Every finding on record at North Arkansas Regional Medical Center

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 and NFPA 80, it was determined the facility failed to maintain twelve of thirteen fire-rated door assemblies (Office 1-4, Board Room, Staff Room Entry 1, Staff Room Entry 2, Mechanical Room, Conference Room Entry 1, Conference Room Entry 2, Top of Stairwell, Bottom of Stairwell, Clean Room) in accordance with NFPA standards in that ten fire-rated door assemblies (Office 1-4, Board Room, Staff Room Entry 1, Staff Room Entry 2, Mechanical Room, Conference Room Entry 1, Conference Room Entry 2) did not have self-closing devices installed, one fire-rated door assembly (Top of Stairwell) did not fully close and latch when released, and one fire-rated door assembly (Clean Room) was wedged in the open position. Findings follow: A. Review of NFPA 101 2012 Edition: 7.2.1.8.2 showed any door leaf required to be kept closed shall only be held open by a device which automatically releases the door leaf upon operation of a smoke detector and upon loss of power to the device. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. B. Review of NFPA 80 2010 Edition: 5.1.3.2 showed fire-rated doors shall be kept closed and latched or arranged for automatic closing. Review of NFPA 80 2010 Edition: 6.1.4.2.1 showed self-closing doors shall be equipped with a closing device to cause the door to close and latch each time the door is opened. Review of NFPA 80 2010 edition: 5.2.13.3 showed blocking or wedging of doors in the open position shall be prohibited. C. Observation on 7/19/22 from 2:40 to 2:45 pm of the Clean Room showed the doorway was comprised of a fire-rated door assembly which was wedged in the open position by a rubber doorstop stuck under the door leaf. D. Observation on 7/19/22 from 3:00 pm to 3:30 pm of the facility's fire-rated door assemblies showed ten fire-rated door assemblies (Office 1-4, Board Room, Staff Room Entry 1, Staff Room Entry 2, Mechanical Room, Conference Room Entry 1, Conference Room Entry 2) did not have self-closing devices installed and one fire-rated door assembly (Top of Stairwell) did not fully close and latch when released. E. The above findings in C and D were verified with the Director at the times of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, it was determined the facility failed to install eleven alcohol-based hand-rub (ABHR) dispensers at a safe distance from hazardous locations as required by NFPA 101. The failed practice created a fire hazard in eight of eight Patient Rooms (Patient Room 1-8), the Nurse Office, and Staff Office. Findings follow: A. Review of NFPA 101 2012 Edition: 19.3.2.6 (8) showed ABHR dispensers shall not be installed above an ignition source within a 1-inch horizontal distance from each side of the ignition source. B. Observation on 7/19/22 from 2:00 pm to 2:45 pm of the facility's in-patient unit showed all eight Patient Rooms (Patient Room 1 - Patient Room 8) contained an alcohol-based hand-rub (ABHR) dispenser which was installed within one horizontal inch of an electrical light switch in each room. Further observation of the in-patient unit showed the Nurse Office, Guest Room 1, and Staff Office all had an ABHR dispenser installed within one horizontal inch of an electrical light switch in each room. C. The above findings in B were verified with the Director at the times of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 and NFPA 80, it was determined the facility failed to maintain thirteen of thirteen fire-rated door assemblies (Office 1-4, Board Room, Staff Room Entry 1, Staff Room Entry 2, Mechanical Room, Conference Room Entry 1, Conference Room Entry 2, Top of Stairwell, Bottom of Stairwell, Clean Room) in accordance with NFPA standards in that no annual inspection was being conducted of the fire-rated door assemblies in the facility. Findings follow: A. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 Edition: 5.2.1 showed fire door assemblies shall be inspected and tested not less than annually. B. In an interview on 7/20/2022 at 08:30 AM with the Director of Maintenance, it was verified the facility did not conduct any annual inspection or testing of the fire-rated door assemblies in the building.

Based on interview and review of the facility's generator logs and National Fire Protection Association (NFPA) 101 and NFPA 110, it was determined the facility failed to maintain one of one emergency generator as required by NFPA 101 Life Safety Code 2012 Edition in that the emergency generator was not being visually inspected weekly or tested under load monthly to ensure functionality in the event of an emergency. The failed practice had the likelihood to affect all patients, staff, and visitors in that in the event of a power outage emergency the generator may not function properly and could fail to support all equipment and emergency lighting relying on the essential electrical system for emergency power. Findings follow: A. Review of NFPA 101 2012 Edition: 9.1.3 showed emergency generators must be installed and maintained in accordance with NFPA 110 Standard for Emergency and Standby Power Systems. B. Review of NFPA 110 2010 Edition: 8.4.1 showed emergency power supply systems shall be inspected weekly and exercised under load at least monthly. Further review of NFPA 110 2010 Edition: 8.4.2 showed diesel generator sets shall be exercised monthly under load for 30 minutes. C. In an interview on 7/20/2022 at 08:30 AM with the Director of Maintenance it was verified the emergency generator had not been visually inspected weekly or run under load for 30 minutes monthly in the 12 months prior to the survey (August 2021 to July 2022).

Based on interview and review of NFPA 99, it was determined the facility failed to maintain its medical gas system in accordance with NFPA standards in that no regular maintenance was being performed on the system. The failed practice had the likelihood to affect all in-patients relying on oxygen in that the piped medical gas system could fail to deliver the necessary amount of oxygen to patients. Findings follow: A. Review of NFPA 99 2012 Edition: 5.2.14 showed facilities shall have a routine maintenance program for their piped medical gas systems. B. In an interview on 7/20/2022 at 08:30 AM with the Director of Maintenance it was verified the piped medical gas system did not have a routine maintenance program in place.