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Based on observation and interview, the facility failed to provide a two-hour rated construction of 1 of 1 separation walls between business occupancy and health care occupancy. This deficient practice could affect all patients, staff, and visitors of the health care facility.

Findings include:

Based on observation during a tour of the facility with the Director of Environmental Services on 11/29/16 between 9:30 a.m. and 10:00 a.m., the two hour fire wall that separated the medical office building from the hospital contained the following unsealed penetrations:
a) Above the ceiling tiles by the north campus separation doors there was a one inch unsealed hole
b) Above the ceiling tiles by the speech therapy separation doors there was a one inch unsealed pipe sleeve containing wires and a quarter inch unsealed gap around a pipe.
c) Above the ceiling tiles by the DeKalb Business Health separation doors there was a one inch unsealed pipe sleeve containing wires.
d) Above the ceiling tiles by the northeast MAC separation doors there was a one inch unsealed pipe sleeve containing wires and two unsealed one inch penetrations.
Base on interview at the time of observation, the Director of Environmental Services acknowledge the unsealed penetrations and provide the measurements.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 hazardous rooms with fuel fired equipment, was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. LSC 39.3.2.1 states hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops shall be protected in accordance with section 8.7. LSC 8.7.1.3 doors in barriers required to have a fire resistant rating shall have a minimum ¾-hour fire protection rating and shall be self-closing in accordance with 7.2.1.8. This deficient practice could affect all occupants of the building.

Findings include:

Based on observations during a tour of the facility with the Assistant Director of Maintenance on 11/29/16 at 9:29 a.m., the door to the furnace room, which contained a fuel fired furnace and was not sprinkled, was not equipped with a self-closing device. Based on interview, this was acknowledged by the Assistant Director of Maintenance at the time of observation.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 hazardous rooms with fuel fired equipment, was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. LSC 39.3.2.1 states hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops shall be protected in accordance with section 8.7. LSC 8.7.1.3 doors in barriers required to have a fire resistant rating shall have a minimum ¾-hour fire protection rating and shall be self-closing in accordance with 7.2.1.8. This deficient practice could affect all occupants of the building.

Findings include:

Based on observations during a tour of the facility with the Director of Environmental Services on 11/29/16 at 10:50 a.m., the door to the mechanical room, which contained a fuel fired furnace and was not sprinkled, was not equipped with a self-closing device. Based on interview, this was acknowledged by the Director of Environmental Services at the time of observation.

Based on observation and interview the facility failed to maintain vertical openings of a one hour fire resistance rating for 1 of 6 exit stairs. This deficient practice could affect 20 patients using the west hospital stairway exit.

Findings include:

Based on observation during a tour of the facility with the Director of Environmental Services on 11/29/16 at 10:00 a.m., on the first floor above the ceiling tiles by the door to the west hospital stairway exit there was a two inch unsealed hole around the sprinkler line. Based on interview during the observation, the Director of Environmental Services acknowledged the unsealed penetration and provide the measurements.

Based on observation and interview, the facility failed to ensure the corridor door to 2 of over 15 hazardous such as areas storage room over 50 square feet and rooms with soiled materials, was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect 38 patients in 2 of 11 smoke compartments.

Findings include:

Based on observations during a tour of the facility with the Assistant Director of Maintenance on 11/28/16 between 12:30 p.m. and 2:00 p.m., the following hazardous area rooms had doors that lacked a self-closing device or did not automatically latch into the frame:
a) The door to the Biohazard room in the PPG office, which contained soiled materials, was equipped with a self-closing device but did not self-latch into the frame.
b) The door to the supply room B211, which contained combustible storage such as medical supplies in boxes and clean linen; and measured over 50 square feet, was not equipped with a self-closing device.
Based on interview, this was acknowledged by the Assistant Director of Maintenance at the time of observations.

Based on observation and interview, the facility failed to ensure 1 of 1 cooking facilities that served over 30 people was not open to the corridor. This deficient practice could affect all occupants of the building.

Findings include:

Based on observations during a tour of the facility with the Director of Environmental Services on 11/29/16 at 11:30 a.m., neither the two doors from the kitchen to the dining room nor the dining room door to the corridor were equipped with a positive latching device causing the kitchen to be open to the corridor. Based on interview, this was acknowledged by the Director of Environmental Services at the time of observations.

Based on observation and interview, the facility failed to ensure complete automatic sprinkler system was provided for 1 of 1 Quality Director Office closets in accordance with NFPA 13-2010, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice could affect up to 30 people in the main entrance smoke compartment.

Findings include:

Based on observations during a tour of the facility with the Director of Environmental Services on 11/28/16 at 12:34 p.m., the Quality Director Office closet lacked sprinkler coverage due to no sprinkler in the closet. Based on an interview at the time of observation, the Director of Environmental Services acknowledged there was no sprinkler head in the closet.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler heads was continuously maintained in reliable operating condition. This deficient practice was not in a patient care area but could affect up to 10 staff in the maintenance shop.

