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Based on observation it was determined the facility failed to fill penetrations in two (2) of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 "Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.''

Findings include:

On January 30, 2018, the surveyor, accompanied by the Director of Facilities Management, Director of System Safety and Security, Administrative Director of Support Services, and Infection Preventionist Quality Services and Patient Safety observed unsealed penetrations in the smoke barriers in the following locations:

1. Tower 2, 2nd floor by door #050080, a 4 inch conduit penetrated the smoke barrier and was not sealed.
2. Tower 2, 1st floor by door #055157, a 4 inch conduit penetrated the smoke barrier and was not sealed.

During the exit conference on January 31, 2018, the above findings were again acknowledged by the Director of Facilities Management, Director of System Safety and Security, Administrative Director of Support Services, and Infection Preventionist Quality Services and Patient Safety.

Based on observation, it was determined the facility failed to ensure that staff did not use daisy chain power strips.

The use of daisy chained power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters."

Findings include:

On January 30, 2018, the surveyor, accompanied by the Director of Facilities Management, Director of System Safety and Security, Administrative Director of Support Services, and Infection Preventionist Quality Services and Patient Safety, observed the following strips in the facility and not directly plugged in to the receptacle wall outlets.

1. 4th floor, IDF room, power strip daisy chained to a battery back-up power strip.

2. 3rd floor, IDF room, three (3) power strips daisy chained into a fourth (4) power strip.

3. 1st floor, IDF room, power strip daisy chained into another power strip.

4. In Radiology, PACS Control room, power strip daisy chained into another power strip.

5. Communications room, power strip daisy chained into another power strip.

During the exit conference on January 31, 2018, the above findings were again acknowledged by the Director of Facilities Management, Director of System Safety and Security, Administrative Director of Support Services, and Infection Preventionist Quality Services and Patient Safety.