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Based on observation and staff interview the facility failed to provide openings into the corridor that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th, 2014 at 8:44 am, it was observed that the paired exit access doors into the corridor from the OR suite [Main corridor Backstreet] were not equipped with an astragal to prevent the passage of smoke. This facility was constructed in 2002 in accordance to 'New Health occupancy' guidelines which requires astragals at paired door openings into a corridor. Removal of the astragal reduces this opening below the code minimum standards required at the time of construction.

2. On August 5th, 2014 at 9:04 am, it was observed that the east paired exit access doors into the corridor from the ED suite were not equipped with an astragal to prevent the passage of smoke. This facility was constructed in 2002 in accordance to 'New Health occupancy' guidelines which requires astragals at paired door openings into a corridor. Removal of the astragal reduces this opening below the code minimum standards required at the time of construction.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide openings in the smoke compartment barrier that were resistant to the passage of smoke in accordance to NFPA 101 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th, 2014 at 9:50 am, it was observed that the double leaf door in the two-hour fire/smoke barrier was not equipped with an astragal to ensure that the opening was resistant to the passage of smoke. This facility was constructed in 2002 in accordance to 'New Health occupancy' guidelines which requires astragals at openings in a smoke barrier. Removal of the astragal reduces this opening below the code minimum standards required at the time of construction.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 [2000 Ed] Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 5 of 7 smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 4th, 2014 at 3:42 pm it was observed within small Surgery Storage the wall joints were not taped completely and that tape was not fully embedded in joint compound to a one-hour fire barrier standard.

2. On August 4th, 2014 at 3:50 pm it was observed within Biomed Workshop a 1- 1/2" galvanized pipe in the west wall was not fire caulked to a two-hour fire barrier standard.

3. On August 5th, 2014 at 8:00 am it was observed within Laundry that a 1-1/2" polyvinly chloride (pvc) pipe in the west wall was not fire caulked to a one-hour fire barrier standard.

4. On August 5th, 2014 at 8:08 am it was observed within the Main Electrical room that a 3" pipe in the south wall was not fire caulked to a two-hour fire barrier standard.

5. On August 5th, 2014 at 8:12 am it was observed within Housekeeping room that a 3/4" bx cable in the west wall entered a 2"x 2" hole and was not fire caulked to a one-hour fire barrier standard. Note that the annular space around this cable was too large for a fire caulk application.

6. On August 5th, 2014 at 8:17 am it was observed within the corridor above the double doors into the Kitchen near BioMed a 3/4" electrical conduit was not fire caulked to a one-fire barrier standard.

7. On August 5th, 2014 at 8:50 am it was observed in the east wall of OR Post Op #26 a 3/4" electrical conduit was not fire caulked to a one-fire barrier standard.

8. On August 5th, 2014 at 10:06 am it was observed within the OR Equipment room that 4 holes were found in the north wall and 2 holes were present in the east wall. None of these penetrations were sealed to a one-fire barrier standard. Note that the annular spaces around these penetrations are too large for a fire caulk application.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on record review and staff interview the facility failed to provide fire drills in a random unexpected pattern. This deficient practice could affect the patients in 5 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th, 2014 at 2:05 pm, while reviewing facility fire drill records the fire drill timing was conducted in a regular pattern for each of the shifts involved. The regularity and timing of these drills sets a familiar pattern for staff to expect drills at a certain time during their shift.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a Fire Alarm system that was installed in accordance to NFPA 72 Fire Alarm Code as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 7 smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th at 9:50 am it was observed within the Imaging RT office that no fire alarm strobe was installed within this space which is occupied by up to three staff members. Common areas are required to be protected by a visible appliance of the fire alarm system.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a sprinkler system that was installed in accordance to NFPA 13 - Installation of Sprinkler Systems [1999 Ed] as evidenced by the following item(s). This deficient practice could affect the patients in 7 of 7 smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th at 7:49 am it was observed within the Main Electrical room containing the normal and emergency main distribution gear was protected with a full sprinkler system. No non-combustible shields were found within this room to protect any of this gear from the water discharge from these sprinkler heads during a fire situation.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide miscellaneous components of the means of egress to code minimum standards as evidenced by the following item(s). This deficient practice could affect the patients in 7 of 7 smoke compartments, as well as an undetermined number of visitors.