Findings include:

Based on observations during a tour of the facility with the Director of Environmental Services on 11/28/16 at 12:16 p.m., in the maintenance shop locker room there was a sprinkler head mounted 36 inches below the ceiling, which could delay activation of the sprinkler system in event of a fire. Based on interview during observation, the Director of Environmental Services acknowledged sprinkler heads was mounted 36 inches below the ceiling deck.

Based on observation and interview, the facility failed to ensure there were no impediments to the closing of 3 of 16 office room doors on first floor entry smoke compartment. This deficient practice could affect all patients, visitors, and staff.

Findings include:

Based on observations during a tour of the facility with the Director of Environmental Services on 11/28/16 between 12:00 p.m. and 3:00 p.m. the corridor doors to the following rooms were propped open with a door wedge or held open with a chain:
a) The laundry folding room.
b) The Volunteer Center.
c) The Imaging Office.
Based on interview at the time of observation, this was acknowledged by the Director of Environmental Services.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 7 of 9 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. NFPA 101 2012 edition 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC 8.5. 8.5.2.2 States smoke barriers required by this code shall be continuous from outside wall to outside wall, from floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6.2 Requires penetrations for cable, conduit, pipe, or wire...of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. This deficient practice affects all patients, staff, and visitors in the hospital.

Findings include:

Based on observations during a tour of the facility with the Director of Environmental Services and the Assistant Maintenance Director on 11/29/16 between 10:00 a.m. and 11:30 p.m., the following smoke barrier walls had unsealed pipe sleeves containing wires and unsealed penetrations around pipes, conduits, and/or wires measuring form half of an inch to four inches in size:
a) Above the ceiling tiles of the smoke barrier wall by room 216.
b) Above the ceiling tiles of the smoke barrier wall by room 208.
c) Above the ceiling tiles of the smoke barrier wall by room 301.
d) Above the ceiling tiles of the smoke barrier wall by room 316.
e) Above the ceiling tiles of the smoke barrier wall to PACU.
f) Above the ceiling tiles of the smoke barrier wall by PACU elevators.
g) Above the ceiling tiles of the smoke barrier wall to surgery.
Based on interview at the time of observation, the Director of Environmental Services and the Assistant Maintenance Director acknowledged and provided the measurements of the penetrations.

Based on record review and interview, the facility failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2.
1. Use of alarms.
2. Transmission of alarms to fire department.
3. Emergency phone call to fire department
4. Response to alarms.
5. Isolation of fire.
6. Evacuation of immediate area.
7. Evacuation of smoke compartment.
8. Preparation of floors and building for evacuation.
9. Extinguishment of fire.
This deficient practice affects all patients, staff and visitors in the event of an emergency.

Findings include:

Based on record review on 11/28/16 at 10:55 a.m. with the Director of Environmental Services, the facility's fire safety plan and procedures did not address the emergency phone call to the fire department. Based on interview, this was verified by the Director of Environmental Services at the time of record review.

Based on observation and interview, the facility failed to ensure there were ground-fault circuit interrupters (GFCI) for 4 of 4 wet procedure locations in the O.R. This deficient practice could affect four patients and staff during surgery.

Findings include:

Based on observations during a tour of the facility with the Director of Environmental Services on 11/28/16 between 2:30 p.m. and 3:00 p.m. operating rooms one, two, three, and four did not have any of the electrical outlets GFCI protected or a risk assessment plan conducted. Based on interview at the time of observation, the Director of Environmental Services acknowledged none of the electrical outlets in the operating rooms were GFCI protected and stated a risk assessment was not conducted to show the electrical outlets could be unprotected by a GFCI.

Based on record review and interview, the facility failed to ensure 3 of 3 emergency generators was allowed a 5 minute cool down period after a load test. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 6.4.2.1.5.9 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on record review with the Director of Environmental Services on 11/28/16 at 10:30 a.m., the generator log forms for generators A, B, and C documented the generators were tested monthly for at least 30 minutes under load, however, there was no documentation on the forms that showed the generators had a cool down time following the load tests. Based on interview at the time of record review, the Director of Environmental Services acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 3 of 3 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. This deficient practice could affect up to 20 patients in 2 of 11 smoke compartments

Findings include:

Based on observations during a tour of the facility with the Director of Environmental Services on 11/28/16 between 12:00 p.m. and 3:00 p.m. and on 11/29/16 at 9:05 a.m., the following equipment or high current draw equipment was plug into and supplied power by an extension cord or extension cord power strip:
a) A coffee pot in the Utilization Review office.
b) I.T. equipment in the third floor I.T. closet.
c) A space heater in the Quality Director office.
Based on interview at the time of observations, the power strips and/or extension cords were acknowledged by the Director of Environmental Services.