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Based on observation the hospital failed to maintain the required two hour fire barrier between the hospital and the nonconforming clinic that was a business occupancy.
Failure to maintain the required 2 hour fire barrier between the hospital and other occupants places the patients at risk for injury in the case of a fire.

Finding:

On 11/1/2011 the surveyor observed a one and one half (1-1/2) hour fire rated door in the 2 hour fire wall that separated the hospital from the clinic that did not close and latch. The fire door was located in the corridor adjacent to the hospital waiting room and reception area.
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Based on observation the hospital failed to maintain doors protecting corridor openings to resist the passage of smoke and to ensure that there are no impediments to the closing of the doors. Failure of the doors to close and latch could result in toxic products of combustion and smoke to enter from the rooms into the exit corridor.

Findings:

1. On 11/1/2011 the surveyor observed the door between Trauma Room #1 and the exit access corridor in the emergency department was unable to close. This was due to electrical cords from a computer on wheels that passed through the trauma room doorway. The computer was plugged into an electrical receptacle in the hallway and then moved into the trauma room.

2. On 11/1/2011 the surveyor observed that patient room #112 door in the exit corridor did not close and latch.

3. On 11/1/2011 the surveyor observed the door between the blood draw room and the exit corridor had a kick down door stop which could restrict the door from closing.

Based on observation the hospital failed to maintain the separation of hazardous areas and the exit corridor. Failure to maintain this separation risks possible injury to the patients from the spread of toxic products of combustion and smoke from a hazardous area into the exit corridor and into the smoke compartment with patient sleeping rooms.

Finding:

On 11/1/2011 the surveyor observed that the combined soiled linen/soiled utility behind the nurses station in the acute care unit did not have a latching device on the door and the door failed to close and latch.

Based on observation and staff interviews the hospital failed to ensure hospital staff carried keys to the patient locked seclusion room at all times. Failure by hospital staff to carry keys to the patient seclusion room at all times causes a risk for a patient to be locked in the room and staff unable to unlock the door in an emergency.

Finding:

1. On 11/1/2011 the surveyor observed the seclusion room in the emergency department with an automatic magnetic door lock that locked upon closing. A key was required to unlock the magnetic door lock or the door lock was released with activation of the fire alarm.

2. The surveyor interviewed three staff in the emergency department and asked if they had keys to the seclusion room and 2 of 3 staff did not have keys with them or they were not aware they had keys. Staff Member #5, who was in the Emergency Department at the time of the survey, said he/she did not have a key with him/her at the time. Staff Member #11 who worked in the Emergency Department reported to the surveyor that he/she did not have a key to the seclusion room. It was later determined that Staff Member #11 did have a key, but the key was mislabeled on his/her key ring.

3. Nursing staff at the acute care nursing station said they would be expected to assist the Emergency Department with patient care if needed, but they did not have keys to the seclusion room.
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Based on record review it was determined that the hospital failed to conduct fire drills at least quarterly on each shift to ensure that staff are familiar with fire safety procedures and can assist the patient in an emergency.

The lack of fire drill training for the facility staff places the patients at risk for injury in an emergency and in the case of a fire.

Findings include:

On 11/1/2011 during a review of the fire drill records the surveyor found that the hospital missed fire drill training for two shifts during the first quarter of 2011. Only one fire drill was conducted on January 31 at 2:06 PM for the quarter.

Also fire drills were missed during the third quarter of 2011 for the night shift.

Based on observation and review of equipment records the hospital failed to maintain records on site to document that the cooking facilities are being maintained and serviced semi-annually. Failure to maintain the hood and duct fire suppression system could result in the system not operating properly in the event of a fire.

Finding:

On 11/1/2011 during a review of the service records for the duct fire suppression system the surveyor found that the inspection of fire suppression system was not always completed on a semi annual basis. The semi annual inspections were completed on April 28, 2010 and on March 15, 2011.

