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The facility failed to ensure complete two-hour fire rated wall assemblies between the hospital building and the adjoining nonconforming Ambulance Garage. A two-hour fire resistive rated wall separated the hospital from the Ambulance Garage. Observation determined the 90-minute fire rated door in the occupancy separation wall failed to latch into its frame.

The facility failed to ensure the existing type of building construction met the required building construction type required in Chapter 19.

Observation determined:1) The one-hour fire rated ceilings had multiple unsealed spaces throughout the basement and the first floor.

2) An unprotected structural column in the Boiler Room.3) Fire-rated ceiling tiles were removed above the Laminar Hood in Pharmacy.

The facility failed to provide corridors that were separated from use areas by walls with at least ?-hour fire resistance rating.

Observation determined the first floor corridor walls did not extend to the fluted deck.

1) Unsealed spaces were not sealed with fire rated materials between the steel support beam and the concrete block wall supporting the beam. 2) Unsealed spaces were not sealed with fire rated materials at the head of wall joint between the steel beam and the fluted roof deck.

The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the door closed and resistant to the passage of smoke.

Observation determined:

1) The lack of positive latching hardware on the door to the Basement AHEC Storage Room.

2) The presence of a carpet transition strip beneath the north door to the Activity Room resulted in a force greater than fifteen (15) lbf. to open the door.
3) The Emergency Room waiting area had no door separating the room from the corridor. The area had no smoke detector.

The facility failed to ensure doors to stair enclosures were self-closing and automatic latching.

Observation determined the first floor exit stairway door for the "Old Laboratory Area" did not automatically latch into its frame.

The facility failed to ensure two (2) of two (2) smoke barriers within the facility were smoke resisting and had a fire resistance rating of at least one-half hour.

Observation determined the north and south smoke barriers had multiple openings around pipes, conduits and low voltage wires penetrating the smoke barriers. These spaces were not properly sealed with appropriate fire sealant materials, existing applications of fire caulk had fallen away, or the installation was incomplete.

The facility failed to separate four (4) of six (6) hazardous areas from other spaces with construction having a one-hour fire resistance rating.

Observation determined:

1) Unsealed spaces around five (5) through-wall pipe penetrations of the west Boiler Room wall into the Boiler Room exit stairway enclosure.

2) Multiple unsealed spaces in the fire-rated ceiling in the basement "Old Radiology Storage Room". 3) Unsealed spaces in the fire-rated ceiling in the Medical Records Storage Room ceiling.4) Unsealed spaces filled with fiberglass insulation around multiple through-wall pipe penetrations of the south Boiler Room wall.
5) The first floor Supply Room door did not self-close to the latched position.

The facility failed to ensure all components of the means of egress were provided with emergency lighting of at least 1? hour duration. 7.9., 19.2.9.1.Interview with Maintenance Staff determined the emergency generator had not been interconnected to automatically provide emergency lighting to the southeast exit stairway from the basement and the new construction adjacent to the new elevator in the hospital (adjacent to the occupancy separation between the clinic and the hospital).

The facility failed to conduct quarterly fire drills on each shift. Fire drill records review determined a fire drill was not conducted on the night shift during the fourth quarter of 2012.

The fire alarm system must be in compliance with NFPA 72. This standard requires an annunciation panel located at a constantly occupied area.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the manufacturer's specifications. NFPA 72, 7-1.1.1.

1) The annunciation panel must monitor the fire alarm panel's primary functions:

a) Audible and visible signal that would indicate system trouble.

b) Visible signals that indicate which fire alarm zone is into alarm.

c) Audible and visible monitor of the fire alarm system supervisory signal.

Observation determined the fire alarm panel was located in the Boiler Room, which was not constantly attended.

2) Interview with Maintenance Staff determined fire alarm system components (two smoke detectors, fire alarm horn, fire alarm manual pull station and two sprinklers) were not interconnected to the hospital fire alarm system. Staff indicated these components sound the fire alarm system in the clinic building, not in the hospital. These fire alarm system and sprinkler system components were installed in the newly constructed portion of the hospital adjacent to the north side of the occupancy separation wall between the clinic addition and the hospital.
3) Manual fire alarm boxes must be located within 5 ft. of the exit doorway opening at each exit on each floor. 2-8.2.2.A fire alarm manual pull station was not located at newly constructed SE exit stair.

The facility failed to test the fire alarm system monthly.

Records review determined the facility failed to test the fire alarm system during the months of June, July, September, October, and November 2012.

The facility failed to ensure loosely hanging fabrics serving as decorations were flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. Records review determined:1) No documentation was available that would indicate the flame retardant properties of the materials for the quilt in the AHEC Office. 2) No documentation was available that would indicate the flame retardant properties of the materials for the large wall hanging in the Administrator's Office.

The facility failed to ensure the relative humidity was maintained equal to or greater than 35% in the Operating Room.

Review of the facility's policy indicated the relative humidity was to be maintained between 30% and 60% in the Operating Room.

Means of egress must have exit and directional signs with continuous illumination visible from any direction of exit access. 7.10, 39.2.10.The facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit.
Observation determined two (2) of two (2) exit signs were not illuminated.

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined multiple powerstrips located throughout the facility were used in place of permanent wiring.

