10 at 10:30 am of the required three year battery changes for all emergency battery operated lamps at the facility.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17) and Safety Officer (employee #18), it was determined that the facility failed to ensure that a written plan was found at all nursing stations for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 7/9/10 at 10:00 am that personnel have a plan or assignments with specific tasks in the event of an emergency (for example: extinguisher use, circuit breaker shut off, oxygen valve shut off, placing patients in their rooms, closing patient's room doors, etc). All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Safety Officer (employee #18), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation as required by the 2000 edition of the Life Safety Code of the NFPA Section 5.5.

Findings include:

1. Written documents about conducted fire drills for the hospital were reviewed with the facility's Safety Officer (employee #18) on 7/9/10 at 11:00 am and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that smoke detectors are available in the intravenous storage room located near patient's cubicle in the emergency room, housekeeping closets, biohazardous trash closets, autoclave room, physical therapy room, respiratory therapy department, medical record department and pharmacy, fire alarm documentation was not found and strobe lights are needed in public bathrooms as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #17) from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm:
a. The intravenous storage room located near patient's cubicle in the emergency room.
b. The housekeeping closet near operating suites #1 through #5.
c. The biohazardous trash closet of the operating room department.
d. The housekeeping closet near operating suites #6 and #7.
e. The Autoclave room near operating suites #6 and #7.
f. In the physical therapy room.
g. In the Respiratory therapy department.
h. In the medical record department on the ground floor (some areas have smoke detectors but their placement does not allow for complete coverage of the area and other areas do not have smoke detectors).
i. The housekeeping closets near the maternity/delivery room.
j. The housekeeping closet at the ambulatory procedure department.
k. The intravenous storage room at the pharmacy.
l. The smoke detector in the pharmacy department needs to be rearranged to provide full coverage of the area.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 7/9/10 at 10:05 am with the facility's Engineer (employee #17), however no evidence was found of the following:
a. A detailed description of tests performed and readings.
b. Smoke detector sensitivity tests.

3. Patient's and visitor's public bathrooms (both male and female) were visited on 7/9/10 from 9:00 am till 4:00 pm with the facility's Engineer (employee #17) and provided evidence that they do not have strobe lights to alert deaf persons using these bathrooms in the event that the fire alarm is activated.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility is not performing visual inspections, sensing chamber tests or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 7/9/10 at 11:25 am with the facility's Engineer (employee
#17) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response which includes the smoke detectors in the air conditioner system (twice a year).

c. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

d. Location of pull-down stations and tests (monthly).

e. Visible (strobe lights) and audible signal tests (monthly).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that
the automatic sprinkler system for the gift shop and storage area in the basement are installed in accordance with NFPA 13 and is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Findings include:

1. Review of documentation and observations of the sprinkler system on 7/8/10 at 2:00 pm and on 7/9/10 at 9:30 am the following was determined related with NFPA 13 and NFPA 25:
a. No evidence was provided that the sprinkler is interconnected to the fire alarm system.
b. No evidence was found of valve identification signs for the control valve, drain valve or inspector test valve.
c. The sprinkler system alarm is not in an area where it can be heard.
d. No evidence was provided of installation documentation.
e. No evidence was found of the flow and tamper switches, which are electrically connected to the building's fire alarm system.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that the automatic sprinkler system for the gift shop and storage area in the basement are continuously maintained in reliable operating condition and are inspected and tested periodically as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings include:

1. Review of documentation and observations of the sprinkler system on 7/9/10 at 11:00 am, the following was determined related with NFPA 13 for the hospital with the facility's Engineer (employee #17):
a. No evidence was found of any sprinkler maintenance documentation.
b. No evidence was found of any tests performed on the sprinkler system (such as weekly no-flow tests of the fire pump).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that the automatic extinguishing system above the stoves are appropriately designed and maintained as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.2.3, 19.3.2.6 and NFPA 96.

Findings include:

1. The automatic extinguishing system above the stoves was observed on 7/8/10 from 11:00 am till 12:00 noon with the facility's Engineer (employee #17) and failed to provide evidence of the following:
a. Fuel source is automatically disconnected when the extinguishing system is activated.
b. Verification that activation of the extinguishing system activates the facility's fire alarm.
c. Verification that the hood suppression system is UL 300 compliant.
d. Staff are trained in the operation of the hood extinguishing system.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17) and interview, it was determined that the facility failed to monitor means of egress at the back exit door of the kitchen and at the pharmacy department to ensure that it is maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. The back exit door of the kitchen was visited on 7/7/10 at 10:00 am with the facility's dietitian (employee #24) and it provided evidence that it was locked closed. The dietitian stated during an interview on 7/7/10 at 10:05 am "the back door has be closed since 5/12/09 due to the new building construction that is taken place at the back of the hospital". "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