Based on observation the hospital failed to restrict the use of portable electric heaters in the hospital patient areas. Failure to not restrict the use of portable electric heaters in patient care areas could result in injury to the patients.

Finding:

During a tour of the patient care areas on 11/1/2011 the surveyor observed portable electric heaters in rooms #114 and #115. Both of these former patient rooms were converted to offices and the offices were located within the same smoke compartment as the patient sleeping rooms.
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Based on observation the hospital failed to maintain the means of egress free of obstructions to allow full instant use in the event of a fire or other emergencies. Failure to not block the hallways could result in delayed evacuation of patients in the case of a fire.

Finding:

During fire life safety tour on 11/1/2011 the surveyor observed items stored in the exit corridor of the emergency department at the ambulance entrance. The items in the exit corridor included: a patient bedside table, a trash can of greater than 32 gallon capacity, a cloth linen hamper, a walker, and a bio-hazard container.

Based on observation the hospital failed to store trash containers with a capacity less than 32 gallons in a room protected as a hazardous area. This could result in a fire within the trash container obstructing the means of egress.

Finding:

On 11/1/2011 the surveyor observed a plastic trash can greater than 32 gallon capacity stored in the corridor of ambulance entrance to the emergency department.


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Based on observation the hospital failed to maintain the electrical wiring and equipment in compliance with the National Electrical Code. Failure to properly maintain electrical wiring could result in a fire from overheating of electrical cords and equipment from improper use.

Finding:

On 11/1/2011 during a tour of the hospital the surveyor observed the following:

1. A multi-outlet power strip plugged into another multi-outlet power strip (piggy backed) at the nurse station in the acute care area.
2. A piggy backed power strip arrangement in the Director of Nursing Services office.
3. Two separate piggy backed power strips in the computer lab.
4. Electric cords passing through the doorway between the computer lab and the Patient Care Services Office that could be damaged when the door is closed.
5. An uncovered electrical receptacle box with exposed wires showing in the lab adjacent to the Unicel DXC 600 chemical analyzer.
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Based on observation the hospital failed to maintain the required two hour fire barrier between the hospital and the nonconforming clinic that was a business occupancy.
Failure to maintain the required 2 hour fire barrier between the hospital and other occupants places the patients at risk for injury in the case of a fire.

Finding:

On 11/1/2011 the surveyor observed a one and one half (1-1/2) hour fire rated door in the 2 hour fire wall that separated the hospital from the clinic that did not close and latch. The fire door was located in the corridor adjacent to the hospital waiting room and reception area.
.

Based on observation the hospital failed to maintain doors protecting corridor openings to resist the passage of smoke and to ensure that there are no impediments to the closing of the doors. Failure of the doors to close and latch could result in toxic products of combustion and smoke to enter from the rooms into the exit corridor.

Findings:

1. On 11/1/2011 the surveyor observed the door between Trauma Room #1 and the exit access corridor in the emergency department was unable to close. This was due to electrical cords from a computer on wheels that passed through the trauma room doorway. The computer was plugged into an electrical receptacle in the hallway and then moved into the trauma room.

2. On 11/1/2011 the surveyor observed that patient room #112 door in the exit corridor did not close and latch.

3. On 11/1/2011 the surveyor observed the door between the blood draw room and the exit corridor had a kick down door stop which could restrict the door from closing.

Based on observation the hospital failed to maintain the separation of hazardous areas and the exit corridor. Failure to maintain this separation risks possible injury to the patients from the spread of toxic products of combustion and smoke from a hazardous area into the exit corridor and into the smoke compartment with patient sleeping rooms.

Finding:

On 11/1/2011 the surveyor observed that the combined soiled linen/soiled utility behind the nurses station in the acute care unit did not have a latching device on the door and the door failed to close and latch.

Based on observation and staff interviews the hospital failed to ensure hospital staff carried keys to the patient locked seclusion room at all times. Failure by hospital staff to carry keys to the patient seclusion room at all times causes a risk for a patient to be locked in the room and staff unable to unlock the door in an emergency.

