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I. Based on observation and staff interview, it was determined the facility failed to ensure fire door assemblies in the Emergency Department were capable of maintaining the fire resistance in 1 of 6 fire barrier walls. Findings included:

Observation on 4/4/17 at 1:35 PM revealed that fire door 1144 did not have the proper fire resistance rating in the 1-hour fire barrier wall. This finding was confirmed by Corporate Safety Officer A at the time of discovery (2012 NFPA 101:8.3).

II. Based on observation and staff interview, it was determined the facility failed to ensure 1 of 6 fire barrier walls was capable of maintaining the fire resistance of the barrier. Findings included:

Observation on 4/4/17 at 1:40 PM revealed that above the suspended ceiling at the cross-corridor fire door 1144, a cable penetration was not properly sealed. This finding was confirmed by Corporate Safety Officer A at the time of discovery (2012 NFPA 101:8.3.5).

III. Based on observation and staff interview, it was determined the facility failed to ensure 1 of 1 fire doors in the Operating Room wing was properly maintained. Findings included:

Observation on 4/4/17 at 11:45 AM revealed that fire door 2265 did not latch properly when released from the open position. This finding was confirmed by Locksmith A at the time of discovery (2012 NFPA 101:8.3.3).

Based on observation and staff interview, it was determined that the facility failed to ensure that there was a 1-hour fire resistance rated separation between the ambulatory surgical center and adjacent offices. Findings included:

1. During a tour of the Beebe Outpatient Surgery Center with Lead Mechanic A on 4/5/17 at 11:59 AM, the following was observed and acknowledged at the time of discovery:

a. door assembles did not have the proper fire resistance rating in the 1-hour fire barrier wall

Based on observation and staff interview, it was determined the facility failed to ensure 2 of 3 stairway enclosures on the second floor were capable of maintaining the fire resistance. Findings included:

During a tour of the second floor on 4/3/17, the following was observed and acknowledged at the time of discovery:

A. 1:45 PM: Fire door ST-222 did not latch properly when released from the open position. This finding was confirmed by Corporate Safety Officer A.

B. 2:01 PM: Fire doors by room 221 had an undercut exceeding ¾ inches. This finding was confirmed by Director of Facilities A.

Based on observation and staff interview, it was determined the facility failed to ensure 1 of 1 medical gas storage rooms on the 5th floor was capable in resisting the passage of smoke. Findings included:

Observation on 4/3/17 at 11:28 AM revealed that corridor door 5022A was sticking and did not fully close and latch properly. This finding was confirmed by Director of Facilities at the time of discovery.

Based on observation and staff interview, it was determined the facility failed to properly install alcohol based hand rub (ABHR) dispensers on 1 of 5 floors. Findings included:

Observation on 4/4/17 at 11:42 AM revealed that an ABHR dispenser was installed directly above an outlet by the operating room nursing station. This finding was confirmed by Corporate Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure fire alarm system components for 1 of 1 fire alarm systems, were inspected, maintained and tested in accordance with National Fire Protection Association (NFPA) 72. Findings included:

Observation on 4/4/17 at 2:09 PM revealed that a fire alarm pull station was obstructed from use in the Emergency Department Lean Track nurse's station. This finding was confirmed by Corporate Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined the facility failed to maintain the sprinkler system in a reliable operating condition in accordance with National Fire Protection Association (NFPA) 25 in 1 of 4 fire suppression systems. Findings included:

1. During a hospital tour, the following was observed and acknowledged by Corporate Safety Officer A at the time of discovery:

a. 4/3/17 at 11:15 AM: wires resting/draped over the sprinkler piping by the 5th floor Medication Room

b. 4/4/17 at 11:50 AM: an escutcheon was missing from the storage closet 267A1 in Same Day Surgery

2. During a hospital tour, the following ceiling penetrations were observed and acknowledged at the time of discovery:

a. 4/3/17 at 11:37 AM: 4th floor dialysis storage room - confirmed by Director of Facilities A

b. 4/4/17 at 12:07 PM: Packing Processing - confirmed by Corporate Safety Officer A

c. 4/4/17 at 12:17 PM: Dirty Processing - confirmed by Corporate Safety Officer A

d. 4/4/17 at 2:00 PM: By room 1044.1 - confirmed by Corporate Safety Officer A

Based on observation and staff interview, it was determined that the facility failed to ensure corridor doors were capable of resisting the passage of smoke in 1 of 2 (3rd floor) smoke compartments. Findings included:

Observation on 4/3/17 at 12:01 PM revealed that door 3096 did not latch properly. This finding was confirmed by Corporate Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure fire/smoke barriers were capable of resisting the passage of smoke in 1 of 1 fire-resistance rating barrier. Findings included:

1. During a tour of the Tunnell Cancer Center (Wound Care area) with Corporate Safety Officer A on 4/5/17 at 11:40 AM, the following was observed and acknowledged at the time of discovery:

a. a gap exceeding more than 1/8 inch from the leading edge of both doors creating the fire-resistance rating barrier

Based on observation and staff interview, it was determined that on 2 of 5 floors, the facility failed to ensure that electrical installations were in accordance with National Fire Protection Association (NFPA) 70. Findings included:

1. During a hospital tour on 4/4/17, the following was observed and acknowledged by Corporate Safety Officer A at the time of discovery:

a. 11:25 AM: 2nd floor Mechanical Room 2227
- an electrical outlet without a protective cover

b. between 1:43 PM - 2:08 PM: Emergency Department
- an electrical junction box without a cover above the ceiling by door 22
- electrical panels in the oxygen storage room had boxes stored in front of them within 36 inches

Based on observation and staff interview, it was determined that the facility failed to ensure curtains were installed correctly in 1 of 1 smoke compartments. Findings included:

1. During a tour of the Tunnell Cancer Center (Wound Care area) with Corporate Safety Officer A on 4/5/17 between 11:30 AM and 11:47 AM, the following was observed and acknowledged at the time of discovery:

a. Curtains installed in the following areas did not have the correct mesh openings:
- Scale Tronix® area
- By room 213

Based on observation and staff interview, it was determined that the facility failed to ensure electrical wiring on 2 of 5 floors was in accordance with National Fire Protection Association (NFPA) 70. Findings included:

1. During a hospital tour, the following was observed and acknowledged at the time of discovery:

a. 4/3/17 at 11:18 AM: 5th floor nurse's Station 3
- relocatable power tap being used to supply power to computer equipment not in accordance with manufacturer's instructions
- confirmed by Director of Facilities A

b. 4/4/17 between 2:07 PM - 2:09 PM: Emergency Department
- two (2) relocatable power taps plugged together (daisy-chained) being used to supply power to a computer on wheels in the oxygen storage room
- a relocatable power tap being used on the Lean Track nurse's station to supply power to a medical heating pad unit
- confirmed by Corporate Safety Officer A