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Based on observation, the facility failed to maintain the integrity of the corridor doors by failing to provide doors with devices suitable for keeping the doors closed, failing to keep impediments from obstructing the closing of doors, and failing to provide doors that resist the passage of smoke and could result in the spread of fire and smoke. This affected 1of 3 smoke compartments on the Fourth floor, 2 of 3 compartments on the Third floor and 1 of 3 compartments on the Second floor.

Findings:

During a tour of the facility with the Facility Services Manager and the Administrator on July 12, 2010, the corridor doors were observed.

Fourth Floor:
At 9:41 a.m., the corridor door to patient room 1423 was impeded from closure by a trash can that was placed in front of the door.

Third Floor:
At 9:58 a.m.., the corridor door to patient room 1330 failed to latch when closed.
At 10:05 a.m., the corridor door to patient room 1304 failed to latch when closed.

Second Floor:
At 10:30 a.m., the corridor door to patient room 1226 failed to latch when closed.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction as evidenced by unsealed penetrations in 1 of 3 smoke barrier walls on the fourth floor, 1 of 3 smoke barrier walls on the third floor and 1 of 6 smoke barrier walls in the basement. This failure would allow the spread of fire and smoke from one compartment to another, resulting in the potential harm to patient, staff and visitors.

NFPA 101, 200 Edition, Section 8.3 Smoke Barriers
8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Facility Service Manager and the Administrator on July 12, 2010, the smoke barrier walls were observed.

Fourth Floor:
At 9:52 a.m., the smoke barrier wall above fire door 41047, had a 2 inch by 3 inch unsealed penetration in the left side of the wall.

Third Floor:
At 10:15 a.m., the smoke barrier wall above fire door 3106, had an unsealed conduit with wires running through on the left side of the wall and a ? inch cut out in the center of the wall.

Basement:
At 1:58 p.m., the smoke barrier wall above fire door B1108 (corridor entrance to kitchen), had an unsealed penetration around a conduit.

Based on observation, the facility failed to ensure the stairway path of escape was free of all impediments and obstructions this was evidenced by an obstruction in 1 of 3 exit stairwells on the fourth floor. This failure could result in the potential delay of an evacuation in the event of a fire or other emergency.

Findings:

During a tour of the facility with the Facility Services Manager on July 12, 2010, the exit stairwells were observed.

Fourth Floor:
At 9:20 a.m., there was a delivery hand cart left unattended in exit stairwell #3. This was acknowledged by the Facility Services Manager.

Based on observation, the facility failed to maintain a Fire Alarm System with approved component devices or equipment installed to provide effective warning of a fire in any part of the building. This failure could result in potential harm to patients in the event of a fire or other emergency in the first floor surgery suite.

Findings:

During the testing of the fire alarm system with the Fire Alarm Technician and Facility Services Manager on July 13 and July 14, 2010, the fire alarm system was observed and fire alarm devices were tested.

First Floor:
At 4:02 p.m.,and 4:15 p.m., the chime-strobe located across from operating room 1, 2, 3 and the chime-strobe located in the corridor across from pre/post op failed to activate an audible alarm during the testing of the smoke detectors and the manual pull station located in the suite. The strobes worked and the fire doors were activated. The Fire Alarm Technician confirmed a fire alarm signal was received at the fire alarm control panel. This was acknowledged by Facility Services Manager.

At 4:35 p.m., the Facility Services Manager notified Hospital Security and OR staff of the audible failures in the surgery suite. The fire alarm technician was on site and immediately started to trouble shoot the problem.

The surgery suite has a total of 2 combination chime-strobes devices and 1 additional strobe. The census was 1 patient in OR2 and 4 patients in the pre/post op area.

On July 14, 2010, between 8:25 a.m., and 8:45 a.m., the smoke detectors and manual pull station in the Surgery suite were tested. The two chime-strobe devices functioned as designed both initiated an audible and a visual alarm. The Facility Services Manager provided documentation indicating the two devices were repaired on July 13, 2010, at 8:00 p.m.

Based on observation, the facility failed to ensure that the automatic sprinkler system was maintained in reliable operating condition and was inspected periodically as evidenced by missing sprinkler escutcheon rings. This failure affected 2 of 3 smoke compartments on the fourth floor, 1 of 3 smoke compartments on the second floor, 1 of 10 smoke compartments on the first floor and 1 of 6 smoke compartments in the basement.