The facility failed to ensure complete two-hour fire rated wall assemblies between the hospital building and the adjoining nonconforming Ambulance Garage. A two-hour fire resistive rated wall separated the hospital from the Ambulance Garage. Observation determined the 90-minute fire rated door in the occupancy separation wall failed to latch into its frame.

The facility failed to ensure the existing type of building construction met the required building construction type required in Chapter 19.

Observation determined:1) The one-hour fire rated ceilings had multiple unsealed spaces throughout the basement and the first floor.

2) An unprotected structural column in the Boiler Room.3) Fire-rated ceiling tiles were removed above the Laminar Hood in Pharmacy.

The facility failed to provide corridors that were separated from use areas by walls with at least ?-hour fire resistance rating.

Observation determined the first floor corridor walls did not extend to the fluted deck.

1) Unsealed spaces were not sealed with fire rated materials between the steel support beam and the concrete block wall supporting the beam. 2) Unsealed spaces were not sealed with fire rated materials at the head of wall joint between the steel beam and the fluted roof deck.

The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the door closed and resistant to the passage of smoke.

Observation determined:

1) The lack of positive latching hardware on the door to the Basement AHEC Storage Room.

2) The presence of a carpet transition strip beneath the north door to the Activity Room resulted in a force greater than fifteen (15) lbf. to open the door.
3) The Emergency Room waiting area had no door separating the room from the corridor. The area had no smoke detector.

The facility failed to ensure doors to stair enclosures were self-closing and automatic latching.

Observation determined the first floor exit stairway door for the "Old Laboratory Area" did not automatically latch into its frame.

The facility failed to ensure two (2) of two (2) smoke barriers within the facility were smoke resisting and had a fire resistance rating of at least one-half hour.

Observation determined the north and south smoke barriers had multiple openings around pipes, conduits and low voltage wires penetrating the smoke barriers. These spaces were not properly sealed with appropriate fire sealant materials, existing applications of fire caulk had fallen away, or the installation was incomplete.

The facility failed to separate four (4) of six (6) hazardous areas from other spaces with construction having a one-hour fire resistance rating.

Observation determined:

1) Unsealed spaces around five (5) through-wall pipe penetrations of the west Boiler Room wall into the Boiler Room exit stairway enclosure.

2) Multiple unsealed spaces in the fire-rated ceiling in the basement "Old Radiology Storage Room". 3) Unsealed spaces in the fire-rated ceiling in the Medical Records Storage Room ceiling.4) Unsealed spaces filled with fiberglass insulation around multiple through-wall pipe penetrations of the south Boiler Room wall.
5) The first floor Supply Room door did not self-close to the latched position.

The facility failed to ensure all components of the means of egress were provided with emergency lighting of at least 1? hour duration. 7.9., 19.2.9.1.Interview with Maintenance Staff determined the emergency generator had not been interconnected to automatically provide emergency lighting to the southeast exit stairway from the basement and the new construction adjacent to the new elevator in the hospital (adjacent to the occupancy separation between the clinic and the hospital).

The facility failed to conduct quarterly fire drills on each shift. Fire drill records review determined a fire drill was not conducted on the night shift during the fourth quarter of 2012.

The fire alarm system must be in compliance with NFPA 72. This standard requires an annunciation panel located at a constantly occupied area.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the manufacturer's specifications. NFPA 72, 7-1.1.1.

1) The annunciation panel must monitor the fire alarm panel's primary functions:

a) Audible and visible signal that would indicate system trouble.

b) Visible signals that indicate which fire alarm zone is into alarm.

c) Audible and visible monitor of the fire alarm system supervisory signal.

Observation determined the fire alarm panel was located in the Boiler Room, which was not constantly attended.

2) Interview with Maintenance Staff determined fire alarm system components (two smoke detectors, fire alarm horn, fire alarm manual pull station and two sprinklers) were not interconnected to the hospital fire alarm system. Staff indicated these components sound the fire alarm system in the clinic building, not in the hospital. These fire alarm system and sprinkler system components were installed in the newly constructed portion of the hospital adjacent to the north side of the occupancy separation wall between the clinic addition and the hospital.
3) Manual fire alarm boxes must be located within 5 ft. of the exit doorway opening at each exit on each floor. 2-8.2.2.A fire alarm manual pull station was not located at newly constructed SE exit stair.

The facility failed to test the fire alarm system monthly.

Records review determined the facility failed to test the fire alarm system during the months of June, July, September, October, and November 2012.

The facility failed to ensure loosely hanging fabrics serving as decorations were flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. Records review determined:1) No documentation was available that would indicate the flame retardant properties of the materials for the quilt in the AHEC Office. 2) No documentation was available that would indicate the flame retardant properties of the materials for the large wall hanging in the Administrator's Office.

The facility failed to ensure the relative humidity was maintained equal to or greater than 35% in the Operating Room.

Review of the facility's policy indicated the relative humidity was to be maintained between 30% and 60% in the Operating Room.

Means of egress must have exit and directional signs with continuous illumination visible from any direction of exit access. 7.10, 39.2.10.The facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit.
Observation determined two (2) of two (2) exit signs were not illuminated.

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined multiple powerstrips located throughout the facility were used in place of permanent wiring.