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Based on observation and interview, the provider failed to maintain the fire-resistive design of two of two building separation walls (south and west two-hour walls separating the hospital and the clinic). Findings include:

1. Observation on 8/16/22 at 2:28 p.m. revealed the two-hour fire-rated separation wall between the southern hospital wing and the clinic had four layers of 5/8 inch gypsum board on the wall above the lay-in ceiling. The gypsum board had unsealed openings around penetrations by conduit and piping.
Those openings were not sealed or provided with any approved material to maintain the fire rating of the wall.

Interview with the lead maintenance mechanic at the same time confirmed that finding.

The deficiency could affect 100% of the occupants of the smoke compartment.

2. Observation and interview with the lead maintenance mechanic on 8/16/22 at 2:52 p.m. revealed the two-hour fire rated separation wall between the western wing hospital and the clinic had four layers of 5/8 inch gypsum board on the wall above the lay-in ceiling. The gypsum board had unsealed openings around penetrations of the board by conduits and piping. Those openings were not sealed or provided with any approved material to maintain the fire rating of the wall.
Interview with the lead maintenance mechanic at the same time confirmed that finding.

The deficiency could affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to furnish illumination of means of egress was provided at one randomly observed exit discharge location (door A). Findings include:

1. Observation on 8/16/22 at 1:30 p.m. revealed door "A" was a marked exit. The exit discharge at that location was not furnished with any exterior illumination. Lighting is required to be furnished at all exit discharges and must be capable of providing one and one-half hours of emergency lighting upon loss of normal power.

Interview with the lead maintenance mechanic at the same time confirmed that condition. He stated he was not aware that exit discharge was not in compliance.

This deficiency has the ability to affect all occupants of the smoke compartments.

Based on observation and interview, the provider failed to maintain a one-hour fire resistive enclosure for the elevator shaft. Findings include:

1. Observation 8/16/22 at 3:16 p.m. on revealed the elevator lobby door providing the required one-hour fire restive rating to the elevator shaft was not latching into the door frame. That door must close and latch to maintain its fire rating.

Interview with the lead maintenance mechanic at the same time confirmed that finding.
He stated he was unaware that door was not latching.

The deficiency affected one of numerous requirements for protecting vertical openings.
That deficiency has the potential to affect 100% of the smoke compartment occupants.

Based on observation and interview, the provider failed to maintain the fire rating for one randomly observed hazardous area (maintenance shop) as required. Findings include:

1. Observation on 8/16/22 at 1:05 p.m. revealed fire-rated door to the maintenance shop had a one and a-half by one-inch hole at the top of the door. That hole violated the fire rating of that door and of the maintenance shop.

Interview with the lead maintenance mechanic at the same time confirmed that finding. He stated that door had holes in it the entire time he had worked there.

The deficiency affected one of numerous requirements for hazardous storage rooms.

Based on observation and interview, the provider failed to maintain the required clearance for three randomly observed pieces of electrical equipment (EQ1, LS1, and CR1 electrical panels) in the emergency department workroom. Findings include:

1. Observation on 8/16/22 at 3:43 p.m. revealed items stored in front of the electrical panels for the emergency power system. Those items stored within the required 36 inches of clear space included a bair hugger, glide scope stand, and paper recycling storage container.
Electrical equipment is required to have 36 inches of working space depth and 30 inches of working space in width.

Interview with the lead maintenance mechanic at the time of the observation confirmed that finding.
He stated the maintenance department had worked to keep that area free from obstruction, but items continually get placed in that area.

The deficiency affected one of numerous requirements for the maintenance of electrical equipment.

Ref. NFPA 99 Chapter 6, NFPA 70 Section 110 article 26.