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The requirement of 2000 NFPA 101, 19.7.2.1 and 19.7.3 was not met.

The Standard:
The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate alarm signal to warn other occupants and summon staff, confinement of the effects of the fire by closing the doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancies fire plan.

Personnel hearing the code (code phrase to ensure transmission of an alarm) shall first activate the building fire alarm system.

Findings:
Documentation and interview on 2/22/2011 revealed the required fire plan was not followed. Staff did not pull the fire alarm manual station to alert the fire department, during the event which occured on 4/23/2010.

The requirement of 1999 NFPA 72 1-5.2.5.2 is not met.

The Standard:
Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL (FACP). The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Findings:
Observation on 2/22/2011 revealed the FACP was not marked with the panel and circuit number providing power and the panel did not have the circuit marked in red and identified as "FACP".

The requirement of NFPA 101, 2000, 4.6.12.2 is not met.

The Standard:
Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings:
During the investigation on 2/22/2011, interview revealed an abandoned master med gas alarm was still in place in the mail room and was not indicated as not in use.