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Based on observation and interview the facility failed to ensure a door protecting a stairwell was an identifiable fire-rated door assembly. This failed practice placed occupants using stairwell to access the roof at risk for exposure to a smoke and/or fire environment. Findings:

Observation on 10/27/16 at 10:07 am revealed a stairwell (435) connected to the exit corridor (434) contained door that did not contain information indicating its fire-resistant rating.

Review of the facility floor plans on 10/27/16 revealed the door protecting the stairwell (435) was within a 2 hour fire rated wall construction.

The observation was acknowledged by the Safety/Security Manager and Deputy Director of Facilities at the time of its discovery.

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Based on observation and interview the facility failed to ensure exit lights were installed and/or displayed in a manner that indicated the correct direction of egress. This failed practice placed occupants in 6 out of 23 smoke compartments at risk for delayed egress and/or prolonged exposure to a smoke/fire environment.

Observation of the basement elevator lobby (B-20) on 10/26/16 at 11:00 am revealed the lack of an appropriate exit sign indicating path of egress when traveling from either corridor to elevator lobby. Additional observation revealed current exit sign in elevator lobby contained a chevron arrow indicating incorrect direction of egress.

Observation of the ground floor elevator lobby on 10/26/16 at 1:28 pm revealed an exit sign located above the door leading into an exit stairwell (70). Further review revealed this exit sign illuminated both directional chevrons. As installed, it appeared the sign was indicating an exit was located in stairwell and an exit egress incorporated use of the elevators.

Observation of the dental clinic on 10/27/16 at 8:50 revealed an exit sign illuminating both directional chevrons. Further observation revealed the exit sign was to contain only one chevron.

Observations were acknowledged by the Director of Facilities, Safety/Security Manager and Deputy Director of Facilities at the time of their discovery.

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Based on observation, plan review and interview the facility failed to ensure cross corridor smoke barrier were free of unprotected penetrations. This failed practice placed all occupants in 4 out of 23 smoke compartments at risk for exposure to a smoke environment. Findings:

Observation of the double doors leading into day surgery on 10/26/16 at 3:15 pm revealed an 8-inch spiral duct that penetrated the wall above the door. Further observation revealed the duct was partially unprotected. As a result, the penetration did not prevent the passage of smoke.

Review of the facility floor plans on 10/26/16 revealed cross corridor door/wall construction was identified by the facility as a one-hour smoke barrier.

The observation was acknowledged by the Safety/Security Manager and Deputy Director of Facilities at the time of its discovery.

Observation of the first floor corridors (E-272 and E-177) on 10/27/16 revealed a wall above the double doors separating first floor west from first floor east contained two unprotected penetrations.

Review of the facility floor plans on 10/26/16 revealed cross corridor door/wall construction (between E-272 and E-177) was identified by the facility as a one-hour smoke barrier.

The observations were acknowledged by the Safety/Security Manager and Deputy Director of Facilities at the time of their discovery.

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Based on record review and interview the facility failed to ensure emergency lighting monthly testing was conducted at 30-day intervals per NFPA 101: Life Safety Code, Chapter 7. This failed practice placed all occupants of the facility at risk for delay in egress due to potential failure of emergency lighting equipment. Findings:

Record review on 10/27/16 of the facility ' s emergency lighting test logs revealed:

· 42 day gap between testing conducted on 4/3/16 and 5/25/16;
· 6 day gap between testing conducted on 6/26/16 and 7/5/16;

· 55 day gap between testing conducted on 8/2/16 and 9/26/16; and

· 16 day gap between testing conducted on 9/26/16 and 10/12/16.

The observation was acknowledged by the Safety/Security Manager and Deputy Director of Facilities at the time of its discovery.

