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Based on observation and staff interview the facility failed to properly maintain fire barriers in accordance with the 2012 NFPA 101 Life Safety Code. The deficiency affected one (1) of five (5) smoke compartments.

The findings were:

Observation on 3/01/18 at 3:05 PM revealed that the 2-hour fire barrier separating the hospital from the neighboring clinic had unprotected ducting and electrical penetrations in the chapel room ceiling. Failure to properly maintain fire barriers could result in injury or death in the event of a fire. Interview with the maintenance director at the time of the observation acknowledged the deficiency, and revealed he was aware of the requirement, but was unaware of the unprotected penetrations.

Reference: 2012 NFPA 101 19.1.3.5, 8.3.5.1

Based on observation and staff interview the facility failed to properly maintain means of egress in accordance with the 2012 NFPA 101 Life Safety Code. The deficiency affected one (1) of five (5) smoke compartments.

The findings were:

Observation on 3/01/18 at 1:15 PM in the hallway adjacent to the OB corridor providing access to the office material storage room revealed the hallway was used to store equipment, which reduced the width to approximately 24 inches. Failure to properly maintain the means of egress could result in injury or death in the event of an emergency. Interview with the maintenance director at the time of the observation acknowledged the deficiency, and revealed he was aware of the requirement and that the hallway was being used for equipment storage.

Reference: 2012 NFPA 101 19.2.3.1, 7.3.4.1(2)

Based on observation and staff interview the facility failed to properly protect hazardous areas in accordance with 2012 NFPA 101 Life Safety Code. The deficiencies affected one (1) of five (5) smoke compartments, and the basement floor.

The findings were:

1. Observation on 3/01/18 at 11:46 AM in the X-Ray electrical room revealed the space was being used for storage of combustible materials. The room size was approximately 80 square feet and the room was not equipped with a door closer. Failure to properly protect hazardous areas could result in injury or death in the event of a fire. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was aware of the requirement, but was unaware that the room was being used for storage.

2. Observation on 3/01/18 at 2:18 PM in the Pharmacy Tech office revealed the space was being used to store a large quantity of combustible material. The room size was greater than 50 square feet and a door closer had been installed on the door, but it had been disabled. Failure to properly protect hazardous areas could result in injury or death in the event of a fire. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was aware of the requirement, but was unaware that the room was being used for storage.

3. Observation on 3/01/18 at 2:31 PM in the Purchasing Room revealed the space was being used to store a large quantity of combustible material. The room had a door closer installed on the door along with a magnetic hold open device. It could not be established that the electronic hold open device was connected to the fire alarm system. Failure to properly protect hazardous areas could result in injury or death in the event of a fire. Interview with the purchaser revealed that when the fire alarm goes off the hold open device does not release to allow the door to close. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was aware of the requirement, but was unaware of the use of the magnetic hold open device.

Reference: 2012 NFPA 101 19.3.2.1.3

Based on observation and staff interview the facility failed to properly identify the fire alarm system in accordance with 2010 NFPA 72 National Fire Alarm and Signaling Code. The deficiency affected the one (1) fire alarm circuit breaker located in the hospital. The fire alarm system serves the entire facility.

The findings were:

Observation on 3/01/18 at 10:56 AM of the electrical panel located in the ambulatory wing corridor revealed that the fire alarm circuit breaker was identified as "FA" in black marker. Failure to properly identify the fire alarm system could result in injury or death in the event that the system is unintentionally deactivated. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was unaware of the requirement for identifying the fire alarm system circuit breaker as "FIRE ALARM CIRCUIT" in red marking.

Reference: 2010 NFPA 72 10.5.5.2.2 & 10.5.5.2.3

Based on documentation and staff interview the facility failed to properly test and maintain the fire alarm system in accordance with the 2010 NFPA 72 National Fire Alarm and Signaling Code. The deficiency affects the one (1) fire alarm system. The fire alarm system serves the entire hospital.

