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Based on Life Safety Code (LSC) survey, Perry County Memorial Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(d), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

The original hospital building was constructed in 1949 and is a two story structure with a split level basement. A two story structure with a split level basement was added to the south end of the original building in 1952 and a second two story structure with a basement was added to the east side of the original building in 1974. A one story addition with a basement was built in 1994. The original building and the 1952 and 1974 additions were determined to be of Type II (000) construction and partially sprinklered. The basement and the second floor of the original building and the 1952 and 1974 additions are fully sprinklered and the only portions of the first floor which are sprinklered are Medical Records, Radiology and the Gift Shop. The 1994 addition is separated from the other portions of the facility by a two hour rated fire wall and was determined to be of Type I (332) construction and fully sprinklered. The entire facility has smoke detection in all corridors. The facility has a capacity of 25 and had a census of 13 at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure a sprinkler head was installed in 1 of 3 elevator rooms to provide coverage for all portions of the building (see K 056) and failed to ensure the elevator equipment in 1 of 3 elevator equipment rooms was provided with a means for disconnecting the main electrical power supply to the affected elevator machine room automatically upon or prior to the application of water from the sprinkler located in the elevator machine room (see K 160).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review, observation and interview, the facility failed to ensure a sprinkler head was installed in 1 of 3 elevator rooms to provide coverage for all portions of the building and failed to ensure the elevator equipment in 1 of 3 elevator equipment rooms was provided with a means for disconnecting the main electrical power supply to the affected elevator machine room automatically upon or prior to the application of water from the sprinkler located in the elevator machine room.

Findings:

1. Observations with DPO1 and MS1 during a tour of the facility from 11:10 a.m. to 11:25 a.m. on 08/08/13 indicated the Elevator Machine Room in the second floor penthouse was not sprinklered. 19.3.5

2. In interview at the time of observation, DPO1 acknowledged the Elevator Machine Room in the second floor penthouse was not sprinklered.

3. Observations with DPO1 and MS1 during a tour of the facility from 11:10 a.m. to 11:25 a.m. on 08/08/13 indicated the Elevator Machine Room near the Diabetes Education Room was provided with sprinkler protection but lacked a means for disconnecting the main power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. 19.5.3, 9.4.3.2

4. In interview at the time of observation, DPO1 stated the facility has sought electric shunt trip installation quotes but acknowledged a shunt trip device for the aforementioned elevator equipment room has not been installed.