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Based on observation and interview, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls. This was evidenced by penetrations in the smoke barrier walls. This could allow the migration of smoke and/or fire in the event of a fire. This affected 2 of 4 floors and the basement.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3 Smoke Barriers
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Assistant Hospital Administrator (AHA),the Facilities Manager, the Technical Services Director, and Security Staff on 3/9/15 through 3/11/15, the smoke barrier walls were observed, and staff was interviewed.

Third floor Med Surg on 3/9/15:
1. At 11:107 a.m., the smoke barrier wall near room 1316, had an unsealed penetration around a conduit. The conduit was located next to a red conduit. This was confirmed by facility staff during the survey.

First Floor on 3/9/15:
2. At 1:33 p.m., on the right side of the smoke barrier wall near room 11036, the conduit with white, green, and blues wires running through was unsealed and on the left side of the smoke barrier wall there was a partially unsealed conduit with green wires running through. This was confirmed by facility staff during the survey.

Basement on 3/10/14:
3. At 2:42 p.m., the smoke barrier wall entering the cafeteria had an unsealed conduit with blue and white wires running through. This was confirmed by facility staff during survey.
During interview, the AHA stated that there was ongoing construction and that the conduits should have been sealed, and must have been over looked.

Based on observation, the facility failed to ensure that the smoke barrier doors closed and resisted the passage of smoke. This was evidenced by a smoke barrier door that failed to close upon the release of its hold open device. This could result in the migration of smoke and or fire to other smoke compartments. This affected the basement level.

Findings:

During the testing of the fire alarm system with the Assistant Hospital Administrator, the Facilities Manager, and Security Staff on 3/9/15 through 3/11/15, the smoke barrier doors were observed.

Basement Level on 3/10/15:
At 11:17 a.m., the smoke barrier door B1176 entering plant operations, failed to fully close. Facility staff tested the door a second time and observed the doors failure to fully close and latch.

Based on observation and interview, the facility failed to protect a hazardous area. This was evidenced by the failure to ensure that the door protecting the hazardous area were equipped with a self closing device. This affected 1 of 4 floors in the hospital.

NFPA 101, Life Safety Code, 2000 Edition
Section 19.3 Protection
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to the following:
(1) Boiler and fuel fired heater rooms
(2) Central/bulk laundries larger than 100 ft. (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft. (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a tour of the facility with the Assistant Hospital Administrator (AHA), the Facilities Manager, the Technical Services Director, and Security Staff on 3/9/15 through 3/11/15, the construction and doors to the hazardous rooms were observed, and staff was interviewed.

First Floor Emergency Department on 3/9/15:
At 2:16 p.m., the door to room 11120, was not equipped with a self-closure device. The room was label as a Bio Hazardous waste storage room. During an interview, the AHA acknowledged the finding, and stated that there used to be a self-closure on the door and did not know why it was removed.

Based on observation and interview, the facility failed to provide emergency illumination. This was evidenced by no battery-powered emergency lighting in the labor delivery operating room. This could result in the loss of lighting during a procedure in the event of power loss and failure of the emergency generator. This affected 1 of 1 procedure rooms on the 4th floor in the hospital.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

NFPA 70, National Electrical Code, 1999 Edition
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provision for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arrange to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:

During a tour of the facility with the Assistant Hospital Administrator (AHA), the Facilities Manager, the Technical Services Director, and Security Staff on 3/9/15 through 3/11/15, the
emergency lighting was observed, and staff was interviewed.

At 10:10 a.m., the labor delivery operating room did not have a emergency battery-powered light in the room. During interview, the AHA acknowledged there was not emergency battery powered light in the room.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by sprinkler escutcheon rings that were missing. The sprinkler escutcheon ring is a part of the assembly of the sprinkler. This could result in delaying activation of the sprinkler in the event of a fire. This affected areas in 2 of 4 floors in the hospital.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
Chapter 12 System Inspection, Testing, and Maintenance
12-1 General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water- Base Fire Protection Systems, 1998 Edition
Chapter 2 Sprinkler Systems
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g. upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with the Assistant Hospital Administrator, the Facilities Manager, the Technical Services Director, and Security Staff on 3/9/15 through 3/11/15, the smoke barrier walls were observed.

Second Floor - Med Surge on 3/9/15:
1. At 11:14 a.m., room 1201, was missing a sprinkler escutcheon ring.

2. At 11:32 a.m., room 21039, was missing 1 of 4 sprinkler escutcheon rings.

First Floor - Intensive Care Unit on 3/9/15:
3. At 11:51 a.m., room 11223, was missing 1 of 3 sprinkler escutcheon rings.