The findings were:

Review of the fire alarm testing and activation documentation on 3/01/18 at 4:00 PM revealed that the facility was conducting the fire alarm activation testing twice per quarter. Failure to properly maintain and test the fire alarm system could result in injury or death in the event of an emergency. Interview with the facility maintenance director at the time of the observation revealed that the facility conducts the testing of the fire alarm system in conjunction with the fire drills. The facility has two shifts so the facility is only conducting fire drills, and thus fire alarm activation, twice in a quarter. Additional interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was unaware that the fire alarm activation testing must be conducted monthly.

Reference: 2010 NFPA 72 Table 14.4.5(24)

Based on observation and staff interview the facility failed to properly maintain the fire sprinkler system in accordance with the 2010 NFPA 13 Standard for the Installation of Sprinkler Systems. The deficiencies affect one (1) of five (5) smoke compartments, and the basement.

The findings were:

1. Observation on 3/01/18 at 11:45 AM in the X-Ray electrical room revealed that the ceiling had a missing ceiling tile. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was aware that ceiling tiles need to be in place so sprinkler heads activate correctly.

2. Observation on 3/01/18 at 2:35 PM and throughout the survey of the basement revealed multiple rooms with missing or damaged ceiling tiles. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. Interview with the facility maintenance director at the time of the observations acknowledged the deficiency, and revealed he was aware that ceiling tiles need to be in place so sprinkler heads activate correctly.

Reference: 2010 NFPA 13 8.5.4.1

Based on observation and staff interview the facility failed to properly maintain the elevator machine rooms in accordance with the 2012 NFPA 101 Life Safety Code. The deficiencies affected the basement.

The findings were:

Observation on 3/01/18 of the elevator machine room and freight elevator machine room at 2:15 PM and 2:25 PM, respectively, revealed that the rooms were being used for storage. Failure to properly maintain the elevator machine rooms could result in injury or death in the event of an emergency. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was unaware that the elevator machine rooms could not be used for storage.

Reference: 2012 NFPA 101 19.5.3, 9.4.2.2; ASME A17.3 2.8.1

Based on observation and staff interview the facility failed to properly maintain clearance to electrical systems in accordance with 2011 NFPA 70 National Electrical Code. The deficiencies affected two (2) of five (5) smoke compartments on the main floor, and the basement floor.

The findings were:

1. Observation on 3/01/18 at 11:02 AM of an electrical shut-off panel located in the Mammography room revealed storage directly in front of it, which obstructed access to the panel. Failure to maintain clearance to electrical equipment could result in injury or death in the event of an emergency. Interview with the facility maintenance director at the time of the observation acknowledge the deficiency, and revealed he was aware of the requirement for maintaining 36 inches of clearance around any electrical equipment.

2. Observation on 3/01/18 at 1:40 PM of an electrical shut-off panel located in the OR lobby room revealed storage directly in front of it, which obstructed access to the panel. Failure to maintain clearance to electrical equipment could result in injury or death in the event of an emergency. Interview with the facility maintenance director at the time of the observation acknowledge the deficiency, and revealed that he was aware of the requirement for maintaining 36 inches of clearance around any electrical equipment.

3. Observation on 3/01/18 at 1:50 PM of an electrical shut-off panel located in the OR sterilization room revealed storage directly in front of it, which obstructed access to the panel. Failure to maintain clearance to electrical equipment could result in injury or death in the event of an emergency. Interview with the facility maintenance director at the time of the observation acknowledge the deficiency, and revealed that he was aware of the requirement for maintaining 36 inches of clearance around any electrical equipment.

4. Observation on 3/01/18 at 2:33 PM of an electrical shut off panel located in the Purchasing room revealed storage directly in front of it, which obstructed access to the panel that was located approximately 7 feet above the floor and labeled "Nuclear Medicine". Failure to maintain clearance to electrical equipment could result in injury or death in the event of an emergency. Interview with the facility maintenance director at the time of the observation acknowledge the deficiency, and revealed that he was aware of the requirement for maintaining 36 inches of clearance around any electrical equipment.

Reference: 2012 NFPA 101 19.5.1, 9.1.2; 2011 NFPA 70 110.26(A)

Based on observation and staff interview the facility failed to properly store soiled linen and trash receptacles in accordance with 2010 NFPA 101 Life Safety Code. The deficiency affected one (1) of five (5) smoke compartments.

