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Based on an observation, not all fire barrier doors are being maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from one portion of the building to another.

The finding is:

On 10/30/2019 at 11:00am while in the company of the DF, the means of egress door from the elevator machine room was not self closing to comply with 19.3.2.1.2.

Based on observation during the survey walk through, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On 10/30/2019 at 11:50am while accompanied by the DF, the corridor located within the surgical department consists of a dead end exceeding 70' from the furthest O.R. this condition does not comply with 19.2.5.1 providing two designated paths of egress.

Based on observation during the survey walk through, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On 10/30/2019 at 11:45am while accompanied by the DF, the second floor corridor located within the Surgical department does not comply with 7.4. The corridor provides one means of egress to the main corridor, however, the other designated means of egress is through the recovery suite which does not comply with 19.2.5.4.

Based on observation, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The finding is:

On 10/30/2019 at 1:20pm, while accompanied by the DF documentation review determined that battery-powered emergency lights are not being tested annually for 90 minutes. This condition does not comply with NFPA 99 2012 6.3.2.2.11.4 and NFPA 70 2011 517-63A.

Based upon observation, hazardous areas are not separated by a minimum of smoke resisting construction. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

The finding is:

On 10/30/2019 at 12:45pm while in the company of the DF, the means of egress door from the clean utility room on the second floor does not have a listed fire resistance rating to comply with the requirements of a non sprinkler protected hazardous area, 19.3.2.1.2.

Based on observation, the facility failed to install and maintain automatic sprinkler protection in accordance with the code requirements. This deficient practice could impair activation of the sprinkler system and delay an emergency response.

The finding is:

On 10/30/2019 at 1:45pm while in the company of the DF, documentation for the sprinkler system annual inspection dated August 14, 2019 indicated that the fire department valve leaks. the inspector further recommended replacement. There is no documentation which determined that the check valve had been replaced or repaired. This condition does not comply with NFPA 25 2011, 8.3.2 and table 8.6.1.

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

The finding is:

On 10/30/2019 12:20pm while accompanied by the DF a corridor door does not latch to a closed position which does not comply with 19.3.6.3.
Location observed: Second floor OR -A.

Based upon observation, sprinklered hazardous areas are not separated by a minimum of smoke resisting construction. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

The finding is:

On 10/30/2019, at 9:55am while in the company of the DF the surveyor observed that the rubbish chute door does not close to a latched position and does not meet all the requirements of 5.2.3.3.2.1.
Location observed Second floor

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

The finding is:

On 10/30/2019 at 1:00pm during document review in the company of the DF, Facility fire drill documentation for the past 12 months did not indicate the following:
1. Fire drill conducted during the third shift.

Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

The finding is:

While in the company of the DF, documentation for fire rated doors was reviewed. Documentation provided does not comply with 7.2.1.15.3. The following information was not available:

1. There is no indication of the location or labeling of the facility required fire doors to comply with 7.2.1.15.4.

2. There is no indication of the type of door, hardware, or function of the door to comply with 7.2.1.15.2.

3. There is no indication a complete fire door inspection having been conducted for 2018 to comply with 7.2.1.15.3.

4. Documents did not indicate the actual repair or maintenance provided for each door's condition. The documents do not comply with NFPA 80 2010, 5.2.1.