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Based on an observation the facility failed to provide properly rated fire-resistance fire barrier doors. The deficiencies in fire rated door assemblies could affect patients, staff and visitors if smoke or fire were allowed to pass from one building to the adjacent nonconforming building.

Findings include:

A. On 4/29/19 at 10.30 AM, while accompanied by DO and DPO it was determined that on the First Floor, Old Lobby 2-hour fire rated double doors did not contain the required latching points per door leaf. Each door leaf contained a latch into the upper door frame but failed to include a second latch point per door leaf. This is not per Section 8.2 and 19.1.3.5 and NFPA 80 2010 Edition Fire Doors and Other Opening Protections.

B. On 4/29/19 at 10.42 AM, while accompanied by DO and DPO it was determined that on the First Floor, Imaging west 2-hour fire rated double doors did not close and latch to the door fram when tested. Each door was lacking the required latching points per door leaf. Each door leaf contained a latch into the upper door frame but failed to include a second latch point per door leaf. This is not per Section 8.2 and 19.1.3.5 and NFPA 80 2010 Edition Fire Doors and Other Opening Protections.

C. On 4/29/19 at 10.48 AM, while accompanied by DO and DPO it was determined that on the First Floor, C-Wing to Surgery the 2-hour fire rated double doors did not contain the required latching points per door leaf. Each door leaf contained a latch into the upper door frame but failed to include a second latch point per door leaf. This is not per Section 8.2 and 19.1.3.5 and NFPA 80 2010 Edition Fire Doors and Other Opening Protections.

Based on an observation, the facility failed to provide the required illumination that can prevent facility occupants from safely negotiating the means of egress during failure of normal power. This deficient practice could affect patients, staff and visitors if proper testing was not completed and emergency lighting failed during a fire event.

Findings include:

A. On 04/29/19 at 3:40 PM, while accompanied by DO and DPO it was determined that the required battery powered emergency lighting has not been tested for the required 30-second monthly or 90-minute annually. This does not comply with 19.2.9 and 7.9.

B. On 04/29/19 at 3:48 PM, while accompanied by DO and DPO it was determined that three battery powered emergency lighting/exit signs did not illuminate when tested. This does not comply with 19.2.9 and 7.9.

Based on an observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire event.

Findings include:

A. On 04/29/19 at 9:45 AM while accompanied by DO and DPO it was determined that in the Basement, HR storage room contained paper supplies, containers and file storage. The door was not self-closing and did not comply with Section 19.3.2.

B. On 04/29/19 at 9:50 AM while accompanied by DO and DPO it was determined that in the Basement, Emergency Management Storage room, ceiling had missing ceiling tiles. This does not comply with Section 19.3.2.

C. On 04/29/19 at 9:55 AM while accompanied by DO and DPO it was determined that in the Basement, Boiler room, contained two pallets of cardboard boxes. The boxes did not contain supplies that are used for maintenance of the boilers. This does not comply with Section 19.3.2.

D. On 04/29/19 at 10:05 AM while accompanied by DO and DPO it was determined that on the First Floor, old ICU waiting room has been converted into a large storage room. The door to the room was not self-closing and does not comply with Section 19.3.2.

E. On 04/29/19 at 10:14 AM while accompanied by DO and DPO it was determined that on the First Floor the following rooms are being used for hospital storage and the doors to the room do not self-close. This does not comply with Section 19.3.2.

1. Room 200
2. Room 206
3. Room 207

F. On 04/29/19 at 11:35 AM while accompanied by DO and DPO it was determined that on the First Floor, Emergency Department, Storage room door to the exit path was not self-closing and does not comply with Section 19.3.2.

G. On 04/29/19 at 11:38 AM while accompanied by DO and DPO it was determined that on the First Floor, Emergency Department, IT/Storage room door to the exit path was not self-closing and does not comply with Section 19.3.2.

H. On 04/29/19 at 11:50 AM while accompanied by DO and DPO it was determined that on the Third Floor, Patient room 321 is being used for mattress and bed storage, door was not self-closing and does not comply with Section 19.3.2.

Based on observations, staff interviews, and document reviews, the facility failed to provide proper fire alarm notification. This deficient practice could affect patients, staff, and visitors in the hospital due to the lack of visual notification of the fire alarm system. This could delay staff response during a fire event if the visual notification was not available.

Finding includes:

On 4/29/19 at 11:58AM, while accompanied by DO and DPO it was determined that on the Third Floor, three on-call sleeping rooms were provided. The rooms are lacking a visual notification device as required per 19.3.4.3.2, 9.6.4 and NFPA 72 Section 18.5.4.6.

Based on staff interviews, and document reviews, the facility failed to provide proper fire alarm documentation. This deficient practice could affect patients, staff, and visitors in the facility if proper testing of the fire alarm system did not function properly during a fire event.

Finding includes:

On 4/29/19 at 3:58 PM, while accompanied by DO and DPO it was determined that the facility did not maintain a fire alarm inspection report. This does not comply with 9.7.5 and NFPA 25.

Based on observations, staff interview, and document review, the facility failed to properly supervise all sprinkler system control valves. This deficient practice could affect patients, staff, and visitors in the hospital because the sprinkler system could be shut off without notification if the sprinkler system valves are not monitored as required.

Finding includes:

On 4/29/19 at 12:35 PM, during document review it was determined that the sprinkler inspection report dated 3/22/19 identified that 1 of 10 waterflow alarms failed during testing. Based on an interview with DO and DPO it could not be determined if the alarm was repaired or replaced. This does not comply with 9.7.2.1 and NFPA 72.

Based on observations, the facility failed to provide proper electrical distribution in patient care areas and equipment related to the emergency electrical system. This deficient practice could affect patients, staff and visitors if proper electrical wiring is not maintained in patient care areas.

Findings include:

On 04/29/19 1:45 PM, while accompanied by DO, it was determined that on the First Floor, Surgery Suite, Operating room #4 did not contain a normal power outlet. This does not comply with the requirements of NFPA 99, section 6.3.2.2.1.2.