Findings:

During a tour of the facility with the Facility Services Manager and Administrator on July 12, 2010, the facility sprinkler system was observed.

Fourth Floor:
9:30 a.m., the sprinkler escutcheon ring was missing in the men's locker room that is located across from the Nurse Station.
At 9:45 a.m., the sprinkler escutcheon ring was missing in the restroom of the men's locker room that is located across nursery room 1 and 2.
At 9:48 a.m., in Nursery room two, 2 of 4 sprinkler escutcheon rings were missing.
At 9:50 a.m., in Nursery room one, 1 of 4 sprinkler escutcheon rings was missing.

Second Floor:
At 10:35 a.m., in the clean utility room 21039, 1 of 3 sprinkler escutcheon rings was missing.

First Floor:
At 11:50 a.m., in the Infectious Waste room 11120, the sprinkler escutcheon ring was missing.

Basement:
At 2:00 p.m., in the shipping receiving department, 1 of 3 sprinkler escutcheon rings was missing.

Based on observation, the facility failed to maintain the electrical equipment and wiring in accordance with NFPA 70, National Electrical Code as evidenced by microwave ovens and refrigerators that were not plugged directly into electrical outlets and the unauthorized use of electrical equipment such as power strips plugged into power strips. This failure affected 1 of 10 smoke compartments on the first floor, 3 of 6 smoke compartments in the basement.

Findings:

During a tour of the facility with the Facility Services Manager on July 12, 2010, the electrical equipment was observed.

First Floor:
At 11:42 a.m., the microwave in the Radiology Staff Lounge was plugged into a power strip and not directly into the electrical outlet.

Basement:
At 2:03 p.m., the microwave and refrigerator was plugged into a power strip and not directly into the electrical outlet.
At 2:06 p.m., a power strip was plugged into a power strip under the Pharmacy order entry desk.
At 2:08 p.m., a power strip was plugged into a power strip in the Pharmacy IV room.
At 2:18 p.m., a power strip was plugged into a power strip in the Health Information Management Systems office.

At 2:30 p.m., a power strip was plugged into a power strip in Room 1036, Utilization Management office.

Based on observation, the facility failed to maintain the integrity of the corridor doors by failing to provide doors with devices suitable for keeping the doors closed, failing to keep impediments from obstructing the closing of doors, and failing to provide doors that resist the passage of smoke and could result in the spread of fire and smoke. This affected 1of 3 smoke compartments on the Fourth floor, 2 of 3 compartments on the Third floor and 1 of 3 compartments on the Second floor.

Findings:

During a tour of the facility with the Facility Services Manager and the Administrator on July 12, 2010, the corridor doors were observed.

Fourth Floor:
At 9:41 a.m., the corridor door to patient room 1423 was impeded from closure by a trash can that was placed in front of the door.

Third Floor:
At 9:58 a.m.., the corridor door to patient room 1330 failed to latch when closed.
At 10:05 a.m., the corridor door to patient room 1304 failed to latch when closed.

Second Floor:
At 10:30 a.m., the corridor door to patient room 1226 failed to latch when closed.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction as evidenced by unsealed penetrations in 1 of 3 smoke barrier walls on the fourth floor, 1 of 3 smoke barrier walls on the third floor and 1 of 6 smoke barrier walls in the basement. This failure would allow the spread of fire and smoke from one compartment to another, resulting in the potential harm to patient, staff and visitors.

NFPA 101, 200 Edition, Section 8.3 Smoke Barriers
8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Facility Service Manager and the Administrator on July 12, 2010, the smoke barrier walls were observed.

Fourth Floor:
At 9:52 a.m., the smoke barrier wall above fire door 41047, had a 2 inch by 3 inch unsealed penetration in the left side of the wall.

Third Floor:
At 10:15 a.m., the smoke barrier wall above fire door 3106, had an unsealed conduit with wires running through on the left side of the wall and a ? inch cut out in the center of the wall.

Basement:
At 1:58 p.m., the smoke barrier wall above fire door B1108 (corridor entrance to kitchen), had an unsealed penetration around a conduit.

Based on observation, the facility failed to ensure the stairway path of escape was free of all impediments and obstructions this was evidenced by an obstruction in 1 of 3 exit stairwells on the fourth floor. This failure could result in the potential delay of an evacuation in the event of a fire or other emergency.

