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Based on observation the facility failed to provide corridor doors that close, latch, or resist the passage of smoke for 3 of 11 doors on the 3rd floor North wing of the facility as per NFPA 101 (Life Safety Code). This deficiency affects the 2 patients in the labor and delivers area in the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, "Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.

Findings:

During tour of the facility between October 11, 2012 and October 12, 2012, of the Labor and Delivery area on the North wing of the 3rd floor. The two old C-section rooms and the Bio-hazard room had doors that were no latching when closed.
When the door latches than a smoke resistive seal is formed to protect the room ' s occupants.

Based on observation, the facility failed to assure all elevator shafts are enclosed with construction having at least a one hour fire resistance rating for 2 of 4 elevators in the facility. This deficiency affects all 51 patients in the facility.

Findings:

During an inspection of the elevators shafts on October 12, 2012 between 1:00 p.m. and 2:30 p.m. it was observed that the following elevator had areas of the shafts that were not one-hour fire resistive.

1. The shaft for elevator 1 &2 has an old dictation wire is that is penetrating the wall at the fourth floor and enters the third floor.

Based on observations the facility failed to assure smoke barriers that were constructed with at least a one-half hour fire resistance rating for 4 of 12 smoke barrier walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. This deficient practice had the potential to affect 7 of 12 smoke compartments and 51 patients in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Findings:

During tour of the facility between October 11, 2012 and October 12, 2012 the integrity of the smoke barrier walls was observed to be compromised in the following areas.

The 4th floor west smoke barrier wall has a ½ inch hole in it that is not sealed. This hole is for the wire that is going to the new nurse call system.
The 4th floor south smoke barrier wall has a ½ inch hole with a new yellow nurse call wire running through it that is not completely sealed.
The 3th floor west smoke barrier wall has a ½ inch hole in it that is not sealed. This hole is for the wire that is going to the new nurse call system.
The 2th floor south smoke barrier wall has a ½ inch hole with a new yellow nurse call wire running through it that is not completely sealed.

Based on observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor for 4 of 10 hazardous areas as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency could have the potential to cause harm to all 32 patients on the 4th floor.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During tour of the facility between October 11, 2012 and October 12, 2012, it was observed that the following hazardous areas did not have doors that were self closing or resisting the passage of smoke.

The door to storage room by room 412 on the 4th floor did not have a closer on it.
The door to storage room by room 432 on the 4th floor did not have a closer on it.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. This deficiency has the potential to affect all patients in the Business, Medical Record, and Laboratory area of the facility.

Findings:

During the facility tour on October 11, 2012, between the hours of 8:30 a.m. and 4:00 p.m. it was observed that the Cashier desk does not have a sprinkler head in it. The cashier area has a glass window that prevents the current sprinkler head from covering this entire area.

Based on observation the facility failed to provide corridor doors that close, latch, or resist the passage of smoke for 3 of 11 doors on the 3rd floor North wing of the facility as per NFPA 101 (Life Safety Code). This deficiency affects the 2 patients in the labor and delivers area in the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, "Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.

Findings:

During tour of the facility between October 11, 2012 and October 12, 2012, of the Labor and Delivery area on the North wing of the 3rd floor. The two old C-section rooms and the Bio-hazard room had doors that were no latching when closed.
When the door latches than a smoke resistive seal is formed to protect the room ' s occupants.

Based on observation, the facility failed to assure all elevator shafts are enclosed with construction having at least a one hour fire resistance rating for 2 of 4 elevators in the facility. This deficiency affects all 51 patients in the facility.

Findings:

During an inspection of the elevators shafts on October 12, 2012 between 1:00 p.m. and 2:30 p.m. it was observed that the following elevator had areas of the shafts that were not one-hour fire resistive.

1. The shaft for elevator 1 &2 has an old dictation wire is that is penetrating the wall at the fourth floor and enters the third floor.

Based on observations the facility failed to assure smoke barriers that were constructed with at least a one-half hour fire resistance rating for 4 of 12 smoke barrier walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. This deficient practice had the potential to affect 7 of 12 smoke compartments and 51 patients in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Findings:

During tour of the facility between October 11, 2012 and October 12, 2012 the integrity of the smoke barrier walls was observed to be compromised in the following areas.

The 4th floor west smoke barrier wall has a ½ inch hole in it that is not sealed. This hole is for the wire that is going to the new nurse call system.
The 4th floor south smoke barrier wall has a ½ inch hole with a new yellow nurse call wire running through it that is not completely sealed.
The 3th floor west smoke barrier wall has a ½ inch hole in it that is not sealed. This hole is for the wire that is going to the new nurse call system.
The 2th floor south smoke barrier wall has a ½ inch hole with a new yellow nurse call wire running through it that is not completely sealed.

Based on observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor for 4 of 10 hazardous areas as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency could have the potential to cause harm to all 32 patients on the 4th floor.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During tour of the facility between October 11, 2012 and October 12, 2012, it was observed that the following hazardous areas did not have doors that were self closing or resisting the passage of smoke.

The door to storage room by room 412 on the 4th floor did not have a closer on it.
The door to storage room by room 432 on the 4th floor did not have a closer on it.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. This deficiency has the potential to affect all patients in the Business, Medical Record, and Laboratory area of the facility.

Findings:

During the facility tour on October 11, 2012, between the hours of 8:30 a.m. and 4:00 p.m. it was observed that the Cashier desk does not have a sprinkler head in it. The cashier area has a glass window that prevents the current sprinkler head from covering this entire area.