Findings include:
1. On August 4th at 1:27 pm it was observed during a tour of the facility that the required means of egress from the southeast door of the medsurg wing had a vertical rise between two panels of the sidewalk that was greater than 1/4". This does not meet Section 19.2.1 General and Section 7-1.6.2 of Chapter 7 Means of Egress.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on record review and staff interview, the facility failed to record all data required by NFPA 110 Standard for Emergency and Standby Power Systems as evidenced by the following item(s). This deficient practice could affect the patients in 7 of 7 smoke compartments, as well as an undetermined number of visitors.

Findings include:
1. On August 5th at 2:03 pm it was observed during record review that the transfer times from cold start to load pickup of the generator were not being recorded. Both the Life Safety and Critical Care branch shall transfer in less than 10 seconds to meet code minimums. This time shall be recorded for code minimum compliance.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide an Electrical system that was installed in compliance to NFPA 70 National Electrical Code as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th, 2014 at 7:53 am it was observed within the Main Electrical room that the new Electrical distribution panel for the new Medical office building had none of the circuits labeled.

2. On August 5th, 2014 at 7:57 am it was observed within the Main Electrical room that the Critical panel for the hospital had circuits breakers #2 - #26 for kitchen equipment installed in this panel. This does not comply with Section 3-4.2.2.2 Emergency System (c) of NFPA 99 Health Care Facilities [1999 Ed]. Kitchen equipment is not allowed to be installed on the Critical Care branch of the Emergency Electrical System.

3. On August 5th, 2014 at 7:59 am it was observed within the Main Electrical room that Elev DP-1 panel the circuits were not labeled.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide openings into the corridor that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th, 2014 at 8:44 am, it was observed that the paired exit access doors into the corridor from the OR suite [Main corridor Backstreet] were not equipped with an astragal to prevent the passage of smoke. This facility was constructed in 2002 in accordance to 'New Health occupancy' guidelines which requires astragals at paired door openings into a corridor. Removal of the astragal reduces this opening below the code minimum standards required at the time of construction.

2. On August 5th, 2014 at 9:04 am, it was observed that the east paired exit access doors into the corridor from the ED suite were not equipped with an astragal to prevent the passage of smoke. This facility was constructed in 2002 in accordance to 'New Health occupancy' guidelines which requires astragals at paired door openings into a corridor. Removal of the astragal reduces this opening below the code minimum standards required at the time of construction.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide openings in the smoke compartment barrier that were resistant to the passage of smoke in accordance to NFPA 101 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th, 2014 at 9:50 am, it was observed that the double leaf door in the two-hour fire/smoke barrier was not equipped with an astragal to ensure that the opening was resistant to the passage of smoke. This facility was constructed in 2002 in accordance to 'New Health occupancy' guidelines which requires astragals at openings in a smoke barrier. Removal of the astragal reduces this opening below the code minimum standards required at the time of construction.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 [2000 Ed] Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 5 of 7 smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 4th, 2014 at 3:42 pm it was observed within small Surgery Storage the wall joints were not taped completely and that tape was not fully embedded in joint compound to a one-hour fire barrier standard.

2. On August 4th, 2014 at 3:50 pm it was observed within Biomed Workshop a 1- 1/2" galvanized pipe in the west wall was not fire caulked to a two-hour fire barrier standard.

3. On August 5th, 2014 at 8:00 am it was observed within Laundry that a 1-1/2" polyvinly chloride (pvc) pipe in the west wall was not fire caulked to a one-hour fire barrier standard.

