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Based on observations, the facility failed to prevent use of unapproved hold open devices that would impede the closing and latching of exit corridor doors in accordance with NFPA 101, 2000 Edition, Section 18.3.6.3.3.¹² This deficiency could affect the occupants in 1 of 4 smoke compartments.

Findings include:

The exit corridor door to room 401 was exercised at 9:29 a.m. on 11/6/14. The door was held open by a 13 gallon capacity garbage can that belonged to the patient's room.

¹ NFPA 101, 2000 Edition, Section 18.3.6.3.3. Hold-open devices that release when the door is pushed or pulled shall be permitted.

² NFPA 101, 2000 Edition, Annex A.18.3.6.3.3, Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observations, the facility failed to maintain the smoke resistance rating of barriers in accordance with NFPA 101, 2000 Edition, Section 8.3.6.1.¹ The deficiency could affect the occupants in 2 of 4 smoke compartments.

Findings include:

1. The 1-hour rated fire/smoke barrier was observed in the staff Breakroom 212 at 11:30 a.m. on 11/6/14. A green colored cable extended through an unsealed penetration above the ceiling tiles.

2. The 1-hour fire/smoke barrier across from room 306 was observed at 11:34 a.m. on 11/6/14. An open ended conduit extended through the barrier above the ceiling tiles.

3. The 1-hour fire/smoke barrier was observed in "High Ob's" near the nurses' station at 11:45 a.m. on 11/6/14. An open ended conduit extended through the barrier above the ceiling tiles.

¹NFPA 101, 2000 Edition, Section 8.3.6.1, Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and review of construction plans, the facility failed to provide for an automatic sprinkler system coverage for all areas in accordance with NFPA 101, 2000 Edition, Section 18.3.5.1. This deficiency could affect the occupants in 1 of 4 smoke compartments.

Findings include:

The alcove used for clean linen storage on 400 hall was observed at 9:28 a.m. on 11/6/14. The alcove lacked complete sprinkler coverage. The alcove measured three feet by eight feet.

Based on observation and staff interview, the facility failed to maintain the width of an exit corridor in accordance with NFPA 101, 2000 Edition, Section 18.2.3.3.¹ The deficiency could affect the occupants in 1 of 4 smoke compartments.

Findings include:

A patient bed was brought and parked in the Central Supply exit corridor at 3:42 p.m. on 11/5/14. The bed was still there at 5:06 p.m. Staff member A, plant director, stated the patient bed was placed in the hall for a pick up. The crew was late to pick up the bed. He stated exit corridors were not be used for storage.

¹NFPA 101, 2000 Edition, Section 18.2.3.3, Aisles, corridors, and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (2.4 m) in clear and unobstructed width. Where ramps are used as exits, see 18.2.2.6.

Based on observation, the facility failed to maintain requirements of NFPA 70, 1999 Edition, Articles 110-13(a), 110-22, and 240-22 or CMS interpretations.¹ ² ³ This deficiency could affect the occupants in 3 of 4 smoke compartments.
Findings include:

1. Electrical panel ECP2B in the Teledata room 311 was observed at 9:25 a.m. on 11/6/14. The circuit breakers 18, 19, 20 and 21 were in the on positions. The panel directory reflected blank spots for these breakers.¹

2. The High Obs nurses' station was observed at 9:43 a.m. on 11/6/14. A power strip was dangling under the nurses' desk. Several devices were plugged into the power strip.²

3. The electrical panels in 200 hall sub-electrical room were observed at 10:03 a.m. on 11/6/14. The following concerns were noted:¹
a) Circuit breakers 14 through 24 in electrical panel ECL2 were in on positions, but, the panel directory reflected they were spares.
b) Circuit breakers 21 through 33 in electrical panel NL2 were in on positions, but, the panel directory reflected they were spares.
c) Circuit breakers 83, 66, 68, 72 , and 74 in electrical panel NP2 Section II were in on positions, but, the panel directory reflected they were spares.

4. The Physician's Suite 621 was observed at 10:15 a.m. on 11/6/14. Two power strips were daisy chained, then plugged into the wall receptacle. A microwave was plugged into one of the power strips.³

¹ NFPA 70 National Electric Code, 1999 Edition, Article 110-22, Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
² NFPA 70, 1999 Edition, Article 110-13(a), Electrical equipment shall be firmly secured to the surface on which it is mounted (if not temporary in service).
³ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on review of the fire plan and the fire watch policy, the facility failed to ensure the fire watch policy was complete and indicated notification of the authority having jurisdiction (State Agency) whenever the automatic sprinkler system was out of service and a fire watch was instituted in accordance with NFPA 101, 2000 Edition, Section 9.7.6.1. This deficiency could affect the occupants in 4 of 4 smoke compartments.

Findings include:

The fire plan and fire watch policies were reviewed at the facility on 11/5/14. The fire watch policy did not address when the required automatic sprinkler system was out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction (State Agency) would have to be notified. The policy lacked the name Certification Bureau and the contact information (406-444-4170) of the authority having jurisdiction.

Based on review of the fire plan and the fire watch policy, the facility failed to ensure the fire watch policy was complete and indicated notification of the authority having jurisdiction (State Agency) whenever the fire alarm system was down and a fire watch was instituted in accordance with NFPA 101, 2000 Edition, Section 9.6.1.8. This deficiency could affect the occupants in 4 of 4 smoke compartments in the building.

Findings include:

The fire plan and fire watch policies were reviewed at the facility on 11/5/14. The fire watch policy did not address when the fire alarm system was out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction (State Agency) would be notified. The policy lacked the name, Certification Bureau, and the contact information (406-444-4170) of the authority having jurisdiction.