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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 as evidenced by unsealed penetrations. The penetrations could result in the reduction in the staff's ability to protect in place due to smoke and fire. This affected 2 of 8 floors in the main hospital.

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.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

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 Administrator, the Director of Facilities Management, the Manager of Facility Operations, the Superintendent, and the Inspector of Record on 7/9/14, the smoke barrier walls were observed.

1. At 10:26 a.m., there was an approximately one square inch unsealed penetration with some wires coming through above the entry door of the south wall and an approximately 3 inch by 1 inch unsealed penetration in the wall and above the cooler in the south wall of Room B 250.

2. At 10:38 a.m., there was an approximately 4 inch by 3 inch unsealed penetration above the electrical panel with several wires coming through in Room B 251. There was some clear non-rated tape over the unsealed penetration.

3. At 10:39 a.m., the Manager of Facility Operations said that the unsealed penetration was in the wall for approximately 6 months while the electrical construction project was active.

Based on observation, and interview, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by the fire alarm sounding an alarm and no announcement was made. This could delay response to a fire emergency. This affected 8 of 8 floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with the Administrator, the Director of Facilities Management (DOFM), the Manager of Facility Operations, the Superintendent, and the Inspector of Record on 7/9/14, the fire alarm system was sounding, the audible speakers were monitored, and staff were interviewed.

1. At 11:36 a.m., the fire alarm system was sounding the fire alarm, and no announcement was made to inform staff of the cause (Code Red or Testing) of the alarm.

2. At 11:39 a.m., the DOFM said during an interview, that an announce is required to be made within 90 seconds of the alarm. No announcement was made.

At 11:40 a.m., the Telephone Supervisor said during an interview that they are required to announce 5 times the location of the alarm, (Code Red and location), each time the fire alarm is activated. She said that she did not know why the fire alarm was activated, and what the problem was. The fire alarm control panel indicated trouble and she said that the vendor was working on the fire alarm system. She said that if it was a test, then an announcement would have been announced that the system is being tested.

Based on observation, and interview, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full instant use in the case of fire or other emergency. This was evidenced by items that were stored in a egress corridor. This could result in a delay in evacuation in the event of a fire, or other emergency. This affected 1 of 8 floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a tour of the facility with the Administrator, the Director of Facilities Management (DOFM), the Manager of Facility Operations, the Superintendent, and the Inspector of Record, on 7/9/14, the exit corridors were observed, and staff was interviewed.

1. At 11:30 a.m., there were three potty chairs, two large shelves (approximately 4 feet by 4 feet), a metal cart, and a table that were stored in the east exit corridor (all of the items were near the east exit door) from the south old operating room. There were several patients in the room next to the obstructed corridor.

2. At 11:31 a.m., the DOFM said during an interview, that the items should not be stored in the corridor, and the items were removed.

Based on observation, and interview, the facility failed to maintain their smoke barrier walls to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by unsealed pipes in the smoke barrier walls. This could allow smoke and fire to migrate to other compartments within the building. This affected 4 of 8 floors

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service 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 for 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 conditions:
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 Administrator, the Director of Facilities Management (DOFM), the Manager of Facility Operations, the Superintendent, and the Inspector of Record, on 7/9/14, the smoke barriers were observed, and staff were interviewed.

1. At 10:42 a.m. there was an approximately 1 inch unsealed pipe in the north wall of Room B-251.

2. At 10:59 a.m., there was an approximately 2 inch unsealed pipe with a 3 inch by 1/4 inch gap in the caulking material in Room B-J-02.

3. At 11:12 a.m., there were two approximately 2 inch unsealed pipes with a 2 inch by 3/4 inch gap in each of the caulking materials in Room 2-E-34.

4. At 11:20 a.m., there was an approximately 1/2 inch unsealed J box (connection box) near the ceiling that was unsealed (no cap on the end) in Room 2-E-34.

5. At 11:28 a.m., there were two 3 inch unsealed pipes in the north wall of Room 2-E-34.

6. At 11:32 a.m., there were four 1 inch unsealed pipes near the east wall of Room 2-E-36.

7. At 12:46 p.m., there was a 2 inch unsealed pipe in the south wall of Room ME-3074.

8. At 1:17 p.m., there were two 3 inch unsealed pipes in the north wall of Room ME-2142.

9. At 2:10 p.m., there was a 2 1/2 inch unsealed pipe in the south wall of Room ME-1012.

10. At 2:15 p.m., staff 1 and staff 2 were interviewed, and both staff said that all penetrations during the construction project should be sealed the same day the penetrations were made.

11. At 2:25 p.m., the Manager of Facility Operations said during an interview, that he conducted monthly rounds to look for issues, and said that he apparently missed some.

Based on observation, and interview, the facility failed to maintain there electrical system as evidenced by uncovered electrical boxes. This increases the risk of electrical shock and fire. This affected 1 of 8 floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with the Administrator, the Director of Facilities Management (DOFM), the Manager of Facility Operations, the Superintendent, and the Inspector of Record on 7/9/14, the electrical system was observed, and a staff person was interviewed.

1. At 11:08 a.m., there was a 1 1/2 inch conduit pipe with an approximate 4 inch by 3 inch cover that was hanging on one screw (uncovered) on Room 2-E-34.

2. At 11:12 a.m., there were two four gang outlet boxes that were missing cover plates in Room 2-E-34.

3. At 11:33 a.m., there was an approximately 12 inch by 12 inch uncovered electrical box on the east wall of Room 2-E-36.

