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Based on observation and staff interview, the facility failed to provide corridor openings that would resist the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1. This deficient practice could affect the patients in 1 of 6 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

On September 21st, 2015 at 1:25 PM (on the first floor) while on tour with Staff G, it was observed that the two sets of paired doors into the Corridor from the OB suite were not provided with positive latching hardward and resistant to the passage of smoke in compliance with 19.3.6.3.1 and 19.3.6.3.2.

This deficient practice was confirmed by observation and interview with Staff G at the time of discovery.

Based on observation and a staff interview, the facility failed to provide a one-hour rated enclosure with 45-minute rated doors around a hazardous area per NFPA 101 [2000 Ed] Section 19.3.2.1. This deficient practice could affect the patients in one of six smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:

1. On September 21st, 2015 at 1:49 PM (on the first floor) while on tour with Staff G, it was observed that a 2" pvc pipe in the east wall of the HVAC room (a one-hour fire barrier) was not fire caulked to a one-hour rating.

2. On September 21st, 2015 at 2:30 PM (on the first floor) while on tour with Staff G, it was observed that a hole (2" x 5") in the south wall and 10+ electrical conduits were not fire caulked to a one-hour fire rating within the Electrical room (near PT). This room is enclosed with a one-hour fire barrier in accordance with the hospital's life safety plans.

This deficient practice was confirmed by observation and interview with Staff G at the time of discovery.

Based on observations and staff interviews, the facility failed to provide and maintain a fire alarm system with approved components and devices installed according to NFPA 72 Section 19.3.4 in all 'common areas' of the building. This deficient practice could affect the patients in one of the six smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

On September 21st, 2015 at 3:40 PM (within the first floor) while on tour with Staff G, it was observed that two offices [Patient Accounts and Data Processing] in the Accounting department were occupied by two people. Any space occupied by two persons is defined as a 'common area'. NFPA 72 requires that all 'common areas' be equipped with a visible strobe appliance.

This deficient practice was confirmed by observation and an interview with Staff G at the time of discovery.

Based on observations and staff interviews, the facility failed to provide and maintain an HVAC system in compliance with NFPA 90A. This deficient practice could affect the patients in one of the six smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

It was observed on September 21st at 3:45 PM (on the lower level) while on tour with
Staff G, that an opening was present between the Decontaminant and the Clean Workroom and not equipped with a door. Air movement was unrestricted between these two different spaces (a soiled area and a clean area). This condition did not allow for the proper pressure relationships and air flows from these different spaces.

This deficient practice was confirmed by observation and interview with Staff G at the time of discovery.

Based on observation and staff interview, the facility failed to provide an electrical system that was installed and maintained in accordance to NFPA 70. This deficient practice could affect the patients in one of six smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

On September 22nd, 2015 at 7:50 AM (on the lower level) while on tour with Staff G, it was observed that an open junction box was present in the west wall of OR#2.

This deficient practice was confirmed by observation and interview with Staff G at the time of discovery.

Based on observation and staff interview, the facility failed to provide corridor openings that would resist the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1. This deficient practice could affect the patients in 1 of 6 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

On September 21st, 2015 at 1:25 PM (on the first floor) while on tour with Staff G, it was observed that the two sets of paired doors into the Corridor from the OB suite were not provided with positive latching hardward and resistant to the passage of smoke in compliance with 19.3.6.3.1 and 19.3.6.3.2.

This deficient practice was confirmed by observation and interview with Staff G at the time of discovery.

Based on observation and a staff interview, the facility failed to provide a one-hour rated enclosure with 45-minute rated doors around a hazardous area per NFPA 101 [2000 Ed] Section 19.3.2.1. This deficient practice could affect the patients in one of six smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:

1. On September 21st, 2015 at 1:49 PM (on the first floor) while on tour with Staff G, it was observed that a 2" pvc pipe in the east wall of the HVAC room (a one-hour fire barrier) was not fire caulked to a one-hour rating.

2. On September 21st, 2015 at 2:30 PM (on the first floor) while on tour with Staff G, it was observed that a hole (2" x 5") in the south wall and 10+ electrical conduits were not fire caulked to a one-hour fire rating within the Electrical room (near PT). This room is enclosed with a one-hour fire barrier in accordance with the hospital's life safety plans.

This deficient practice was confirmed by observation and interview with Staff G at the time of discovery.

Based on observations and staff interviews, the facility failed to provide and maintain a fire alarm system with approved components and devices installed according to NFPA 72 Section 19.3.4 in all 'common areas' of the building. This deficient practice could affect the patients in one of the six smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

On September 21st, 2015 at 3:40 PM (within the first floor) while on tour with Staff G, it was observed that two offices [Patient Accounts and Data Processing] in the Accounting department were occupied by two people. Any space occupied by two persons is defined as a 'common area'. NFPA 72 requires that all 'common areas' be equipped with a visible strobe appliance.

This deficient practice was confirmed by observation and an interview with Staff G at the time of discovery.

Based on observations and staff interviews, the facility failed to provide and maintain an HVAC system in compliance with NFPA 90A. This deficient practice could affect the patients in one of the six smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

It was observed on September 21st at 3:45 PM (on the lower level) while on tour with
Staff G, that an opening was present between the Decontaminant and the Clean Workroom and not equipped with a door. Air movement was unrestricted between these two different spaces (a soiled area and a clean area). This condition did not allow for the proper pressure relationships and air flows from these different spaces.

This deficient practice was confirmed by observation and interview with Staff G at the time of discovery.

Based on observation and staff interview, the facility failed to provide an electrical system that was installed and maintained in accordance to NFPA 70. This deficient practice could affect the patients in one of six smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

On September 22nd, 2015 at 7:50 AM (on the lower level) while on tour with Staff G, it was observed that an open junction box was present in the west wall of OR#2.

This deficient practice was confirmed by observation and interview with Staff G at the time of discovery.