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Based on random observation while accompanied by the Head of Maintenance, corridor doors are not always positive latching to comply with 19.3.6.3.2 and/or that corridor doors are not installed to maintain a smoke tight condition. Failure to maintain corridor doors in accordance with NFPA 101 could allow smoke to spread from room to room in a fire emergency

Findings include:

A. 07/30/13 at 2:05 pm, 1st floor corridor doors contain a push/pull with deadbolt hardware. These corridor doors do not comply with 19.3.6..2 for containing positive latching hardware. Example locations observed:

1. Cafeteria pair of doors
2. Dishwashing room pair of doors

Based on observation during the survey walk-through accompanied by the Head of Maintenance, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. 07/30/2013 at 9:50am Hazardous areas were observed at which doors are not self-closing to comply with 19.3.2.1 and 8.2.3.2.3.1(2). Location observed:
Dry Goods Storage door contains a foot peg which is a noncompliant hold open device that prevents the door from being self closing.

B. 07/30/2013 at 10:30am Hazardous areas were observed which contain holes within the fire rated enclosure and do not comply with 19.3.2.1. for a fire resistant and smoke resistant construction. Locations observed: Laundry Storage Room contains a unsealed vertical gap between concrete blocks.

C. 07/30/2013 at 10:45 Hazardous areas were observed which contain holes within the fire rated enclosure and do not comply with 19.3.2.1. for a fire resistant and smoke resistant construction. Locations observed: Storage room containing the "bailer" does not maintain a smoke resistant construction due to the lack of self closing doors.

Based on random observation and staff interview accompanied by the Head of Maintenance, not all duct penetrations at designated 2 hour rated fire barriers are protected against the passage of fire and smoke to comply with 8.3.5. This condition could allow fire and smoke to travel from one building addition to an adjacent addition during a fire emergency affecting patients, staff and visitors in both compartments from reaching an exit discharge.

The finding is:

A. 07/30/2013 at 1:50pm It was determined that 2-hour barrier separations (designated on the facility floor plan) containing duct penetrations lack damper installations to comply with NFPA 90A 3-4. Separations are located between building additions.

Based on random observation during the survey walk-through accompanied by the Head of Maintenance, not all portions of the building fire alarm system are installed in accordance with 19.3.4.This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

The findiing is:

A. 07/30/2013 at 2:15pm The Elevator Lobby door from the Emergency Department did not close upon activation of the fire alarm.

Based on random observation during the survey walk through accompanied by the Head of Maintenance not all portions of the building's fire alarm system is inspected and tested to comply with 19.3.4 and NFPA 72. Failure to inspect and test all devices connected to the fire alarm system could allow for an unknown system component failure during a fire event that would impact upon any person within the facility.

The finding is:

A. 07/30/2013 at 9:00am Through document review, it was determined that the quarterly testing of the fire alarm system does not indicate the inspecting and testing of devices other than the smoke detectors.

Based on random observation and staff interview accompanied by the Head of Maintenance, not all duct penetrations at smoke barriers are protected against the passage of smoke to comply with 8.3.5. This condition could allow fire and smoke to travel from one smoke compartment to an adjacent compartment during a fire emergency affecting patients, staff and visitors in both compartments from reaching an exit discharge.

The finding is:

A. 07/30/2013 at 1:35pm it was noted that a duct penetrating a designated smoke barrier (facility floor plan) could not be determined to be equipped with a smoke damper due to the lack of an access panel to comply with 8.3.5.1 and NFPA 90A 2.3.4.1. Location observed: Main Level 1963 building smoke barrier above the corridor separation adjacent to the MRI, X-Ray Wing.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.