4. At 11:35 a.m., the Manager of Facility Operations said during an interview, that all of the boxes should have covers.

Based on observation, and interview, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls as evidenced by unsealed penetrations. The penetrations could result in the reduction in the staff's ability to protect in place due to smoke and fire. This affected 2 of 8 floors in the main hospital.

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.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

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 Administrator, the Director of Facilities Management, the Manager of Facility Operations, the Superintendent, and the Inspector of Record on 7/9/14, the smoke barrier walls were observed.

1. At 10:26 a.m., there was an approximately one square inch unsealed penetration with some wires coming through above the entry door of the south wall and an approximately 3 inch by 1 inch unsealed penetration in the wall and above the cooler in the south wall of Room B 250.

2. At 10:38 a.m., there was an approximately 4 inch by 3 inch unsealed penetration above the electrical panel with several wires coming through in Room B 251. There was some clear non-rated tape over the unsealed penetration.

3. At 10:39 a.m., the Manager of Facility Operations said that the unsealed penetration was in the wall for approximately 6 months while the electrical construction project was active.

Based on observation, and interview, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by the fire alarm sounding an alarm and no announcement was made. This could delay response to a fire emergency. This affected 8 of 8 floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with the Administrator, the Director of Facilities Management (DOFM), the Manager of Facility Operations, the Superintendent, and the Inspector of Record on 7/9/14, the fire alarm system was sounding, the audible speakers were monitored, and staff were interviewed.

1. At 11:36 a.m., the fire alarm system was sounding the fire alarm, and no announcement was made to inform staff of the cause (Code Red or Testing) of the alarm.

2. At 11:39 a.m., the DOFM said during an interview, that an announce is required to be made within 90 seconds of the alarm. No announcement was made.

At 11:40 a.m., the Telephone Supervisor said during an interview that they are required to announce 5 times the location of the alarm, (Code Red and location), each time the fire alarm is activated. She said that she did not know why the fire alarm was activated, and what the problem was. The fire alarm control panel indicated trouble and she said that the vendor was working on the fire alarm system. She said that if it was a test, then an announcement would have been announced that the system is being tested.

Based on observation, and interview, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full instant use in the case of fire or other emergency. This was evidenced by items that were stored in a egress corridor. This could result in a delay in evacuation in the event of a fire, or other emergency. This affected 1 of 8 floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a tour of the facility with the Administrator, the Director of Facilities Management (DOFM), the Manager of Facility Operations, the Superintendent, and the Inspector of Record, on 7/9/14, the exit corridors were observed, and staff was interviewed.

1. At 11:30 a.m., there were three potty chairs, two large shelves (approximately 4 feet by 4 feet), a metal cart, and a table that were stored in the east exit corridor (all of the items were near the east exit door) from the south old operating room. There were several patients in the room next to the obstructed corridor.

2. At 11:31 a.m., the DOFM said during an interview, that the items should not be stored in the corridor, and the items were removed.

Based on observation, and interview, the facility failed to maintain their smoke barrier walls to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by unsealed pipes in the smoke barrier walls. This could allow smoke and fire to migrate to other compartments within the building. This affected 4 of 8 floors

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service 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 for 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 conditions:
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 Administrator, the Director of Facilities Management (DOFM), the Manager of Facility Operations, the Superintendent, and the Inspector of Record, on 7/9/14, the smoke barriers were observed, and staff were interviewed.

1. At 10:42 a.m. there was an approximately 1 inch unsealed pipe in the north wall of Room B-251.

2. At 10:59 a.m., there was an approximately 2 inch unsealed pipe with a 3 inch by 1/4 inch gap in the caulking material in Room B-J-02.

3. At 11:12 a.m., there were two approximately 2 inch unsealed pipes with a 2 inch by 3/4 inch gap in each of the caulking materials in Room 2-E-34.

4. At 11:20 a.m., there was an approximately 1/2 inch unsealed J box (connection box) near the ceiling that was unsealed (no cap on the end) in Room 2-E-34.

5. At 11:28 a.m., there were two 3 inch unsealed pipes in the north wall of Room 2-E-34.

6. At 11:32 a.m., there were four 1 inch unsealed pipes near the east wall of Room 2-E-36.

7. At 12:46 p.m., there was a 2 inch unsealed pipe in the south wall of Room ME-3074.

8. At 1:17 p.m., there were two 3 inch unsealed pipes in the north wall of Room ME-2142.

9. At 2:10 p.m., there was a 2 1/2 inch unsealed pipe in the south wall of Room ME-1012.

10. At 2:15 p.m., staff 1 and staff 2 were interviewed, and both staff said that all penetrations during the construction project should be sealed the same day the penetrations were made.

11. At 2:25 p.m., the Manager of Facility Operations said during an interview, that he conducted monthly rounds to look for issues, and said that he apparently missed some.

Based on observation, and interview, the facility failed to maintain there electrical system as evidenced by uncovered electrical boxes. This increases the risk of electrical shock and fire. This affected 1 of 8 floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with the Administrator, the Director of Facilities Management (DOFM), the Manager of Facility Operations, the Superintendent, and the Inspector of Record on 7/9/14, the electrical system was observed, and a staff person was interviewed.

1. At 11:08 a.m., there was a 1 1/2 inch conduit pipe with an approximate 4 inch by 3 inch cover that was hanging on one screw (uncovered) on Room 2-E-34.

2. At 11:12 a.m., there were two four gang outlet boxes that were missing cover plates in Room 2-E-34.

3. At 11:33 a.m., there was an approximately 12 inch by 12 inch uncovered electrical box on the east wall of Room 2-E-36.

4. At 11:35 a.m., the Manager of Facility Operations said during an interview, that all of the boxes should have covers.