Finding:

1. On 11/1/2011 the surveyor observed the seclusion room in the emergency department with an automatic magnetic door lock that locked upon closing. A key was required to unlock the magnetic door lock or the door lock was released with activation of the fire alarm.

2. The surveyor interviewed three staff in the emergency department and asked if they had keys to the seclusion room and 2 of 3 staff did not have keys with them or they were not aware they had keys. Staff Member #5, who was in the Emergency Department at the time of the survey, said he/she did not have a key with him/her at the time. Staff Member #11 who worked in the Emergency Department reported to the surveyor that he/she did not have a key to the seclusion room. It was later determined that Staff Member #11 did have a key, but the key was mislabeled on his/her key ring.

3. Nursing staff at the acute care nursing station said they would be expected to assist the Emergency Department with patient care if needed, but they did not have keys to the seclusion room.
.
.

Based on record review it was determined that the hospital failed to conduct fire drills at least quarterly on each shift to ensure that staff are familiar with fire safety procedures and can assist the patient in an emergency.

The lack of fire drill training for the facility staff places the patients at risk for injury in an emergency and in the case of a fire.

Findings include:

On 11/1/2011 during a review of the fire drill records the surveyor found that the hospital missed fire drill training for two shifts during the first quarter of 2011. Only one fire drill was conducted on January 31 at 2:06 PM for the quarter.

Also fire drills were missed during the third quarter of 2011 for the night shift.

Based on observation and review of equipment records the hospital failed to maintain records on site to document that the cooking facilities are being maintained and serviced semi-annually. Failure to maintain the hood and duct fire suppression system could result in the system not operating properly in the event of a fire.

Finding:

On 11/1/2011 during a review of the service records for the duct fire suppression system the surveyor found that the inspection of fire suppression system was not always completed on a semi annual basis. The semi annual inspections were completed on April 28, 2010 and on March 15, 2011.

Based on observation the hospital failed to restrict the use of portable electric heaters in the hospital patient areas. Failure to not restrict the use of portable electric heaters in patient care areas could result in injury to the patients.

Finding:

During a tour of the patient care areas on 11/1/2011 the surveyor observed portable electric heaters in rooms #114 and #115. Both of these former patient rooms were converted to offices and the offices were located within the same smoke compartment as the patient sleeping rooms.
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Based on observation the hospital failed to maintain the means of egress free of obstructions to allow full instant use in the event of a fire or other emergencies. Failure to not block the hallways could result in delayed evacuation of patients in the case of a fire.

Finding:

During fire life safety tour on 11/1/2011 the surveyor observed items stored in the exit corridor of the emergency department at the ambulance entrance. The items in the exit corridor included: a patient bedside table, a trash can of greater than 32 gallon capacity, a cloth linen hamper, a walker, and a bio-hazard container.

Based on observation the hospital failed to store trash containers with a capacity less than 32 gallons in a room protected as a hazardous area. This could result in a fire within the trash container obstructing the means of egress.

Finding:

On 11/1/2011 the surveyor observed a plastic trash can greater than 32 gallon capacity stored in the corridor of ambulance entrance to the emergency department.


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Based on observation the hospital failed to maintain the electrical wiring and equipment in compliance with the National Electrical Code. Failure to properly maintain electrical wiring could result in a fire from overheating of electrical cords and equipment from improper use.

Finding:

On 11/1/2011 during a tour of the hospital the surveyor observed the following:

1. A multi-outlet power strip plugged into another multi-outlet power strip (piggy backed) at the nurse station in the acute care area.
2. A piggy backed power strip arrangement in the Director of Nursing Services office.
3. Two separate piggy backed power strips in the computer lab.
4. Electric cords passing through the doorway between the computer lab and the Patient Care Services Office that could be damaged when the door is closed.
5. An uncovered electrical receptacle box with exposed wires showing in the lab adjacent to the Unicel DXC 600 chemical analyzer.
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