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Based on observation, plan review and interview the facility failed to ensure the sprinkler system was maintained accordingly. Specifically, the facility failed to ensure: 1) a sprinkler head was installed in hazardous room ' s closet; 2) sprinkler heads were free from paint and/or dust debris; 3) sprinkler heads were of the same rating within a single area; 4) sprinkler heads were free from obstructions; 5) one escutcheon plate was in place; and 6) documentation of a fire pump weekly inspections was available for review. These failed practices places all occupants in the facility at risk for exposure to smoke and/or fire environment from a potential failure of sprinkler system components. Findings:

Basement West:

Observation of room B-19 on 10/26/16 at 10:45 am revealed a storage room with significant amount of combustible material. Further review revealed an open-to-room closet (B-19A) did not contain a sprinkler head.

Review of the facility floor plans on 10/26/16 revealed room B-19 and closet B-19A were identified by the facility as a hazardous area protected by a 1-hour fire resistant barrier from the corridor (B-11) and a 2-hour fire resistant barrier from the elevator shaft.

The Director of Facilities confirmed the finding at the time of its discovery.

Observation of stairwell 1322 on 10/26/16 at 10:58 am revealed a painted sprinkler head with moderate amount of dust accumulation.

Observation of fire pump room (B-24B) on 10/26/16 at 11:01 am revealed two sprinkler heads with two different mechanisms of action: one fusible link; the other liquid filled bulb.

During an interview on 10/27/16 at 9:30 am the Facilities Manager confirmed one sprinkler head was rated at 165 degrees Fahrenheit and the other was rated at 155 degrees Fahrenheit.

Ground Floor West:

Observation of the Travel Office (94) on 10/26/16 at 1:00 pm revealed a closet (94B) that contained a sprinkler head with in 6 inches of a lighting fixture.

During an interview on 10/26/16 at 1:00 pm the Safety/Security Manager confirmed the sprinkler head was to close to the lighting fixture.

Observation of medical record storage room (90) on 10/26/16 at 13:02 pm revealed two painted sprinkler heads.

Observation of the main emergency room entrance (E-83) on 10/27/16 at 7:47 am revealed a sprinkler head with significant dust debris accumulation.

Observation of the ground floor west stairwell (E-52B) on 10/27/16 at 8:00 am revealed an upright sprinkler head with large pipes running along the side of the head with possible obstruction of spray pattern.

The observations were acknowledged by the Safety/Security Manager and Deputy Director of Facilities at the time of their discovery.

First Floor West:

Observation of the radiology waiting area on 10/27/16 at 8:30 am revealed a sprinkler head recessed into the ceiling. The deflector of the head was even with the escutcheon plate and ceiling preventing the development of an adequate spray pattern.

This observation was acknowledged by the Safety/Security Manager and Deputy Director of Facilities at the time of its discovery.

Second Floor West:

Observation of the stairwell (273) outside of the critical care unit on 10/26/16 at 2:15 pm revealed a painted sprinkler head.

Observation of the sterile process " prep and pack " area on 10/26/16 at 2:45 pm revealed two sprinkler heads with significant building up of dust debris.

The observations were acknowledged by the Safety/Security Manager and Deputy Director of Facilities at the time of their discovery.


Fourth Floor West:

Observation of room 411 on 10/27/15 at 10:15 am revealed a sprinkler head with a missing escutcheon plate.

Observation of room 432 on 10/27/16 at 10:10 am revealed a sprinkler head recessed into the ceiling. The deflector of the head was even with the escutcheon plate and ceiling preventing the development of an adequate spray pattern.

The observations were acknowledged by the Safety/Security Manager and Deputy Director of Facilities at the time of their discovery.


Miscellaneous Areas:

Record review of the facility's fire alarm documentation on 10/27/16 revealed no documentation of weekly fire pump inspections per NFPA 25 (1998) Table 5-1.1 Summary of Fire Pump Inspection, Testing and maintenance.

During an interview on 10/27/16 at 10:40 the Director of Facilities confirmed the facility did not have any documentation of the weekly inspections.

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Based on observation, interview and policy review the facility failed to ensure no smoking signs were placed on doors of patients using oxygen or on all 12 major entrances to the hospital. This failed practice placed all occupants of the facility at risk for a smoke and/or fire environment. Findings:

Random observations from 10/26-27/16 revealed no signage was used on the doors of patients' rooms that had currently been on oxygen therapy. Additional observations revealed no signage was posted at any of the 12 major entrances to the facility.