4. On August 5th, 2014 at 8:08 am it was observed within the Main Electrical room that a 3" pipe in the south wall was not fire caulked to a two-hour fire barrier standard.

5. On August 5th, 2014 at 8:12 am it was observed within Housekeeping room that a 3/4" bx cable in the west wall entered a 2"x 2" hole and was not fire caulked to a one-hour fire barrier standard. Note that the annular space around this cable was too large for a fire caulk application.

6. On August 5th, 2014 at 8:17 am it was observed within the corridor above the double doors into the Kitchen near BioMed a 3/4" electrical conduit was not fire caulked to a one-fire barrier standard.

7. On August 5th, 2014 at 8:50 am it was observed in the east wall of OR Post Op #26 a 3/4" electrical conduit was not fire caulked to a one-fire barrier standard.

8. On August 5th, 2014 at 10:06 am it was observed within the OR Equipment room that 4 holes were found in the north wall and 2 holes were present in the east wall. None of these penetrations were sealed to a one-fire barrier standard. Note that the annular spaces around these penetrations are too large for a fire caulk application.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on record review and staff interview the facility failed to provide fire drills in a random unexpected pattern. This deficient practice could affect the patients in 5 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th, 2014 at 2:05 pm, while reviewing facility fire drill records the fire drill timing was conducted in a regular pattern for each of the shifts involved. The regularity and timing of these drills sets a familiar pattern for staff to expect drills at a certain time during their shift.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a Fire Alarm system that was installed in accordance to NFPA 72 Fire Alarm Code as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 7 smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th at 9:50 am it was observed within the Imaging RT office that no fire alarm strobe was installed within this space which is occupied by up to three staff members. Common areas are required to be protected by a visible appliance of the fire alarm system.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a sprinkler system that was installed in accordance to NFPA 13 - Installation of Sprinkler Systems [1999 Ed] as evidenced by the following item(s). This deficient practice could affect the patients in 7 of 7 smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th at 7:49 am it was observed within the Main Electrical room containing the normal and emergency main distribution gear was protected with a full sprinkler system. No non-combustible shields were found within this room to protect any of this gear from the water discharge from these sprinkler heads during a fire situation.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide miscellaneous components of the means of egress to code minimum standards as evidenced by the following item(s). This deficient practice could affect the patients in 7 of 7 smoke compartments, as well as an undetermined number of visitors.

Findings include:
1. On August 4th at 1:27 pm it was observed during a tour of the facility that the required means of egress from the southeast door of the medsurg wing had a vertical rise between two panels of the sidewalk that was greater than 1/4". This does not meet Section 19.2.1 General and Section 7-1.6.2 of Chapter 7 Means of Egress.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on record review and staff interview, the facility failed to record all data required by NFPA 110 Standard for Emergency and Standby Power Systems as evidenced by the following item(s). This deficient practice could affect the patients in 7 of 7 smoke compartments, as well as an undetermined number of visitors.

Findings include:
1. On August 5th at 2:03 pm it was observed during record review that the transfer times from cold start to load pickup of the generator were not being recorded. Both the Life Safety and Critical Care branch shall transfer in less than 10 seconds to meet code minimums. This time shall be recorded for code minimum compliance.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide an Electrical system that was installed in compliance to NFPA 70 National Electrical Code as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 5th, 2014 at 7:53 am it was observed within the Main Electrical room that the new Electrical distribution panel for the new Medical office building had none of the circuits labeled.

2. On August 5th, 2014 at 7:57 am it was observed within the Main Electrical room that the Critical panel for the hospital had circuits breakers #2 - #26 for kitchen equipment installed in this panel. This does not comply with Section 3-4.2.2.2 Emergency System (c) of NFPA 99 Health Care Facilities [1999 Ed]. Kitchen equipment is not allowed to be installed on the Critical Care branch of the Emergency Electrical System.

3. On August 5th, 2014 at 7:59 am it was observed within the Main Electrical room that Elev DP-1 panel the circuits were not labeled.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.