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Based on observation and staff interview, the facility failed to maintain documentation of means of egress daily inspections, and provide an approved barrier in areas undergoing construction, repair, alterations, or additions per the requirements of:

NFPA 101, 2012 Edition 19.7.9.2, 7.1.10.1*
NFPA 241, 2013 Edition 8.6.2, 8.6.2.1, 8.6.2.2, 8.6.2.3, 8.6.2.4*

The findings include:

1. Observation and interview with the Facility Director on 5/21/2025 at 11:00 AM revealed, the hospital is undergoing construction in the emergency department and the facility is not inspecting and documenting daily means of egress checks.

2. Observation on 5/21/2025 at 11:05 AM revealed, plastic sheathing (not considered an approved barrier or opening protective), was installed across the emergency department to isolate the occupied areas of the hospital from the areas of the facility undergoing construction.

Interview with the Facility Director at the same time revealed, the facility failed to install an approved temporary separation barrier meeting the requirements, when such operations are considered as having a higher level of hazard than the occupied portion of the facility.

The Facility Director was present when the deficiency was identified and acknowledged by the Regulatory Compliance Coordinator during the exit conference on 5/21/2025.