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Based on observation, the facility failed to maintain adequate fire rated building separations from a nonconforming building. This deficient practice could affect patients, staff and visitors if a fire were permitted to spread from the nonconforming building to the Hospital building when proper fire separation is not provided.

Findings include:
On December 13, 2017 at 11:10am while accompanied by the DF it was observed that a new wood frame addition was being constructed with a common wall with the hospital and that existing hospital window openings in the masonry exterior wall were not protected to afford the required 2-hour rating to comply with 19.1.1.4.1 and 19.1.3.4.1.

Based upon direct observation during the survey walk-thru, means of egress are not maintained in accordance with Code requirements. Failure to provide required means of egress can result in occupants inability to reach an exit or area of safety in the event of an emergency.

Findings include:
A. On December 13, 2017 at 11:00am while in the company of the DF, it was observed that the Emergency Department visitor entry corridor area is not provided with at least two identified means of egress due to the lack of exit signage for the 2nd exit access to comply with 19.2.4.3.

B. On December 13, 2017 at 12:15pm while in the company of the DF & MS, it was observed that the 4987 sf Surgery suite is not provided with at least two identified means of egress due to the lack of exit signs at the corridor door at the restricted area outside the Operating rooms and at both sides of the cross corridor doors between the Operating room restricted area and the Prep/recovery area to comply with 19.2.4.3.

C. On December 13, 2017 at 11:50am while in the company of the DF & MS, it was observed that the section of corridor serving patient Room 145 constitutes a dead end corridor greater than 30' in length in noncompliance with 19.2.5.2. The door from this corridor to the Emergency Dept. corridor is not marked with exit signage and is equipped with an infant abduction system magnetic lock which does not comply with 19.2.2.2.4. Compliance with the requirements of 7.2.1.6.1 (delayed egress) or all requirements of 19.2.2.2.5.2 (locks without delayed egress for OB patient needs) were not otherwise provided.

D. On December 13, 2017 at 11:00am while in the company of the DF, it was observed that the pairs of doors from the Emergency suite to the Radiology suite and from the Emergency suite to the Emergency visitor entrance corridor are equipped with magnetic locks and power operators. These doors do not have the access controlled sensors connected to the power operators to prevent operation of the doors from opening when occupants are standing in the path of the door swing. The doors power operation have the potential to injure occupants when allowed to open when occupants are standing in the path of the door swings. The doors otherwise lack vision lights to observe occupants on the other side of the door. The reliability of the door operation to prevent injury is not maintained to comply with 7.1.10.

Based upon direct observation during the survey walk-thru, means of egress doors are not maintained free of impediments that prevent or delay their use during required egress conditions. Failure to permit egress in accordance with permitted conditions can result in failure of occupants being able to reach a place of safety in the event of an emergency.

Findings include:
A. On December 13, 2017 at 10:40am while in the company of the DF, it was observed that the pair of doors from the Radiology suite to the Emergency suite was provided with exit signage and were equipped with magnetic locking devices which prevented egress in noncompliance with 19.2.2.2.4. The provisions of 19.2.2.2.5.2 or 7.2.1.6.1 (delayed egress) were not otherwise provided.

B. On December 13, 2017 at 10:45am while in the company of the DF it was observed that the pair of doors marked with exit signage from the Emergency suite to the corridor are equipped with magnetic locks to prevent ingress into the Emergency suite from the corridor. The doors are arranged as Access Control Egress Doors from the Emergency suite but lack the manual release required by 7.2.1.6.2(3).

Based upon observation, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area.

Findings include:
A. On December 13, 2017 while in the company of the DF, it was observed that Hazardous Areas are not protected in accordance with 19.3.2.1. The following locations and conditions were observed:

1. At 11:10am at the Store room (shared with the Materials Management room), the corridor door equipped with a self-closing device was arranged to have a very slow closing period, typically greater than the 30 seconds permitted by 7.2.1.9.2(3). The closer impedes the closing of the corridor door in noncompliance with 19.3.6.3.10.

2. At 11:30am at the Lab Storage room noted to be 59 sf on the facility plans, the door was not self-closing to comply with 19.3.2.1.3 and 19.3.2.1.5(7).

3. At 12:05pm at the Cardio Storage room noted to be 69 sf on the facility plans, the door was not self-closing to comply with 19.3.2.1.3 and 19.3.2.1.5(7).

Based upon observation, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area.

Findings include:
On December 13, 2017 at 12:30pm while in the company of the DF, it was observed that the Cardiac Rehab Storage room did not have a door assembly in compliance with 39.3.2.1, 8.7.1.2 and 8.4.3.5. The sprinklered room did not have a door that was self-closing to a latched condition to afford the required enclosure of the hazardous area.

Based upon direct observation during the survey walk-thru, the cooking equipment fire suppression system is not maintained in accordance with Code requirements. Failure to maintain the cooking equipment fire suppression systems can result in failure of the system to operate when needed resulting in the spread of fire/smoke and injury to occupants.

Findings include:
On December 13, 2017 at 11:15am while in the company of the DF, it was observed that the Kitchen hood extinguishing system was not documented as being visually inspected for deficiencies on a monthly basis to comply with NFPA 17A-2009, 7.2.

Based upon observation, corridors are not protected in accordance with Code requirements. Failure to provide protection of means of egress corridors can compromise the safety of all occupants utilizing the corridors as a protected means of egress from a fire/smoke event originating adjacent to the corridor.

Findings include:
A. On December 13, 2017 at 11:00am while in the company of the DF, it was observed that the Surgery waiting area open to the corridor is not provided with smoke detection within the space to comply with 19.3.6.1(2) or 19.3.6.1(8).

B. On December 13, 2017 at 11:35am while in the company of the DF & MS, it was observed that the Gift Shop area was open to the corridor and not provided with smoke detection within the space to comply with 19.3.6.1(1) or 19.3.6.1(7).

C. On December 13, 2017 at 11:15am while in the company of the DF, it was observed that the Kitchen corridor door equipped with a self-closing device was arranged to have a very slow closing period, typically greater than the 30 seconds permitted by 7.2.1.9.2(3). The closer impedes the closing of the corridor door in noncompliance with 19.3.6.3.10.

D. On December 13, 2017 at 10:45am while in the company of the DF, it was observed that the Emergency room suite is not separated from the Emergency visitor entry corridor by construction that limits the passage of smoke to comply with 19.3.6.2.3. The 1/4" joints between the patterned glass panels are not sealed to limit the transfer of smoke.

Based upon direct observation during the survey walk-thru, electrical systems are not maintained in conformance with Code requirements. Failure to maintain the electrical system can lead to confusion when selected components require shut-down for maintenance and power circuits cannot be accurately identified.

Findings include:
On December 13, 2017 at 11:40am while in the company of the DF & MS, it was observed that the panel directory for Panel "C2" was not accurate, relative to the placement of circuits in the panel, to comply with NFPA 70-2011, 408.4.