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Based on observation during the morning of 5/20/2011, the following corridor doors did not have the required type of latching hardware:

(1) The corridor doors to patient sleeping rooms on the second floor had roller latches.
(2) The corridor door to the mammograpy room on the first floor had positive latching hardware that must be manually latched.

These corridor doors must have positive latching hardware that latches automatically when closed.

Based on observation during the morning of 5/20/2011, the following doors to storage areas were not self-closing:

(1) Corridor door to third floor "central supply" storage room.
(2) Corridor door to first floor storage room near the elevators.

These doors must have self-closing devices installed so they will close automatically and latch at the door frame.

Based on observation during the morning of 5/20/2011, the fire sprinkler system did not comply with NFPA 13 at the following locations:

(1) The mail room next to the chapel was not protected by the sprinkler system.
(2) The location of the two sprinklers in the chapel did not comply with NFPA 13.(the sprinklers were too close to each other, and they did not provide proper coverage for one end of the chapel.)

Based on observation, and interview with the Director of Plant Operations, during the morning and afternoon of 5/20/2011, the electrical system did not comply with the following requirements of NFPA 70, National Electrical Code:

(1) Many of the electrical circuits were not clearly identified on the directories posted in the panelboards. This prevented it from being determined if the essential electrical system provides power to the items required by NFPA 70.

(2) According to the "electrical 1-line diagram" at the hospital, there is one automatic transfer switch serving the essential electrical system. NFPA 70 requires each branch of the emergency system ( life safety branch and critical branch) and the equipment system must have one or more transfer switches. NFPA 70 permits one transfer switch to serve one or more branches in a facility with a maximum demand on the essential electical system of 150 kVA.

Based on observation during the morning of 5/20/2011, the following corridor doors did not have the required type of latching hardware:

(1) The corridor doors to patient sleeping rooms on the second floor had roller latches.
(2) The corridor door to the mammograpy room on the first floor had positive latching hardware that must be manually latched.

These corridor doors must have positive latching hardware that latches automatically when closed.

Based on observation during the morning of 5/20/2011, the following doors to storage areas were not self-closing:

(1) Corridor door to third floor "central supply" storage room.
(2) Corridor door to first floor storage room near the elevators.

These doors must have self-closing devices installed so they will close automatically and latch at the door frame.

Based on observation during the morning of 5/20/2011, the fire sprinkler system did not comply with NFPA 13 at the following locations:

(1) The mail room next to the chapel was not protected by the sprinkler system.
(2) The location of the two sprinklers in the chapel did not comply with NFPA 13.(the sprinklers were too close to each other, and they did not provide proper coverage for one end of the chapel.)

Based on observation, and interview with the Director of Plant Operations, during the morning and afternoon of 5/20/2011, the electrical system did not comply with the following requirements of NFPA 70, National Electrical Code:

(1) Many of the electrical circuits were not clearly identified on the directories posted in the panelboards. This prevented it from being determined if the essential electrical system provides power to the items required by NFPA 70.

(2) According to the "electrical 1-line diagram" at the hospital, there is one automatic transfer switch serving the essential electrical system. NFPA 70 requires each branch of the emergency system ( life safety branch and critical branch) and the equipment system must have one or more transfer switches. NFPA 70 permits one transfer switch to serve one or more branches in a facility with a maximum demand on the essential electical system of 150 kVA.