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Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in 7 (the Medical/Surgical (Med/Surg) area near Room 133, at the entrance to the Rehabilitation Center, at the entrance to the Women's Center, near the waiting area in the Women's center, near the Sterilizer Mechanical Room, at the entrance to Radiology, and between Administration and the public restrooms) of 11 areas observed by protecting penetrations in the barrier with a system or material capable of limiting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility with the Director of Maintenance on 02/08/2017 at 1055, the following areas were not sealed with a system or material capable of limiting the transfer of smoke from one side of the barrier to the other:
1) One unsealed penetration through the smoke barrier above the fire-rated doors in the Med Surg. area near room 133.
2) Five penetrations in the smoke barrier above the fire-rated doors at the entrance to the Rehabilitation Center.
3) Two unsealed penetrations in the smoke barrier above the fire-rated doors at the entrance to the Women's Center.
4) One penetration in the smoke barrier above the fire-rated doors near the waiting area for the Women's Center.
5) Four penetrations in the smoke barrier above the fire-rated doors near the Sterilizer Mechanical room.
6) Two penetrations in the smoke barrier above the fire-rated doors at the entrance to Radiology.
7) Two penetrations in the smoke barrier above the fire-rated doors between Administration and the public restrooms.
B. During the tour, the Director of Maintenance verified the penetrations were not sealed with a material capable of limiting the transfer of smoke from one side of the barriers to the other.

Referenced code: NFPA 101; 2012 edition, Section 8.4.4.1

Based on observation and interview, it was determined the facility failed to insure there was no impediment to closing the fire-rated door at the entrance to radiology. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that the fire-rated door would fully close in the event of a fire and smoke event.

A. While touring the facility on 02/08/2017 at 1020, it was observed one of two fire-rated doors at the entrance to Radiology failed to fully close when tested.
B. During the tour, the Director of Maintenance verified the door did not fully close when tested.

Referenced code: NFPA 101, 2012 edition, Section 8.3.3.3

Based on observation and interview, the facility failed to provide positive latching hardware on one (General Storage Room) of three doors to rooms with hazardous or combustible materials within the surgical suite by utilizing a roller latch. The failed practice had the potential to affect all patients, staff and visitors due to the potential spread of fire and smoke due to the potential failure of the roller latches to maintain the doors in the closed position in the event of a fire event. This was a continuing deficiency. Findings follow:

A. On a tour of the facility on 02/07/17 at 1310, it was observed the door to the General Storage Room in the surgical suite utilized a roller latch to secure the door.
B. During the tour, the Director of Maintenance verified the use of a roller latch on the door.

Referenced code: 42 CFR Section 482.41(b)(1)(ii)

Based on observation and interview, it was determined electrical panels in two (Operating Room #2 and electrical room in the Women's Center) of nine areas observed did not have a minimum of 36 inches (three feet) working space in front of the panels because of equipment stored in front of the electrical panels. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency. Findings follow:

A. While touring the facility on 02/07/17 at 1300, an infant warmer was observed stored in front of the electrical isolation panel in Operating Room #2.
B. While touring the facility on 02/07/17 at 1355, a ladder was stored leaning against one of five electrical panels observed in the electrical room in the Women's Center.
C. During the tour, it was verified by the Director of Maintenance the electrical panel was blocked.

Referenced Codes: NFPA 99, 2012 edition, Section: 6.3.2.1; NFPA 70, 2011 edition, Section: 110.26