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Based on observations made on 6/5/2012, the facility failed to ensure that all corridor doors were provided with door hardware which allowed all doors to close to positive latching.

Findings include:

At 8:19 a.m. on the fifth floor, the corridor door was exercised at room #558. After the surveyor opened the door, it would not close to positive latching when the door was closed.

Based on observations made by the surveyor during a tour of the interior and exterior of the hospital on 6/5/2012, the surveyor determined not all exit locations were adequately identified with regard to the direction of exiting from the third floor.

Findings include:

In accordance with NFPA 101 and Section 19.2.10 Marking of Means of Egress; means of egress shall have signs in accordance with Section 7.10. Within Section 7.10.1.2 Exits; the following is noted: "exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access."

Between 8:13 a.m. and 8:18 a.m., the surveyor inspected the means of egress from the southeast stairway enclosure of the third floor across the flat roof deck of the second floor. Although exit signs clearly indicate a means of exiting on to the second floor roof, the exit pathway to a gate at the main entrance on the east side of the third floor is not identified.

Based on surveyor observations made on 6/5/2012, the facility failed to maintain the smoke resistance at all smoke barrier locations.

Findings include:

In accordance with NFPA 101 and 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.

The facility utilizes a product called "EZ Path, (the Carbofil firestop solution)" which is a device that provides means by which the integrity of the smoke barriers can be maintained. There were smoke barrier locations where this product was in use. In some instances, the perimeter of the base of the device had not been installed or maintained to prevent unsealed open penetrations at smoke barrier locations which include the following:

1. As observed at 1:48 p.m. on second floor at the nearest smoke barrier by the Critical Care Unit.

2. As observed at 4:01 p.m. on fourth floor smoke barrier separating rooms #424 and #425.

Based on the surveyor's observations of 6/5/2012, the surveyor determined that not all hazardous areas (when required) were separated from other areas by one hour construction and/or walls (includes ceilings) and were being maintained to prevent the passage of smoke from any hazardous area.

Findings include:

1. At 2:56 p.m. on first floor of the maintenance/plant suite, the fire rated wall near the sprinkler risers was examined by the surveyor. There was an unsealed four inch square penetration in the wall which contained a section of conduit.

2. At 3:25 p.m. above the door which opened into the Information Systems Department, there was an unsealed penetration located about the ceiling tile. The penetration was above the ceiling, was approximately six square inches, and contained 2 blue wires.

Based on surveyor observations made on 6/5/2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

The findings include:

In accordance with Chapter 2-2.1.2 of NFPA 25, storage of materials shall not block the discharge spray pattern of the sprinklers in the event the system is activated. Further, NFPA 13 and Section 5-7.5.3.1 states that continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section.

At 11:02 a.m., the side wall sprinkler located in walk-in cooler #4 was examined by the surveyor. A cardboard box was positioned above a "Cloud box of chopped beef steak". The cardboard box stored on the top of the other box was positioned above the horizontal plane of the side wall sprinkler.

Based on observations made by the surveyor on 6/5/2012, all fire extinguishers were not being properly maintained in accordance with NFPA 10.

In accordance with Section 4-3.2 (b) of NFPA 10 (1998 edition), there shall be "no obstructions to access or visibility" of portable fire extinguishers.

Findings include:

At 3:14 p.m., in "Rehab Services", a fire extinguisher in a cabinet was observed. The extinguisher was not fully accessible because a cart with therapy equipment on the top of it was blocking access to the fire extinguisher.

Based on surveyor observations of 6/4/2012, it was determined there was not an acceptable width for a means of egress for all exit access corridors in the facility.

Findings include:

Any required aisle, corridor, or ramp shall be not less than 4 feet in clear width where serving as means of egress from patient sleeping rooms. The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of non-ambulatory persons carried on stretchers or on mattresses serving as stretchers per section 19.2.3.3 of the Life Safety Code. Where a corridor that is required to be at least 4 feet in width but may be 6 or 8 feet than the wider width must be maintained in a clear and unobstructed manner in accordance with section 4.6.7 of the Life Safety Code.

Between 7:40 a.m. and 7:50 a.m.,two corridors on the patient wings, were inspected by the surveyor. Both corridors were being used to store two wooden bookcases, a stationary padded office chair, a wooden desk, three office chairs and other assorted fixtures or furniture accessories.

On 6/6/2012, it was determined when the hospital's fire alarm system was tested, not all smoke dampers would close when that system was activated.

Findings include:

In accordance with Section 3-4.5.4 of NFPA 90A, 1999 Edition, dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.

Between 7:00 a.m. and 8:30 a.m., the surveyor had smoke dampers located at one hour rated smoke barriers in the hospital tested when the fire alarm system was activated. On the fourth floor, three smoke dampers did not close when the fire alarm system was activated. The surveyor was informed by the Director of Facility Services that a "controller" for air handling unit #2 failed. It was understood that this failure did not allow the three pneumatic operated dampers to close.

Based on the surveyor's observations of 6/5/12 and 6/6/12, it was determined that the facility failed to ensure all requirements of the electrical system and its components were always being maintained in accordance with NFPA 70.

Findings include:

1. In accordance with Article 370.28(c) of NFPA 70 (1999 Edition); all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110. At 12:59 p.m., in the Imaging Department where the MIR equipment is located, an electrical receptacle cover plate was missing at an electrical outlet behind a wastebasket.

2. In accordance with Article 110-22 of NFPA 70, circuits at electrical panels shall be maintained and identified. At 10:32 a.m., electrical panel 3SLA in the area of Obstetrics Department was examined. Circuits numbered #18 and #20, those breaker locations were not labeled. The remaining circuits in the panel were identified or were marked as "spare" on the legend sheet.

