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Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishing equipment in four instances, affecting one of fifteen smoke compartments.

Findings include:

1. Observation on October 1, 2019, at 11:05 a.m., revealed an extinguisher obstructed by a cart in the kitchen on the second floor.

Interview with the Health System President, Facility Quality Manager, and Facility Manager on October 2, 2019, at 1:15 p.m., confirmed the fire extinguisher deficiency.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in three instances, affecting two of 15 smoke compartments.

Findings include:

1. Observation on October 2, 2019, revealed the following smoke barrier wall penetrations:

a) 10:11 a.m., there were two wire bundle penetrations in the smoke barrier wall on the third floor near room 319;
b) 10:21 a.m., there was a wire penetration in the smoke barrier wall on the third floor near room 304;
c) 10:24 a.m., there was a wire penetration in the smoke barrier wall above the back door to the third floor nurse station, near room 301.

Interview with the Health System President, Facility Quality Manager, and Facility Manager on October 2, 2019, at 1:15 p.m., confirmed the smoke barrier wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of fifteen smoke compartments.

Findings Include:

1. Observation on October 2, 2019, at 9:54 a.m., revealed the smoke barrier doors near Stairway D, in the Greenbriar Unit, on the Fourth Floor were obstructed by chairs in the corridor.

Interview with the Health System President, Facility Quality Manager, and Facility Manager on October 2, 2019, at 1:15 p.m., confirmed the smoke door deficiency.

Based on documentation review and interview, it was determined the facility failed to perform one of eight required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on October 1, 2019, at 9:30 a.m., revealed the facility lacked documentation for a second shift fire drill in the second quarter.

Interview with the Health System President, Facility Quality Manager, and Facility Manager on October 2, 2019, at 1:15 p.m., confirmed the facility lacked documentation for a second shift fire drill between April and June.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles for two of over 200 receptacles inspected.

Findings include:

1. Observation on October 2, 2019, revealed the following electrical outlets were within six feet of a sink and were not GFCI protected:

a) 10:17 a.m., the outlet in the biohazard room in the third floor overflow unit;
b) 10:31 a.m., the outlet in the pharmacy kitchen on the third floor.

Interview with the Health System President, Facility Quality Manager, and Facility Manager on October 2, 2019, at 1:15 p.m., confirmed the electrical receptacles were not GFCI protected.

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for one of one emergency generators, affecting the entire facility.

Findings include:

1. Observation on October 1, 2019, at 12:35 p.m., revealed the facility lacked a remote manual stop station located outside of the generator enclosure.

Interview with the Health System President, Facility Quality Manager, and Facility Manager on October 2, 2019, at 1:15 p.m., confirmed there was no remote manual stop station located outside of the generator enclosure.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in five instances, on two of five floors.

Findings include:

1. Observation on October 1, 2019, revealed the following electrical equipment deficiencies:

a) 10:43 a.m., a coffee maker was plugged into a power strip in medical records on the second floor;
b) 10:55 a.m., a microwave and refrigerator were plugged into a power strip in the chief technologist office, room 209 on the second floor;
c) 11:15 a.m., two coffee makers and a microwave were connected to a power strip in the staff lounge on the second floor.

2. Observation on October 2, 2019, revealed the following electrical equipment deficiencies:

a) 9:55 a.m., the televisions in the women's and men's lounges on the fourth floor were plugged into extension cords;
b) 10:05 a.m., a microwave was plugged into an extension cord in the HR kitchen on the fourth floor.

Interview with the Health System President, Facility Quality Manager, and Facility Manager on October 2, 2019, at 1:15 p.m., confirmed the misuse of electrical wiring.