2. The pharmacy department was visited on 7/8/10 at 3:30 pm with the facility's Engineer (employee #17) and provided evidence that the pathway through the secondary exit that passes through the intravenous storage room was blocked by a cart, reducing the access through this route. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #17), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to a sprinkler head from the extinguishing system over the fryer that did not have a protective cover, a multiplug in operating suite #4, the large oxygen container was found with cars parked in close proximity, a large diesel storage tank is measured with a large foldable ruler, the large propane gas tank did not have a seismic shut off, no exit plans were found at the ambulatory procedure department and personnel are using rubbing alcohol throughout the hospital.

Findings include:

1. The stove in the kitchen was observed on 7/8/10 at 11:00 am with the facility's Engineer (employee #17) with a sprinkler head from the extinguishing system over the fryer that did not have a protective cover to ensure that it does not get clogged with built up grease. The sprinkler head was observed with a visible covering of grease in the form of a drop. In the event of a fire the built up grease on this sprinkler head may impede the proper operation of this sprinkler.

2. A multiplug was found directly on the floor in operating suite #4 on 7/7/10 at 2:10 pm with the facility's Engineer (employee #17).

3. The large oxygen container located at the back of the hospital was visited with the facility's Engineer (employee #17) on 7/8/10 at 11:30 am and provided evidence that cars are parked in close proximity of the wall that surrounds this oxygen container. According with NFPA 99 section 4-3.5.2.1 (Gases in cylinders and Liquefied Gases in containers) oxygen shall be maintained to prevent contact with oils, greases, organic lubricants, rubber or other material of organic nature. The facility must determine an acceptable distance from the oxygen container, place signs and mark off the area as "No Parking".

4. The large diesel storage tank located at the back of the hospital was visited with the facility's Engineer (employee #17) on 7/8/10 at 11:40 am and provided evidence that they use a large foldable ruler to measure the amount of diesel in this tank. The tank does not have a gauge to automatically measure the amount of diesel left in the tank. The method of placing the ruler into the tank increases the chance of impurities entering the tank, miscalculations of the amount of diesel left in the tank and in the event of an emergency and the generators are running for a few days, the ruler can not be used to measure the diesel left in the tank. An automatic measuring gauge is also useful and it also emits a signal when the tank reaches a critically low level which allows time to fill the tank before the tank is empty.

5. The large propane gas tank located at the back of the hospital was visited on 7/8/10 at 10:45 am with the facility's Engineer (employee #17) and provided evidence that it is not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required.

6. Cooking personnel (employee #16) at the kitchen failed to know exact procedures to following in the event of a fire as determined on 7/8/10 at 11:40 am.

7. Exit plans (for evacuation purposes) were not observed at the ambulatory procedure department on 7/8/10 at 1:45 pm and these plans shall provide locations of the closest extinguishers, fire hoses and pull stations.

8. Observations made throughout the hospital (operating suites, wards, physical therapy department, nursery and emergency room) from 7/7/10 through 7/9/10 from 9:00 am through 4:00 pm provided evidence that personnel are using rubbing alcohol as a disinfectant. Alcohol is not recommended to disinfect equipment nor should it be used due to its volatile nature.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17) at the kitchen, it was determined that the facility failed to ensure that the kitchen is free of Alcohol based hand rub dispensers as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.2.7.

Findings include:

The kitchen was visited on 7/8/10 at 10:00 am with the facility's Engineer (employee #17) and provided evidence that alcohol based hand rub dispensers were observed throughout the kitchen. Alcohol based hand rub can not be installed in the kitchen due to the alcohol content and its flammability and fire sources at the kitchen.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that patient's doors protecting corridors at rooms #267 and #268 do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

During the tour for life safety from fire on 7/8/10 at 2:40 pm, patient's sleeping room doors were tested with the facility's Engineer (employee #17) and it was found that patient's sleeping rooms #267 and #268 do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the smoke barrier near the nursing station on the second floor could not close flush to it frame because a piece of wood was holding it open (the hold open device did not work) which is not in accordance with the requirements of the 2000 edition of the Life Safety Code of the NFPA Sections 7.2.1.8.2.

Findings include:

The smoke barrier doors (with hold open devices) located on the second floor near the nursing station was observed with the facility's Engineer (employee #17) on 7/8/10 at 3:15 pm with a piece of wood placed under one side of the door leaf holding it in the open position because the hold open device did not work, this can permit smoke, fire and noxious gases to enter the smoke barrier compartment in the event of a fire.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that smoke barriers near nursing stations located at the different wards were found with crash carts that limit the space near these doors which is not in accordance with the requirements of the 2000 edition of the Life Safety Code of the NFPA Sections 19.3.7.4.