The findings were:

Observation on 3/01/18 at 11:20 AM of the ambulatory wing corridor revealed that two 50 gallon containers, one for soiled linen and one for trash, were stored next to each other within the corridor. Failure to properly store soiled linen and trash could result in injury or death in the event of a fire. Interview with the facility maintenance director at the time of the observation revealed that the containers are used as a central collection for the ambulatory wing and are emptied at least twice a day. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was unaware of the requirements for storage of soiled linen or trash.

Reference: 2012 NFPA 101 19.7.5.7.1

Based on observation and staff interview the facility failed to properly use portable space-heating devices in accordance with 2012 NFPA 101 Life Safety Code. The deficiency affected one (1) of five (5) smoke compartments, and the basement.

The findings were:

1. Observation on 3/01/18 at 1:10 PM in the OB office revealed a portable space heater in use. The maximum temperature of the heating elements could not be established at the time of the observation. Failure to properly utilized portable space heaters could result in injury or death. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was unaware of the requirement for the heating element temperature to not exceed 212 degrees F.

2. Observation on 3/01/18 at 2:10 PM in the Business managers office revealed portable space heater in use. The maximum temperature of the heating elements could not be established at the time of the observation. Failure to properly utilize portable space heaters could result in injury or death. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was unaware of the requirement for the heating element temperature not to exceed 212 degrees F.

Reference: 2012 NFPA 101 19.7.8

Based on documentation and staff interview the facility failed to properly test and maintain the essential electrical system in accordance with the 2012 NFPA 99 Health Care Facilities Code. The deficiency affects the two (2) essential electrical systems that serve the hospital.

The findings were:

Review of the emergency generator testing documentation on 3/01/18 at 4:30 PM revealed that the facility was not conducting weekly inspections of the two emergency generators. Failure to properly maintain and test the essential electrical system could result in injury or death in the event of an emergency. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was unaware that the emergency generators had to be inspected weekly.

Reference: 2012 NFPA 99 6.4.4.1.1.4, 2010 NFPA 110 8.4.1

Based on observation and staff interview the facility failed to properly use power cords and extension cords in accordance with the 2012 NFPA 99 Health Care Facilities Code. The deficiency affected one (1) of five (5) smoke compartments, and the basement floor.

The findings were:

1. Observation on 3/01/18 at 11:54 AM in the X-Ray room located next to the ultrasound room revealed equipment identified as an "analyzer" powered via two extension cords plugged together to reach an electrical outlet. Failure to properly use extension cords could result in injury or death by causing an electrical hazard. Interview with the facility maintenance director at the time of the observation revealed the "analyzer" equipment is intended to be utilized in the location for an extended period until the X-Ray equipment could be removed. Additional interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was unaware that extension cords were being used.

2. Observation on 3/01/18 at 2:22 PM in the Laundry Room revealed an extension cord in use. Failure to properly use extension cords could result in injury or death by causing an electrical hazard. Interview with the facility maintenance director at the time of the observation revealed that the extension cord is in permanent use due to lack of electrical receptacles in the area. Additional interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was aware that the extension cord was being used.

3. Observation on 3/01/18 at 2:22 PM in the Laboratory Room revealed multiple extension cords in use on a countertop near a sink and water lines. The extension cords were plugged into non-GFI receptacles. One power cord was used as an extension for another power cord to a receptacle. Failure to properly use power cords could result in injury or death by causing an electrical hazard. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed he was aware of the use of the extension cords.

Reference: 2012 NFPA 99 10.2.4.2

Based on documentation and staff interview the facility failed to test the HVAC system in accordance with the 2012 NFPA 99 Health Care Facilities Code. The deficiency affects five (5) out of five (5) smoke compartments, and the basement.

The findings were:

Review of HVAC testing documentation on 3/01/18 at 4:30 PM revealed that documentation of the required 6 year fire damper testing was unavailable. Failure to properly maintain and test the fire dampers could result in injury or death in the event of a Fire. Interview with the facility maintenance director at the time of the observation acknowledged the deficiency, and revealed that he was aware of the requirement for testing.

Reference: 2012 NFPA 99 15.5.2.1, 2012 NFPA 90A 5.4.8, 2010 NFPA 80 19.4.1.1