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Based on record review and interview, the Madison Hospital failed to ensure the corridors and areas open to the corridors on 1 of 3 floors had an interior finish with a Class A or Class B rating. This deficient practice affects all patients, staff and visitors in the facility.

Findings include:

Based on record review and interview on 08/25/10 at 3:30 p.m. with the maintenance supervisor, the walls of the first floor corridors, spaces open to the corridors and exit ways of the Madison Hospital were covered with wallpaper. The maintenance supervisor stated at the time of record review, he was not sure he had documentation available to show the wallpaper had a Class A or Class B rating.

Based on observation and interview, the facility failed to ensure 2 of 3 sets of smoke barrier doors were free from impediments to closing. This deficient practice affects 40 patients in the Madison Hospital including staff and visitors.

Findings Include:

Based on observations made between 12:45 p.m. and 1:15 p.m. on 08/26/10 with the maintenance supervisor, the smoke barrier doors on the first floor between dietary and the main corridor and in the third floor corridor near patient room 350 were blocked open by door kickstops. The maintenance supervisor stated at the time of observation, he did not know why the doors were held open with door kickstops.

Based on observations and interview, the facility failed to ensure openings through 2 of 6 smoke barriers were protected to maintain the smoke resistance of each smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect patients, staff and visitors of the Madison Hospital.

Findings include:

Based on observation with maintenance supervisor on 08/26/10 between 12:40 p.m. and 2:30 p.m., the sprinkler heads in the first floor house keeping, clean linen an soiled laundry rooms and third floor laundry room of the Madison Hospital lacked an escutcheon plate for each sprinkler head, exposing a gap of more than 1/2 inch in the ceiling, which penetrates the smoke barrier. The maintenance supervisor stated at the time of the observation he was aware of the problem due to patients taking the plates or staff knocking them off.

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 participated 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 interview on 08/25/10 at 3:25 p.m. with the maintenance supervisor, the Madison and geriatric hospitals had no evidence or documentation 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 upon 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 Madison and geriatric hospital's Fire Drill records and staff interview on 08/25/10 at 4:05 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.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panels located in an area not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. LSC 9.6.2.10 refers to NFPA 72, the National Fire Alarm Code. NFPA 72 at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice affects all patients, staff and visitors in the facility.

Findings include:

Based on observation on 08/26/10 at 12:45 p.m. during a tour with the maintenance supervisor, the fire alarm control panel was located in the the Madison Hospital's switchboard room and was not electrically supervised by a smoke detector. The maintenance supervisor stated at the time of observation, he was not aware of the problem.

Based on record review and interview, the facility failed to provide complete written documentation 35 of 35 smoke detectors had been tested to ensure the detectors were within there listed and marked sensitivity range. LSC Section 9.6.1.3 says the provisions of 9.6 cover the basic functions of the fire alarm system, including fire detection systems. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, at 7-3.2.1 states, "Detector sensitivity shall be checked within one year after installation and every alternative year thereafter. After the second required calibration test, if sensitivity tests indicate the detectors have remained within their listed and marked sensitivity ranges, the length of time between calibration tests may be extended to a maximum of five years. If the frequency is extended, records of detector caused nuisance alarms shall be maintained. In zones or areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure each smoke detector is within its listed and marked sensitivity range it shall be tested using the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for the purpose.
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its acceptable sensitivity range.
(5) Other calibrated sensitivity test method acceptable to the authority having jurisdiction.
Detectors found to have sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced. The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of aerosol into the detector. NFPA 72, 7-5.2 requires that inspection, testing and maintenance reports be provided for the owner or a designated representative. It shall be the responsibility of the owner to maintain these records for the life of the system and to keep them available for examination by the authority having jurisdiction. Paper or electronic media shall be acceptable. This deficient practice could effect all occupants in the facility including patients, staff, and visitors.

Findings include:

Based on review of the smoke detector maintenance records on 08/26/10 at 9:30 a.m. with the maintenance supervisor, there was no written documentation available to show smoke detectors in the Madison Hospital had been tested for sensitivity since 01/02/07. The maintenance supervisor stated at the time of record review, he would attempt to obtain timely documentation.

1. Based on observation and interview, the geriatric hospital 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 2:25 p.m., the generator area for the geriatric hospital 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 11:00 a.m. on 08/26/10, the fuel source for the emergency generator was natural gas and the geriatric hospital 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 record review, he was not aware of the requirement.