Findings include:

During the observational tour of the facility's wards from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm with the facility's Engineer (employee #17), it was found that crash carts are placed within a few feet from the smoke barrier doors located near the nursing stations. Space is needed on each side of the smoke barriers to adequately accommodate those occupants that are within these compartments.

Based on tests and observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in the hallway of the nursery department, hallway ambulatory procedure department, in the physical therapy department, the emergency lamp in operating suite #5 did not work, no evidence was found of the three year battery changes and no evidence was found of the 90 minute annual tests for all emergency lamps as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Engineer (employee #17) from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm in the following areas:
a. In the hallway of the nursery department.
b. In the hallway of the ambulatory procedure department.
c. In the physical therapy department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

2. The EBOL located at operating suite #5 was tested on 7/7/10 at 2:00 pm and provided evidence that it did not work

3. Documentation about tests to emergency lighting reviewed on 7/9/10 at 9:45 am from the hospital provided evidence that the facility is not performing the annual 90 minute tests to all of the emergency battery operated lamps at the facility.

4. No evidence was found on 7/9/10 at 10:30 am of the required three year battery changes for all emergency battery operated lamps at the facility.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17) and Safety Officer (employee #18), it was determined that the facility failed to ensure that a written plan was found at all nursing stations for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 7/9/10 at 10:00 am that personnel have a plan or assignments with specific tasks in the event of an emergency (for example: extinguisher use, circuit breaker shut off, oxygen valve shut off, placing patients in their rooms, closing patient's room doors, etc). All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Safety Officer (employee #18), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation as required by the 2000 edition of the Life Safety Code of the NFPA Section 5.5.

Findings include:

1. Written documents about conducted fire drills for the hospital were reviewed with the facility's Safety Officer (employee #18) on 7/9/10 at 11:00 am and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that smoke detectors are available in the intravenous storage room located near patient's cubicle in the emergency room, housekeeping closets, biohazardous trash closets, autoclave room, physical therapy room, respiratory therapy department, medical record department and pharmacy, fire alarm documentation was not found and strobe lights are needed in public bathrooms as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #17) from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm:
a. The intravenous storage room located near patient's cubicle in the emergency room.
b. The housekeeping closet near operating suites #1 through #5.
c. The biohazardous trash closet of the operating room department.
d. The housekeeping closet near operating suites #6 and #7.
e. The Autoclave room near operating suites #6 and #7.
f. In the physical therapy room.
g. In the Respiratory therapy department.
h. In the medical record department on the ground floor (some areas have smoke detectors but their placement does not allow for complete coverage of the area and other areas do not have smoke detectors).
i. The housekeeping closets near the maternity/delivery room.
j. The housekeeping closet at the ambulatory procedure department.
k. The intravenous storage room at the pharmacy.
l. The smoke detector in the pharmacy department needs to be rearranged to provide full coverage of the area.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 7/9/10 at 10:05 am with the facility's Engineer (employee #17), however no evidence was found of the following:
a. A detailed description of tests performed and readings.
b. Smoke detector sensitivity tests.

3. Patient's and visitor's public bathrooms (both male and female) were visited on 7/9/10 from 9:00 am till 4:00 pm with the facility's Engineer (employee #17) and provided evidence that they do not have strobe lights to alert deaf persons using these bathrooms in the event that the fire alarm is activated.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility is not performing visual inspections, sensing chamber tests or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 7/9/10 at 11:25 am with the facility's Engineer (employee
#17) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response which includes the smoke detectors in the air conditioner system (twice a year).

c. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

d. Location of pull-down stations and tests (monthly).

e. Visible (strobe lights) and audible signal tests (monthly).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that
the automatic sprinkler system for the gift shop and storage area in the basement are installed in accordance with NFPA 13 and is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Findings include:

1. Review of documentation and observations of the sprinkler system on 7/8/10 at 2:00 pm and on 7/9/10 at 9:30 am the following was determined related with NFPA 13 and NFPA 25:
a. No evidence was provided that the sprinkler is interconnected to the fire alarm system.
b. No evidence was found of valve identification signs for the control valve, drain valve or inspector test valve.
c. The sprinkler system alarm is not in an area where it can be heard.
d. No evidence was provided of installation documentation.
e. No evidence was found of the flow and tamper switches, which are electrically connected to the building's fire alarm system.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that the automatic sprinkler system for the gift shop and storage area in the basement are continuously maintained in reliable operating condition and are inspected and tested periodically as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings include:

1. Review of documentation and observations of the sprinkler system on 7/9/10 at 11:00 am, the following was determined related with NFPA 13 for the hospital with the facility's Engineer (employee #17):
a. No evidence was found of any sprinkler maintenance documentation.
b. No evidence was found of any tests performed on the sprinkler system (such as weekly no-flow tests of the fire pump).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17), it was determined that the facility failed to ensure that the automatic extinguishing system above the stoves are appropriately designed and maintained as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.2.3, 19.3.2.6 and NFPA 96.

