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Based on observation and interview, it was determined the facility did not maintain penetrations for one of three smoke barrier walls observed with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the smoke barrier walls to prevent the passage of smoke and fire through the unsealed penetrations. The facility had an average census of 21 patients. The findings follow:

A. On a tour of the facility with the Director of Engineering on 12/17/14 at 1400 revealed unsealed penetrations of the smoke barrier were observed above the ceiling at the following locations:
1) Above the fire rated doors near the Labor and Delivery Department.
2) Above the fire rated doors near the Mechanical Room.
B. The Director of Engineering verified the unsealed penetrations at the time of the observation.

Based on observation and interview, it was determined the facility did not maintain penetrations for two of three smoke barrier walls observed with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the smoke barrier walls to prevent the passage of smoke and fire through the unsealed penetrations. The facility had an average census of 21 patients. The findings follow:

A. On a tour of the facility with the Director of Engineering on 12/17/14 at 1400 unsealed penetrations of the smoke barrier were observed above the ceiling at the following locations:
1) Above the fire rated doors in the Connecting Corridor near Labor and Delivery.
2) Above the fire rated doors in the 1300 Corridor.
B. The Director of Engineering verified the unsealed penetrations at the time of the observation.

Based on observation and interview, it was determined the facility stored combustible materials in one (storage room in the Outpatient Psychiatric Department) room in such quantities to be considered a fire hazard that was not enclosed by 1 hour fire rated construction. The failed practice had the potential to affect all patients, staff, and visitors because of the potential size and rapid propagation of fire originating from the room. The facility had an average census of 21 patients. The findings follow:

A. On tour of the facility with the Director of Engineering on 12/17/14 at 1400, a storage room in the Outpatient Psychiatric Department was observed with 15 cardboard boxes. Three boxes contained combustible decorations. The room was not provided with fire rated construction or a fire rated door with a self-closing device.
B. In an interview on 12/17/14 at 1430, the Director of Engineering verified the combustible materials stored in the room and the room was not enclosed with 1 hour fire rated construction and a self-closing door.

Based on observation and interview, it was determined the facility allowed flammable decorations to be used at three locations in the egress corridor. The flammable decorations had the potential to affect the health and safety of all patients, staff, and visitors due to the potential of fire propagation in the egress corridor. The facility had an average daily census of 21 patients. The findings follow:

A. On a tour of the facility with the Director of Engineering on 12/17/14 at 1400 revealed paper decorations were covered the entire door on the egress corridor side of the door at the following locations:1) The door to the Lab.
2) The door to the Pharmacy.
3) The door to the Business Office.
B. In an interview on 12/17/14 at 1430, the Director of Engineering verified the location of the flammable decorations, and verified there was no documentation available for review to verify the decorations were flame resistant.

Based on observation, line isolation monitor testing documentation review, and interview, it was determined four of four line isolation panels located in the Surgery Department were not tested monthly as required by NFPA 99, Chapter 6.3.4.1.4. The failed practice had the potential to affect all patients admitted for surgery in the facility because the alarm function of the monitors were not tested to ensure staff was alerted to an electrical ground-fault in the electrical system. The facility had one patient scheduled for surgery on 12/15/14. The findings follow:

A. On a tour of the Surgery Department with the Director of Engineering on 12/15/14 at 1330, four line isolation monitors were observed in the Surgery Department
B. Review of the Line Isolation Monitor testing log on 12/17/14 at 0930 revealed the most recent testing of the monitors was in December 2012.
B. In an interview on 12/17/14 at 0945 the Director of Engineering verified there was no further documentation of monthly line isolation panel testing available for review.

Based on observation and interview, it was determined the facility did not maintain penetrations for one of three smoke barrier walls observed with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the smoke barrier walls to prevent the passage of smoke and fire through the unsealed penetrations. The facility had an average census of 21 patients. The findings follow:

A. On a tour of the facility with the Director of Engineering on 12/17/14 at 1400 revealed unsealed penetrations of the smoke barrier were observed above the ceiling at the following locations:
1) Above the fire rated doors near the Labor and Delivery Department.
2) Above the fire rated doors near the Mechanical Room.
B. The Director of Engineering verified the unsealed penetrations at the time of the observation.

Based on observation and interview, it was determined the facility did not maintain penetrations for two of three smoke barrier walls observed with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the smoke barrier walls to prevent the passage of smoke and fire through the unsealed penetrations. The facility had an average census of 21 patients. The findings follow:

A. On a tour of the facility with the Director of Engineering on 12/17/14 at 1400 unsealed penetrations of the smoke barrier were observed above the ceiling at the following locations:
1) Above the fire rated doors in the Connecting Corridor near Labor and Delivery.
2) Above the fire rated doors in the 1300 Corridor.
B. The Director of Engineering verified the unsealed penetrations at the time of the observation.

Based on observation and interview, it was determined the facility stored combustible materials in one (storage room in the Outpatient Psychiatric Department) room in such quantities to be considered a fire hazard that was not enclosed by 1 hour fire rated construction. The failed practice had the potential to affect all patients, staff, and visitors because of the potential size and rapid propagation of fire originating from the room. The facility had an average census of 21 patients. The findings follow:

A. On tour of the facility with the Director of Engineering on 12/17/14 at 1400, a storage room in the Outpatient Psychiatric Department was observed with 15 cardboard boxes. Three boxes contained combustible decorations. The room was not provided with fire rated construction or a fire rated door with a self-closing device.
B. In an interview on 12/17/14 at 1430, the Director of Engineering verified the combustible materials stored in the room and the room was not enclosed with 1 hour fire rated construction and a self-closing door.

Based on observation and interview, it was determined the facility allowed flammable decorations to be used at three locations in the egress corridor. The flammable decorations had the potential to affect the health and safety of all patients, staff, and visitors due to the potential of fire propagation in the egress corridor. The facility had an average daily census of 21 patients. The findings follow:

A. On a tour of the facility with the Director of Engineering on 12/17/14 at 1400 revealed paper decorations were covered the entire door on the egress corridor side of the door at the following locations:1) The door to the Lab.
2) The door to the Pharmacy.
3) The door to the Business Office.
B. In an interview on 12/17/14 at 1430, the Director of Engineering verified the location of the flammable decorations, and verified there was no documentation available for review to verify the decorations were flame resistant.

Based on observation, line isolation monitor testing documentation review, and interview, it was determined four of four line isolation panels located in the Surgery Department were not tested monthly as required by NFPA 99, Chapter 6.3.4.1.4. The failed practice had the potential to affect all patients admitted for surgery in the facility because the alarm function of the monitors were not tested to ensure staff was alerted to an electrical ground-fault in the electrical system. The facility had one patient scheduled for surgery on 12/15/14. The findings follow:

A. On a tour of the Surgery Department with the Director of Engineering on 12/15/14 at 1330, four line isolation monitors were observed in the Surgery Department
B. Review of the Line Isolation Monitor testing log on 12/17/14 at 0930 revealed the most recent testing of the monitors was in December 2012.
B. In an interview on 12/17/14 at 0945 the Director of Engineering verified there was no further documentation of monthly line isolation panel testing available for review.