Findings:

During a tour of the facility with the Facility Services Manager on July 12, 2010, the exit stairwells were observed.

Fourth Floor:
At 9:20 a.m., there was a delivery hand cart left unattended in exit stairwell #3. This was acknowledged by the Facility Services Manager.

Based on observation, the facility failed to maintain a Fire Alarm System with approved component devices or equipment installed to provide effective warning of a fire in any part of the building. This failure could result in potential harm to patients in the event of a fire or other emergency in the first floor surgery suite.

Findings:

During the testing of the fire alarm system with the Fire Alarm Technician and Facility Services Manager on July 13 and July 14, 2010, the fire alarm system was observed and fire alarm devices were tested.

First Floor:
At 4:02 p.m.,and 4:15 p.m., the chime-strobe located across from operating room 1, 2, 3 and the chime-strobe located in the corridor across from pre/post op failed to activate an audible alarm during the testing of the smoke detectors and the manual pull station located in the suite. The strobes worked and the fire doors were activated. The Fire Alarm Technician confirmed a fire alarm signal was received at the fire alarm control panel. This was acknowledged by Facility Services Manager.

At 4:35 p.m., the Facility Services Manager notified Hospital Security and OR staff of the audible failures in the surgery suite. The fire alarm technician was on site and immediately started to trouble shoot the problem.

The surgery suite has a total of 2 combination chime-strobes devices and 1 additional strobe. The census was 1 patient in OR2 and 4 patients in the pre/post op area.

On July 14, 2010, between 8:25 a.m., and 8:45 a.m., the smoke detectors and manual pull station in the Surgery suite were tested. The two chime-strobe devices functioned as designed both initiated an audible and a visual alarm. The Facility Services Manager provided documentation indicating the two devices were repaired on July 13, 2010, at 8:00 p.m.

Based on observation, the facility failed to ensure that the automatic sprinkler system was maintained in reliable operating condition and was inspected periodically as evidenced by missing sprinkler escutcheon rings. This failure affected 2 of 3 smoke compartments on the fourth floor, 1 of 3 smoke compartments on the second floor, 1 of 10 smoke compartments on the first floor and 1 of 6 smoke compartments in the basement.

Findings:

During a tour of the facility with the Facility Services Manager and Administrator on July 12, 2010, the facility sprinkler system was observed.

Fourth Floor:
9:30 a.m., the sprinkler escutcheon ring was missing in the men's locker room that is located across from the Nurse Station.
At 9:45 a.m., the sprinkler escutcheon ring was missing in the restroom of the men's locker room that is located across nursery room 1 and 2.
At 9:48 a.m., in Nursery room two, 2 of 4 sprinkler escutcheon rings were missing.
At 9:50 a.m., in Nursery room one, 1 of 4 sprinkler escutcheon rings was missing.

Second Floor:
At 10:35 a.m., in the clean utility room 21039, 1 of 3 sprinkler escutcheon rings was missing.

First Floor:
At 11:50 a.m., in the Infectious Waste room 11120, the sprinkler escutcheon ring was missing.

Basement:
At 2:00 p.m., in the shipping receiving department, 1 of 3 sprinkler escutcheon rings was missing.

Based on observation, the facility failed to maintain the electrical equipment and wiring in accordance with NFPA 70, National Electrical Code as evidenced by microwave ovens and refrigerators that were not plugged directly into electrical outlets and the unauthorized use of electrical equipment such as power strips plugged into power strips. This failure affected 1 of 10 smoke compartments on the first floor, 3 of 6 smoke compartments in the basement.

Findings:

During a tour of the facility with the Facility Services Manager on July 12, 2010, the electrical equipment was observed.

First Floor:
At 11:42 a.m., the microwave in the Radiology Staff Lounge was plugged into a power strip and not directly into the electrical outlet.

Basement:
At 2:03 p.m., the microwave and refrigerator was plugged into a power strip and not directly into the electrical outlet.
At 2:06 p.m., a power strip was plugged into a power strip under the Pharmacy order entry desk.
At 2:08 p.m., a power strip was plugged into a power strip in the Pharmacy IV room.
At 2:18 p.m., a power strip was plugged into a power strip in the Health Information Management Systems office.

At 2:30 p.m., a power strip was plugged into a power strip in Room 1036, Utilization Management office.