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While surveying the facility with the physical plant manager and the facility safety officer, the inspector observed through functional examination that the exit door in the required means of egress opening directly outside from the Intensive Care Unit Wing opened with excessive force. The door required considerable force to open in violation of the standard as defined by NFPA 101 Life Safety Code sections 19.2.1 and 7.2.1.4.5:
NFPA 101, section 7.2.1.4.5: The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width.

While surveying the facility with the physical plant manager and the facility safety officer, the inspector observed through functional testing of battery powered emergency lights (for a duration of 30 seconds) that the following emergency lighting units failed to meet the standard:
1. The battery powered emergency light behind the nurse's station on the medical/surgical wing failed to function when tested.
2. The battery powered emergency light in the MRI trailer was found to have one nonfunctioning lighting head (out of the two lighting heads located on the unit).

While surveying the facility with the physical plant manager and the facility safety officer, the inspector observed through review of facility documentation pertaining to fire drills that the facility failed to meet the standard (NFPA 101, section 19.7.1.2) based upon the following observations:
1. The facility failed to conduct fire drills as required by the standard for the second shift (1500 to 2300 hrs). Only two fire drills were conducted for second shift staff over the past year (May 6, 2011 at 1500 hrs and February 12, 2012 at 1530 hrs). In addition a period of over 8 months passed between fire drills for second shift staff.

While surveying the facility with the physical plant manager and the facility safety officer, the inspector observed that no fire sprinkler protection was provided below the suspended ceiling level in the public bathrooms located off the main corridor. Two bathrooms (one men's bathroom and one women's bathroom) were observed to lack fire sprinkler protection as required by the standard.

While surveying the facility with the physical plant manager and the facility safety officer, the inspector observed the following deficiencies in the facility medical gas systems:
1. A removable rubber backed carpet was observed on the floor of the medical gas storage room housing the nitrous oxide medical gas manifold supply system. NFPA 99 Health Care Facilities, section 4-3.1.1.2(5) prohibits flammable materials in storage locations for nitrous oxide.
2. A wheeled clothing rack containing surgical scrubs was observed located in front of the medical gas emergency shutoff panel for the recovery area in the surgical suite. The clothing rack restricting access to the shutoff panel for the recovery area was immediately removed by facility staff when the violation was brought to the attention of the plant manager and safety officer.

While surveying the facility with the physical plant manager and the facility safety officer, the inspector observed a single acetylene cylinder located in the storage room off the plant operations area (housing the clean agent fire suppression system). The use or storage of flammable gas cylinders within buildings (other than storage or industrial occupancies) is prohibited in accordance with NFPA 1 Uniform Fire Code (2006 edition) section 63.2.3.1.3.1 as adopted by the State of Maine pursuant to Title 25 MRSA, Section 2452.

While surveying the off site facilities with the physical plant manager and the facility safety officer, the inspector observed the following deficiencies in business occupancies associated with the hospital:
1. The battery powered emergency light in the Medical Office Building corridor outside the fire sprinkler room was found to have a broken/faulty test button that would not allow for testing of the light in accordance with the standard.
2. In the Topsham Rehab Building (3 Horton Place in Topsham) the room containing the fuel fired, wall mounted, boiler unit was not equipped with a device that self-closes and positively latches the door that serves the room.

While surveying the facility with the physical plant manager and the facility safety officer, the inspector observed the following deficiency pertaining to the facility emergency power supply system (EPSS):
1. The facility failed to exercise the EPSS generator under load for a minimum of 30 minutes in November of 2011 and December of 2011, as indicated by facility EPSS testing/inspection documentation. Interview with the facility electrician confirmed that load testing had not occurred during the two months absent from the facility load testing records for the EPSS.