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Based upon observations and staff interviews on June 15, 2022 between approximately 0745 hours and 1645 hours the facility failed to maintain physical protection of compressed gasses accordance with code requirements. Failure to maintain may place patients, staff, and visitors at a greater risk of exposure to heat, fire, and smoke.

Findings include, but are not limited to:

Carbon monoxide detection was not provided in the vicinity gas fueled appliances in the following locations:
Boiler Room
Mechanical Mezzanine by Fire Alarm Control Panel room.
NFPA 101 19.1.1.1.3, 4.6.1.2, IFC 1103.9


Administration Mechanical Room - combustible materials stored within.
Mechanical Room by Doctor's Lounge - combustible materials stored within.
NFPA 101 19.1.1.1.3, 4.6.1.2, IFC 315.3.3

The above was discussed and acknowledged by the maintenance director.

Based upon observations and staff interviews on June 15, 2022 between approximately 0745 and 1645 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering.

The findings include:

Emergency Exit by 112 - obstructed by potted plant. Corrected during inspection.

OR Department corridors were obstructed by equipment.

NFPA 101 (2012) 19.2.1, 7.1.10.1

The above was discussed and acknowledged by the maintenance director.

Based upon observations and staff interviews on June 15, 2022 between approximately 0745 and 1645 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff and/or visitors to the toxic products of combustion.

The findings include:

Kitchen/Cafe' drop door had displayed food and other items under it that would potentially inhibit closure.

CT Control Room door to CT room - self closer inhibited due to use of door stop.

OR Substerile Room - self closer inhibited due to use of door stop.

NFPA 101 (2012) 19.3.7.8

The above was discussed and acknowledged by the maintenance director.

Based on documentation review and staff interviews on June 15, 2022 between approximately 0745 and 1645 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire.

The findings include:


Pull Station by 118 - obstructed by oxygen supplies. Corrected during inspection.
NFPA 101 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 17.4.5.

Fire Alarm Control Panel Room - Panel LS - the circuit disconnecting power to the fire alarm system shall be distinctly marked in red. A portion of the circuit and the area by the circuit have been sprayed with red spray paint.
NFPA 101 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 (2012) 10.5.5.2.3

Doctor's Sleeping Room - battery was removed from single station smoke alarm.
NFPA 101 (2012) 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 (2010) 29.6.6

The above was discussed and acknowledged by the maintenance director.

Based on observations and staff interviews on June 15, 2022 between approximately 0845 and 1645 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include:

MRI Mechanical Room - unsecured fire extinguisher on floor. Corrected during inspection.

Maintenance Storage Room - unsecured fire extinguisher on the floor. Corrected during inspection.

Fire extinguisher in corridor across from Director of Surgical Services Office - obstructed.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010 ed) 1.1, 7.2.2

The above was discussed and acknowledged by the maintenance director.

Based on observations and staff interviews on June 15, 2022 between approximately 0745 and 1645 hours the facility has failed to properly maintain fire/smoke barriers doors within the facility as capable of resisting the passage of smoke. This could result in the products of combustion traveling from one smoke compartment to another which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

Fire Door 14 - does not close and latch
NFPA 101 (2012) 19.3.7, 8.5, 8.5.3, 8.5.4.1

Labels on the fire doors frames in the following locations had been painted over:
Fire Door 6
Fire Door 11
Fire Door 13
Fire Door 14
Fire Door 15
NFPA 101 (2012) 19.3.7, 8.5, 8.5.3, 8.5.6.3

Fire door to Mechanical Room by Doctor's Lounge - penetrations on the exterior of the door.
NFPA 101 (2012) 19.3.7, 8.5, 8.5.3, 8.5.6.2

Fire Door 7 - penetrations in door frame.
NFPA 101 (2012) 19.3.7, 8.5, 8.5.3, 8.5.6.2





The above was discussed and acknowledged by the maintenance director.

Based on observations and staff interviews on June 15, 2022 between approximately 0745 and 1645 hours the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm.

The findings include:

Electrical panels were blocked in the following locations:

Administration Mechanical Room
Old Electrical Room
Fire Alarm Control Panel/Electrical Room
Electrical Room in Cath Lab
Electrical Room off of X-ray Control Room
OR Department corridor
NFPA 101 19.1.1.1.1, 19.5.1.1, 9.1.2, 2.1, NFPA 70 110.26(A)(2)

The above was discussed and acknowledged by the maintenance director.

Based on documentation review and staff interviews on June 15, 2022 between approximately 0745 and 1645 hours the facility has failed to provide policies for the testing, repairs, and modifications of patient care related electrical equipment as required. This could result in the failure of the patient care related electrical equipment to operate properly which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility was unable to provide documentation of qualifications and continued training for facility personnel performing testing and maintenance on patient care related electrical equipment.
NFPA 99 1.1.1, 10.5.8.1.1

The above was discussed and acknowledged by the maintenance director.

Based on documentation review and staff interviews on June 15, 2022 between approximately 0745 and 1645 hours the facility failed to maintain their hyperbaric chambers and surrounding fire areas in accordance with the referenced NFPAs. The increased pressure and oxygen of these areas could lead to an increased risk of fire endangering patients and staff within the chamber and fire area.

The findings include:

The emergency procedures specific to the hyperbaric facility for fire in the chamber and/or fire in the chamber room are incomplete, having blanks for contact numbers.

NFPA 99 (2012) 14.3.1.4.4

The above was discussed and acknowledged by the facility staff.