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Based on observation and interview, the facility failed to ensure egress doors with locks can be readily open from the egress side. This was evidenced by two of two operating room doors equipped with a lock and no tool readily available to open the doors from the egress side in the event of a fire or other emergency. This affected two of two operating rooms.

Findings:

During a tour of the facility with the Director of Maintenance on 12/21/16, the doors were observed.

At 2:24 p.m., the egress doors to operating room one and operating room two were observed to be equipped with locks. During interview, the Director of Maintenance was asked if he had a key to unlock the doors and he stated he did not. Maintenance asked a staff member that was inside the surgery suite if she had a key and she stated she did not. A key was not readily available to unlock the doors in the event of fire or other emergency.

Based on observation, the facility failed to maintain their automatic sprinkler system, as evidenced by sprinkler heads obstructed by storage. This could affect the operation of the sprinkler system, causing the delay in extinguishing fire. This affected 1 of 2 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
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.
9.7.8 Record Keeping. Testing and maintenance records required by NFPA25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.2 The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.
NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition
8.7.5.2 Obstructions to Sprinkler Discharge Pattern Development. 8.7.5.2.1 General. 8.7.5.2.1.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section.

Findings:

During a tour of the facility with the Director of Facilities on 12/21/16, the sprinkler system was observed.

1. At 1:56 p.m., there was storage within 12 inches of the sprinkler deflector inside the emergency services closet. This was acknowledged by the director of facilities during survey.

2. At 2:16 p.m., the women's dressing room located inside the surgery suite had boxes stored within 18 inches of the sprinkler deflector. This was acknowledged by the director of facilities during survey.

Based on observation, the facility failed to ensure decorations of highly flammable materials were prohibited. This was evidenced by corridors door that were covered with combustible paper material. This affected 1 of 2 smoke compartments.

Findings:

During a tour of the facility with the Director of Facilities on 12/21/16, the facility decorations were observed.

1. At 1:58 p.m., the emergency room supply closet door located across from the emergency room had Christmas wrapping paper covering 50% of the door.

2. At 1:59 p.m., the environmental closet door and the emergency storage room door located next to the emergency room had Christmas wrapping paper covering 50% of the door.