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Based on observation and interview, the facility failed to maintain the smoke resistance of the smoke barriers by sealing the space between penetrating items such as conduit, pipe, and ductwork through the smoke barriers with a material capable of maintaining the smoke resistance of the smoke barriers in accordance with 8.3 in two of two (Medical Gas Storage room and Fire Wall in Nurses' corridor) areas observed. The failed practice had the potential to affect all patients, staff, and visitors because the space between the penetrations and the smoke barriers would allow smoke to pass from one compartment to the next. Findings follow:

A. During a tour on 05/18/2016 at 0935, observations revealed 1 pipe penetrating the ceiling of the smoke and fire rated Medical Gas Room was not sealed with a material capable of maintaining the smoke and fire rating of the room.
B. During a tour on 05/18/2016 at 0950, observations revealed 2 of 7 penetrations made by electrical conduit and 1 of 1 penetration made by an air duct in the fire barrier above the fire rated doors on the first floor Nurses' Corridor. The facility failed to seal the penetrations made through the smoke and fire barrier with a material capable of maintaining the smoke and fire resistance of the barrier.
C. During the tour of the facility, the Facilities Director confirmed that the penetrations were not sealed with a material capable of maintaining the smoke and fire resistance of the barriers.

Based on observation and interview, it was determined that there was no documentation for the required monthly testing [ NFPA 99 3-3.3.4.2 (b) (1999 edition)] of 2 of 2 Line Isolation Monitors (LIMs) for the isolation panels serving the Operating Room (OR) and Emergency Room (ER) #1 and #2 had been performed.

A. During a tour on 05/17/2016 at 1410, it was observed 2 of 2 LIMs for the power isolation panels serving the OR and ER #1 and #2 had no stickers on them to indicate the required monthly testing had been performed.
B. During an interview on 05/18/2016 at 0930 with the Facilities Director, she indicated she was unaware testing was required for the LIMs and no documentation was available for review.

Based on Generator Log review and interview, it was determined the facility failed to ensure the emergency power generator was tested under load for at least 30 minutes monthly for 2 of 12 months (August 2015 and November 2015) from May 2015 through April 2016. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the generator to provide emergency power to the facility in the event of the loss of normal power was not evaluated and could not be assured. Findings follow:

A. Review of the Generator Logs on 05/16/2016 at 1430 revealed there was no documentation of the emergency power generator required monthly testing was available for the months of August 2015 and November 2015.
B. During an interview on 05/18/2016 at 0930, the Facilities Director verified there was no further documentation available for review.

Based on observation and interview, the facility failed to maintain the smoke resistance of the smoke barriers by sealing the space between penetrating items such as conduit, pipe, and ductwork through the smoke barriers with a material capable of maintaining the smoke resistance of the smoke barriers in accordance with 8.3 in two of two (Medical Gas Storage room and Fire Wall in Nurses' corridor) areas observed. The failed practice had the potential to affect all patients, staff, and visitors because the space between the penetrations and the smoke barriers would allow smoke to pass from one compartment to the next. Findings follow:

A. During a tour on 05/18/2016 at 0935, observations revealed 1 pipe penetrating the ceiling of the smoke and fire rated Medical Gas Room was not sealed with a material capable of maintaining the smoke and fire rating of the room.
B. During a tour on 05/18/2016 at 0950, observations revealed 2 of 7 penetrations made by electrical conduit and 1 of 1 penetration made by an air duct in the fire barrier above the fire rated doors on the first floor Nurses' Corridor. The facility failed to seal the penetrations made through the smoke and fire barrier with a material capable of maintaining the smoke and fire resistance of the barrier.
C. During the tour of the facility, the Facilities Director confirmed that the penetrations were not sealed with a material capable of maintaining the smoke and fire resistance of the barriers.

Based on observation and interview, it was determined that there was no documentation for the required monthly testing [ NFPA 99 3-3.3.4.2 (b) (1999 edition)] of 2 of 2 Line Isolation Monitors (LIMs) for the isolation panels serving the Operating Room (OR) and Emergency Room (ER) #1 and #2 had been performed.

A. During a tour on 05/17/2016 at 1410, it was observed 2 of 2 LIMs for the power isolation panels serving the OR and ER #1 and #2 had no stickers on them to indicate the required monthly testing had been performed.
B. During an interview on 05/18/2016 at 0930 with the Facilities Director, she indicated she was unaware testing was required for the LIMs and no documentation was available for review.

Based on Generator Log review and interview, it was determined the facility failed to ensure the emergency power generator was tested under load for at least 30 minutes monthly for 2 of 12 months (August 2015 and November 2015) from May 2015 through April 2016. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the generator to provide emergency power to the facility in the event of the loss of normal power was not evaluated and could not be assured. Findings follow:

A. Review of the Generator Logs on 05/16/2016 at 1430 revealed there was no documentation of the emergency power generator required monthly testing was available for the months of August 2015 and November 2015.
B. During an interview on 05/18/2016 at 0930, the Facilities Director verified there was no further documentation available for review.