4. At 11:54 a.m., room 1012, was missing 1 of 2 sprinkler escutcheon rings.

5. At 11:59 a.m., in the step down unit (SDU), the staff locker room was missing a sprinkler escutcheon ring.

Based on observation and interview, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls. This was evidenced by penetrations in the smoke barrier walls. This could allow the migration of smoke and/or fire in the event of a fire. This affected 2 of 4 floors and the basement.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3 Smoke Barriers
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Assistant Hospital Administrator (AHA),the Facilities Manager, the Technical Services Director, and Security Staff on 3/9/15 through 3/11/15, the smoke barrier walls were observed, and staff was interviewed.

Third floor Med Surg on 3/9/15:
1. At 11:107 a.m., the smoke barrier wall near room 1316, had an unsealed penetration around a conduit. The conduit was located next to a red conduit. This was confirmed by facility staff during the survey.

First Floor on 3/9/15:
2. At 1:33 p.m., on the right side of the smoke barrier wall near room 11036, the conduit with white, green, and blues wires running through was unsealed and on the left side of the smoke barrier wall there was a partially unsealed conduit with green wires running through. This was confirmed by facility staff during the survey.

Basement on 3/10/14:
3. At 2:42 p.m., the smoke barrier wall entering the cafeteria had an unsealed conduit with blue and white wires running through. This was confirmed by facility staff during survey.
During interview, the AHA stated that there was ongoing construction and that the conduits should have been sealed, and must have been over looked.

Based on observation, the facility failed to ensure that the smoke barrier doors closed and resisted the passage of smoke. This was evidenced by a smoke barrier door that failed to close upon the release of its hold open device. This could result in the migration of smoke and or fire to other smoke compartments. This affected the basement level.

Findings:

During the testing of the fire alarm system with the Assistant Hospital Administrator, the Facilities Manager, and Security Staff on 3/9/15 through 3/11/15, the smoke barrier doors were observed.

Basement Level on 3/10/15:
At 11:17 a.m., the smoke barrier door B1176 entering plant operations, failed to fully close. Facility staff tested the door a second time and observed the doors failure to fully close and latch.

Based on observation and interview, the facility failed to protect a hazardous area. This was evidenced by the failure to ensure that the door protecting the hazardous area were equipped with a self closing device. This affected 1 of 4 floors in the hospital.

NFPA 101, Life Safety Code, 2000 Edition
Section 19.3 Protection
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to the following:
(1) Boiler and fuel fired heater rooms
(2) Central/bulk laundries larger than 100 ft. (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft. (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a tour of the facility with the Assistant Hospital Administrator (AHA), the Facilities Manager, the Technical Services Director, and Security Staff on 3/9/15 through 3/11/15, the construction and doors to the hazardous rooms were observed, and staff was interviewed.

First Floor Emergency Department on 3/9/15:
At 2:16 p.m., the door to room 11120, was not equipped with a self-closure device. The room was label as a Bio Hazardous waste storage room. During an interview, the AHA acknowledged the finding, and stated that there used to be a self-closure on the door and did not know why it was removed.

Based on observation and interview, the facility failed to provide emergency illumination. This was evidenced by no battery-powered emergency lighting in the labor delivery operating room. This could result in the loss of lighting during a procedure in the event of power loss and failure of the emergency generator. This affected 1 of 1 procedure rooms on the 4th floor in the hospital.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

NFPA 70, National Electrical Code, 1999 Edition
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provision for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arrange to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:

During a tour of the facility with the Assistant Hospital Administrator (AHA), the Facilities Manager, the Technical Services Director, and Security Staff on 3/9/15 through 3/11/15, the
emergency lighting was observed, and staff was interviewed.

At 10:10 a.m., the labor delivery operating room did not have a emergency battery-powered light in the room. During interview, the AHA acknowledged there was not emergency battery powered light in the room.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by sprinkler escutcheon rings that were missing. The sprinkler escutcheon ring is a part of the assembly of the sprinkler. This could result in delaying activation of the sprinkler in the event of a fire. This affected areas in 2 of 4 floors in the hospital.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
Chapter 12 System Inspection, Testing, and Maintenance
12-1 General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water- Base Fire Protection Systems, 1998 Edition
Chapter 2 Sprinkler Systems
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g. upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with the Assistant Hospital Administrator, the Facilities Manager, the Technical Services Director, and Security Staff on 3/9/15 through 3/11/15, the smoke barrier walls were observed.

Second Floor - Med Surge on 3/9/15:
1. At 11:14 a.m., room 1201, was missing a sprinkler escutcheon ring.

2. At 11:32 a.m., room 21039, was missing 1 of 4 sprinkler escutcheon rings.

First Floor - Intensive Care Unit on 3/9/15:
3. At 11:51 a.m., room 11223, was missing 1 of 3 sprinkler escutcheon rings.

4. At 11:54 a.m., room 1012, was missing 1 of 2 sprinkler escutcheon rings.

5. At 11:59 a.m., in the step down unit (SDU), the staff locker room was missing a sprinkler escutcheon ring.