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Based on observations, review of floor plans, and staff interviews, the facility failed to meet the provisions of the Life Safety Code, National Fire Protection Association, 18.1.1.4.2 and 8.2.3.2.1, related to fire barriers. This could affect all patients in the facility. The total census during this visit was 264 patients.

Findings include:

A tour was conducted on 12/06/11, between 8:10 AM and 12:10 AM, with Staff A, B, D, and G. Observations were conducted in the new in-patient units on the fourth and fifth floors of the new tower, Building D.

Observations were conducted of the fourth and fifth floor connectors to in-patient units in existing building C. A pair of double doors, each equipped with positive latches, were observed located at the end of the connector and the beginning of Building C (two hour fire rated barrier) on the fourth and fifth floors. These doors were equipped with piano hinges that went from the top to the bottom sides of the doors. There were no visible fire rating labels on the doors due to the piano hinges. Staff A, B, D, and G verified these doors lacked a visible fire rating label at the time of tour.

Staff A, B, D, and G verified these doors lacked a visible fire rating label at the time of tour.

Based on observations, review of floor plans, and staff interviews, the facility failed to meet the provisions of the Life Safety Code, National Fire Protection Association, 18.2.5 and 7.8, related to exit discharge lighting. This could affect all patients in the facility. The total census during this visit was 264 patients.

Findings include:

A tour was conducted on 12/06/11, between 8:10 AM and 12:10 AM, with Staff A, B, D, and G. Observations were conducted in the new in-patient units on the fourth and fifth floors of the new tower, Building D. Exit discharges were also observed on the main level, and linen/trash chute rooms were observed on the lower level.

During this tour, the following areas were observed:
Two of three exit discharges were observed without discharge lighting outside the exits. This involved the A side stairwell, and the middle stairwell which exited in the middle of the building on the main level. Observations outside these exit discharges revealed construction is currently ongoing, and these exit discharges lacked any sources of lighting.

Based on observations, review of floor plans, and staff interviews, the facility failed to meet the provisions of the Life Safety Code, National Fire Protection Association, 9.5, and NFPA 82, 3-2.4.3 related to linen and trash chutes. This could affect all patients in the facility. The total census during this visit was 264 patients.

Findings include:

A tour was conducted on 12/06/11, between 8:10 AM and 12:10 AM, with Staff A, B, D, and G. Observations were conducted in the new in-patient units on the fourth and fifth floors of the new tower, Building D. Exit discharges were also observed on the main level, and linen/trash chute rooms were observed on the lower level.

During this tour, the following areas were observed:
The trash chute rooms on the 4th and 5th floors were each observed with two trash chute doors in each room. The trash chute doors were equipped with positive latching, self-closing door mechanisms, and were observed with a label stating 1 and 1/2 hour fire resistance rating. The trash chute room was observed located by rooms D05307 and D05418. At 9:25 AM, when tested, one of the two chute doors failed to self-close when opened and released during testing.

Observations in the lower level, in the discharge rooms for the linen and trash chute, revealed these rooms were equipped with positive, self-closing doors; however, neither door closed and latched into the frame when tested. The linen chute and trash chute were each equipped with a fusible link; however, observations, and interview with Staff A revealed these fusible links had not been connected due to ongoing construction. Staff A and D both verified these room doors failed to latch, and the fusible links were not connected.