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1. Based on record review and interview, the facility failed to provide suitable procedures to ensure the participation of all persons subject to routine fire drills on each shift for 11 of 12 months. LSC 4.7.2 requires the facility to have suitable procedures to ensure all persons subject to the drill participate. This deficient practice could effect all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of the facility's Fire Drill records and staff interview on 08/26/10 at 1:35 p.m. with the maintenance supervisor, the facility had no evidence or documentation for 11 of 12 months, the personnel on floors or units participated in routine fire drills. The maintenance supervisor stated at at the time of the record review, the facility had started having staff sign fire drills in August, upon the completion and participation of each drill.

2. Based on record review and interview, the facility failed to ensure fire drills were conducted at various times and under various conditions for each shift for 3 of 4 quarters. This deficient practice could effect all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of the facility's Fire Drill records and staff interview on 08/26/10, at 1:45 p.m. with the maintenance supervisor, the third shift fire drills were conducted within the 6:00 a.m. hour for the third and fourth quarters of 2009 and the first quarter of 2010. The maintenance supervisor stated at the time of the record review, he was not aware of the requirement.

1. Based on observation and interview, the facility failed to provide emergency task lighting in and around 1 of 1 generator sets in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, Section 5-3.1 requires EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observation with the maintenance supervisor on 08/26/10 at 3:10 p.m., the generator area lacked battery powered emergency lighting. The maintenance supervisor stated at the time of observation, he was not aware of the requirement.

2. Based on record review and interview, the facility failed to ensure the off site fuel source for 1 of 1 emergency generators was from a reliable source. NFPA 110, 1999 Edition, Standard for Emergency and Standby Power Systems, Chapter 3, Emergency Power Supply (EPS), 3-1.1, Energy Sources states the following energy sources shall be permitted for use for the emergency power supply (EPS):
a) Liquid Petroleum products at atmospheric pressure
b) Liquefied petroleum gas (liquid or vapor withdrawal)
c) Natural or synthetic gas
Exception: For Level 1 installations in locations where the probability of interruption of off site fuel supplies is high (e.g., due to earthquake, flood damage or demonstrated utility unreliability), on site storage of an alternate energy source sufficient to allow full output of the emergency power supply system (EPSS) to be delivered for the class specified shall be required, with provision for automatic transfer from the primary energy source to the alternate energy source. CMS requires evidence of reliability of the natural fuel source must contain all of the following:
1. A statement of reasonable reliability of the natural gas delivery;
2. A brief description the supports the statement regarding the
reliability;
3. A statement there is a low probability of interruption of the natural
gas;
4. A brief description that supports the statement regarding the low
probability of interruption;
5. The signature of technical personnel from the natural gas vendor.
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the maintenance supervisor at 1:50 p.m. on 08/26/10, the fuel source for the emergency generator was natural gas and the facility does not have a letter from their natural gas provider stating the fuel source for the generator is a reliable source. The maintenance supervisor stated at the time of observation, he was not aware of the requirement.

Based on observation and interview, the facility failed to ensure 1 of 1 alcohol hand sanitizing dispensers in the nurses' station was not installed over, or adjacent to, ignition sources such as electrical switches and outlets which may arc during normal use creating an ignition source. LSC 19.1.1.3 requires all health care facilities to be designed, constructed, maintained and operated to minimize the possibility of a fire emergency. This deficient practice could affect all patients, staff and visitors.
Findings include:

Based on observation on 08/26/10 at 2:50 p.m. with the maintenance supervisor, the hand sanitizing dispenser in the nurses' station had the dispenser mounted within 12 inches, or less, over a light switch and next to a thermostat. The maintenance supervisor stated at the time of the observation he was aware of the problem.