Findings include:

1. The automatic extinguishing system above the stoves was observed on 7/8/10 from 11:00 am till 12:00 noon with the facility's Engineer (employee #17) and failed to provide evidence of the following:
a. Fuel source is automatically disconnected when the extinguishing system is activated.
b. Verification that activation of the extinguishing system activates the facility's fire alarm.
c. Verification that the hood suppression system is UL 300 compliant.
d. Staff are trained in the operation of the hood extinguishing system.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #17) and interview, it was determined that the facility failed to monitor means of egress at the back exit door of the kitchen and at the pharmacy department to ensure that it is maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. The back exit door of the kitchen was visited on 7/7/10 at 10:00 am with the facility's dietitian (employee #24) and it provided evidence that it was locked closed. The dietitian stated during an interview on 7/7/10 at 10:05 am "the back door has be closed since 5/12/09 due to the new building construction that is taken place at the back of the hospital". "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

2. The pharmacy department was visited on 7/8/10 at 3:30 pm with the facility's Engineer (employee #17) and provided evidence that the pathway through the secondary exit that passes through the intravenous storage room was blocked by a cart, reducing the access through this route. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #17), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to a sprinkler head from the extinguishing system over the fryer that did not have a protective cover, a multiplug in operating suite #4, the large oxygen container was found with cars parked in close proximity, a large diesel storage tank is measured with a large foldable ruler, the large propane gas tank did not have a seismic shut off, no exit plans were found at the ambulatory procedure department and personnel are using rubbing alcohol throughout the hospital.

Findings include:

1. The stove in the kitchen was observed on 7/8/10 at 11:00 am with the facility's Engineer (employee #17) with a sprinkler head from the extinguishing system over the fryer that did not have a protective cover to ensure that it does not get clogged with built up grease. The sprinkler head was observed with a visible covering of grease in the form of a drop. In the event of a fire the built up grease on this sprinkler head may impede the proper operation of this sprinkler.

2. A multiplug was found directly on the floor in operating suite #4 on 7/7/10 at 2:10 pm with the facility's Engineer (employee #17).

3. The large oxygen container located at the back of the hospital was visited with the facility's Engineer (employee #17) on 7/8/10 at 11:30 am and provided evidence that cars are parked in close proximity of the wall that surrounds this oxygen container. According with NFPA 99 section 4-3.5.2.1 (Gases in cylinders and Liquefied Gases in containers) oxygen shall be maintained to prevent contact with oils, greases, organic lubricants, rubber or other material of organic nature. The facility must determine an acceptable distance from the oxygen container, place signs and mark off the area as "No Parking".

4. The large diesel storage tank located at the back of the hospital was visited with the facility's Engineer (employee #17) on 7/8/10 at 11:40 am and provided evidence that they use a large foldable ruler to measure the amount of diesel in this tank. The tank does not have a gauge to automatically measure the amount of diesel left in the tank. The method of placing the ruler into the tank increases the chance of impurities entering the tank, miscalculations of the amount of diesel left in the tank and in the event of an emergency and the generators are running for a few days, the ruler can not be used to measure the diesel left in the tank. An automatic measuring gauge is also useful and it also emits a signal when the tank reaches a critically low level which allows time to fill the tank before the tank is empty.

5. The large propane gas tank located at the back of the hospital was visited on 7/8/10 at 10:45 am with the facility's Engineer (employee #17) and provided evidence that it is not prepared to turn off in the event of an earthquake. The movement from an earthquake can cause metal tubing to crack which may leak gas and can cause an explosion. Seismic shut off devices which automatically turns off the gas at the source is required.

6. Cooking personnel (employee #16) at the kitchen failed to know exact procedures to following in the event of a fire as determined on 7/8/10 at 11:40 am.

7. Exit plans (for evacuation purposes) were not observed at the ambulatory procedure department on 7/8/10 at 1:45 pm and these plans shall provide locations of the closest extinguishers, fire hoses and pull stations.

8. Observations made throughout the hospital (operating suites, wards, physical therapy department, nursery and emergency room) from 7/7/10 through 7/9/10 from 9:00 am through 4:00 pm provided evidence that personnel are using rubbing alcohol as a disinfectant. Alcohol is not recommended to disinfect equipment nor should it be used due to its volatile nature.