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Based on observations and staff interviews, the condition of participation for physical environment is not met as the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors, and failed to have a fire watch plan in place for the sprinkler and fire alarm system.

Findings Include:

During a tour of the facility between 05/19/10-05/20/10, the facility was observed on C and D units on the fifteenth floor of a host hospital. The following life safety code violations were observed:

1. Smoke detectors were located 27 inches away from air returns where airflow patterns could prevent the operation of the unit in the following locations: Rooms 5163, 1569, 1571, 1558, 1557, 1556, 1549, 1555, 1554, 1550, 1551, 1553, 1552, 1562, 1572, 1564, 1570, 1569, 1565, and 1566. Staff C measured the distance between the air return grill and the smoke detector in room 1558 at 9:25 AM.

2. The facility was observed with a complete automatic sprinkler system. A review of the facility fire plan policy on 05/20/10 revealed the facility did not have the following fire watch plan in plan: notification of the authority having jurisdiction, person responsible for performing the fire watch, or frequency of the fire watch rounds. This was verified with Staff E on 05/20/10 at 11:45 AM.

3. The facility was observed with a fire alarm system. A review of the facility fire plan policy on 05/20/10 revealed the facility did not have the following fire watch plan in plan: notification of the authority having jurisdiction, person responsible for performing the fire watch, or frequency of the fire watch rounds. This was verified with Staff E on 05/20/10 at 11:45 AM.

Please refer to A709, 482.41; Physical Environment; for more information.

Based on observations and staff interviews, the hospital failed ensure that the life safety from fire requirements were met related to smoke detector placement, and the fire watch plan for the fire alarm and sprinkler systems.

Findings include:

Refer to K51 regarding smoke detector placement. This affected 21 of 23 patient rooms and affects all patients in the facility.

Refer to K154 regarding the lack of a fire watch plan for the sprinkler system.

Refer to K155 regarding the lack of a fire watch plan for the fire alarm system.

Based on observations and staff interviews, the hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA 101 2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This can affect all patients, staff, and visitors in the facility.

Findings include:

Refer to K51 regarding smoke detector placement. This affected 21 of 23 patient rooms and affects all patients in the facility.

Refer to K154 regarding the lack of a fire watch plan for the sprinkler system.

Refer to K155 regarding the lack of a fire watch plan for the fire alarm system.




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