During an interview on 10/27/16 at 8:52 am the Deputy Director of Facilities confirmed the facility did not utilize signs on patient's rooms or at any of the 12 major entrances indicating no smoking - oxygen is in use.

Review of the facility's policy "Tobacco Free SEARHC Campus," revised date 2/18/15, revealed "Signs will be placed at all entrances to SEARHC campuses."

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Based on observation and interview the facility failed to ensure documentation was maintained for the semi-annual hood cleaning inspection. This failed practice placed all occupants at risk for loss of dietary services and place occupants in the kitchen at an increased risk for fire potential. Findings:

Observation of the central kitchen hood system from 10/26/16 revealed the hood was coated with an oily residue.

The facility was asked to produce documentation to verify the last hood cleaning inspection on 10/26/16. During an interview on 10/26/16 the Deputy Director of Facilities stated the facility was unable to provide any hood cleaning inspection reports over the past three years.

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Based on observation and interview the facility failed to ensure a portable heating device was not in use within a healthcare occupancy. This failed practice placed all occupants in 1 out of 23 smoke compartments at risk for increase fire potential and exposure to a smoke and/or fire environment. Findings:

Observation on 10/26/16 at 3:30 pm revealed an open-element portable space heater located in room 349 of the Day Surgery Department.

Review of the facility floor plans on 10/26/16 revealed room 349 was identified by the facility as a healthcare occupancy area.
During an interview on 10/26/16 at 3:30 pm, the Safety/Security Manager confirmed the open-element portable heating device was not allowed in the observed area.

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Based on observation and interview the facility failed to ensure oxygen storage in excess of 20,000 ft3 was stored in accordance to NFPA 50: Standard for Bulk Oxygen Systems at Consumer Sites. This failed practice placed all occupants in the building at risk for increase fire potential and/or loss of medical gas services. Findings:

Observation of the central medical gas storage room on 10/26/16 at 11:10 am revealed the following:

· 4 - Liquid Oxygen Tanks (175L - 15L bleed off = 160L à approx. 19,456 ft3);

· 25 - H-Tanks (total approx. 6,225 ft3);

· 50 - E-Tanks (total approx. 1,000 ft3); and

· 3 - D-Tanks (total approx. 46 ft3).

The aggregated total of all oxygen supply equaled approximately 26,727 ft3. Observations and calculations were acknowledged by the Director of Facilities, Safety/Security Manager and Deputy Director of Facilities at the time of their discovery.

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Based on observation and interview the facility failed to ensure: 1) powers trips were used in a safe and appropriate manner; and 2)temporary lighting systems were not being used long term. This failed practice placed occupants in 4 out of 23 smoke compartments at risk for electrical shock and/or increased electrical fire potential. Findings:

Ground Floor:

Observation of the Travel Office (94A) on 10/26/16 at 1:00 pm revealed a refrigerator plugged into a power strip.

Observation of the Travel Office (93) on 10/26/16 at 1:01 pm revealed a set of temporary Christmas-like lights hanging in a window.

During an interview on 10/26/16 at 1:01 pm Travel Office Staff #1 stated the lights had been in place for about one year.

Observation of the medical records room (80) on 10/26/16 at 1:02 pm revealed a refrigerator and microwave was supplied power via a power strip. Further observation revealed the power strip was suspended in air via power cords from the microwave and refrigerator. In addition, a large amount of dust debris was observed accumulated on the power strip itself.

Observation of a physician's office (5) on 10/26/16 at 1:37 pm revealed a refrigerator was plugged into a power strip.

Third Floor West:

Observation of an office area (349) on 10/26/16 at 3:30 pm revealed the use of temporary Christmas-like lighting.

Fourth Floor West:

Observation of room 407 on 10/27/16 at 10:15 am revealed a refrigerator was plugged into a power strip.

These observations were acknowledged by the Security/Saftey Manager and the Deputy Director of Facilities at the time of there discovery.

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