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Based on observation during tour and staff interview, 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. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The facility census at the time of the survey was 26 and a capacity of 32. This affected all 21 of 23 patient rooms, and all patients in the facility.

Findings include:

Tour of the facility's main building took place on 05/20/10 between 9:15 AM through 9:37 AM with Staff C (Chief Executive Officer) and Staff D (Division President).

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.

This was verified with Staff C and D on 05/20/10 during tour.

Based on staff interview and fire policy reviews, the facility failed to have a policy in place for the automatic sprinkler system is out of service for more than 4 hours in a 24-hour period in accordance with the code at 9.7.6.1. This affects all patients, staff, and visitors in the facility.

Findings include:

During this visit between 05/19/10-05/20/10, the facility was observed located on C and D units on the fifteenth floor of a host hospital. 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.

Based on staff interview and fire policy reviews, the facility failed to have a policy in place for the fire alarm system is out of service for more than 4 hours in a 24-hour period in accordance with the code at 9.7.6.1. This affects all patients, staff, and visitors in the facility.

Findings include:

During this visit between 05/19/10-05/20/10, the facility was observed located on C and D units on the fifteenth floor of a host hospital. 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.