Based on observations made on 6/5/2012, the facility failed to ensure that all corridor doors were provided with door hardware which allowed all doors to close to positive latching.

Findings include:

At 8:19 a.m. on the fifth floor, the corridor door was exercised at room #558. After the surveyor opened the door, it would not close to positive latching when the door was closed.

Based on observations made by the surveyor during a tour of the interior and exterior of the hospital on 6/5/2012, the surveyor determined not all exit locations were adequately identified with regard to the direction of exiting from the third floor.

Findings include:

In accordance with NFPA 101 and Section 19.2.10 Marking of Means of Egress; means of egress shall have signs in accordance with Section 7.10. Within Section 7.10.1.2 Exits; the following is noted: "exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access."

Between 8:13 a.m. and 8:18 a.m., the surveyor inspected the means of egress from the southeast stairway enclosure of the third floor across the flat roof deck of the second floor. Although exit signs clearly indicate a means of exiting on to the second floor roof, the exit pathway to a gate at the main entrance on the east side of the third floor is not identified.

Based on surveyor observations made on 6/5/2012, the facility failed to maintain the smoke resistance at all smoke barrier locations.

Findings include:

In accordance with NFPA 101 and 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.

The facility utilizes a product called "EZ Path, (the Carbofil firestop solution)" which is a device that provides means by which the integrity of the smoke barriers can be maintained. There were smoke barrier locations where this product was in use. In some instances, the perimeter of the base of the device had not been installed or maintained to prevent unsealed open penetrations at smoke barrier locations which include the following:

1. As observed at 1:48 p.m. on second floor at the nearest smoke barrier by the Critical Care Unit.

2. As observed at 4:01 p.m. on fourth floor smoke barrier separating rooms #424 and #425.

Based on the surveyor's observations of 6/5/2012, the surveyor determined that not all hazardous areas (when required) were separated from other areas by one hour construction and/or walls (includes ceilings) and were being maintained to prevent the passage of smoke from any hazardous area.

Findings include:

1. At 2:56 p.m. on first floor of the maintenance/plant suite, the fire rated wall near the sprinkler risers was examined by the surveyor. There was an unsealed four inch square penetration in the wall which contained a section of conduit.

2. At 3:25 p.m. above the door which opened into the Information Systems Department, there was an unsealed penetration located about the ceiling tile. The penetration was above the ceiling, was approximately six square inches, and contained 2 blue wires.

Based on surveyor observations made on 6/5/2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

The findings include:

In accordance with Chapter 2-2.1.2 of NFPA 25, storage of materials shall not block the discharge spray pattern of the sprinklers in the event the system is activated. Further, NFPA 13 and Section 5-7.5.3.1 states that continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section.

At 11:02 a.m., the side wall sprinkler located in walk-in cooler #4 was examined by the surveyor. A cardboard box was positioned above a "Cloud box of chopped beef steak". The cardboard box stored on the top of the other box was positioned above the horizontal plane of the side wall sprinkler.

Based on observations made by the surveyor on 6/5/2012, all fire extinguishers were not being properly maintained in accordance with NFPA 10.

In accordance with Section 4-3.2 (b) of NFPA 10 (1998 edition), there shall be "no obstructions to access or visibility" of portable fire extinguishers.

Findings include:

At 3:14 p.m., in "Rehab Services", a fire extinguisher in a cabinet was observed. The extinguisher was not fully accessible because a cart with therapy equipment on the top of it was blocking access to the fire extinguisher.

Based on surveyor observations of 6/4/2012, it was determined there was not an acceptable width for a means of egress for all exit access corridors in the facility.

Findings include:

Any required aisle, corridor, or ramp shall be not less than 4 feet in clear width where serving as means of egress from patient sleeping rooms. The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of non-ambulatory persons carried on stretchers or on mattresses serving as stretchers per section 19.2.3.3 of the Life Safety Code. Where a corridor that is required to be at least 4 feet in width but may be 6 or 8 feet than the wider width must be maintained in a clear and unobstructed manner in accordance with section 4.6.7 of the Life Safety Code.

Between 7:40 a.m. and 7:50 a.m.,two corridors on the patient wings, were inspected by the surveyor. Both corridors were being used to store two wooden bookcases, a stationary padded office chair, a wooden desk, three office chairs and other assorted fixtures or furniture accessories.

On 6/6/2012, it was determined when the hospital's fire alarm system was tested, not all smoke dampers would close when that system was activated.

Findings include:

In accordance with Section 3-4.5.4 of NFPA 90A, 1999 Edition, dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.

Between 7:00 a.m. and 8:30 a.m., the surveyor had smoke dampers located at one hour rated smoke barriers in the hospital tested when the fire alarm system was activated. On the fourth floor, three smoke dampers did not close when the fire alarm system was activated. The surveyor was informed by the Director of Facility Services that a "controller" for air handling unit #2 failed. It was understood that this failure did not allow the three pneumatic operated dampers to close.

Based on the surveyor's observations of 6/5/12 and 6/6/12, it was determined that the facility failed to ensure all requirements of the electrical system and its components were always being maintained in accordance with NFPA 70.

Findings include:

1. In accordance with Article 370.28(c) of NFPA 70 (1999 Edition); all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110. At 12:59 p.m., in the Imaging Department where the MIR equipment is located, an electrical receptacle cover plate was missing at an electrical outlet behind a wastebasket.

2. In accordance with Article 110-22 of NFPA 70, circuits at electrical panels shall be maintained and identified. At 10:32 a.m., electrical panel 3SLA in the area of Obstetrics Department was examined. Circuits numbered #18 and #20, those breaker locations were not labeled. The remaining circuits in the panel were identified or were marked as "spare" on the legend sheet.