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Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained.

Findings include:

A. On June 4, 2019 at 11:08 AM, while accompanied by the DPO, observation determined that the Fourth Floor cross-corridor door, from the Med-Surg Unit to the former ICU, can be secured against egress as prohibited by 19.2.2.2.5.1.

B. On June 4, 2019, while accompanied by the DPO, observation determined that doors in egress paths, which are equipped with delayed egress locking mechanisms, are not equipped with a sign, including 1 inch tall letters with 1/8 inch wide stroke widths on a contrasting background, which reads "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS," as required by 7.2.1.6.1.1(4). Locations observed include:

1. 1:20 PM: Second Floor door to the West Exit Stair.

2. 1:22 PM: Second Floor door to the North Exit Stair.

3. 1:24 PM: Second Floor cross-corridor door from the Mother/Baby Unit to the adjacent Med-Surg Unit to the east.

Based on observation, not all exit stairs in the building are constructed as required. This deficient practice could affect patients, staff, and visitors in the building because building occupants could be injured while using the exit stairs if they are not contructed properly.

Findings include:

On June 4, 2019 at 11:20 AM, while accompanied by the DPO, observation determined that the intermediate rails at guardrails for the North Exit Stair permit a sphere larger than 4 inches in diameter to pass as prohibited by 7.2.2.4.5.3.

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

Findings include:

On June 4, 2019 at 12:54 PM, while accompanied by the DPO, observation determined that the door to the Second Floor Administrative Storage Room is not self-closing as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

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

Findings include:

On June 4, 2019 at 2:12 PM, while accompanied by the DPO, observation determined that the door to the Third Floor Outpatient Physical Therapy Storage Room is not self-closing as required by 39.3.2.1, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

Based on observation, not all commercial cooking equipment is installed and maintained as required. These deficiencies could affect patients, staff, and visitors in the hospital by permitting smoke or fire from moving from the kitchen to other parts of the building if the cooking equipment is not properly maintained.

Findings include:

On June 5, 2019 at 9:50 AM, while accompanied by the DPO, observation determined that the Basement Level Kitchen deep fat fryer is located less than 16 inches from adjacent cooking equipment as prohibited by NFPA 96 2011 12.1.2.4.

Based on observation, the facility failed to provide and maintain fire extinguishers as required. This deficient practice could affect patients, staff, and visitors in the immediate area by preventing the extinguishment of a fire if the fire extinguishers do not function properly

Findings include:

On June 5, 2019 at 9:53 AM, while accompanied by the DPO, observation determined that the Basement Level Kitchen Type K fire extinguisher is not readily accessible, as required by NFPA 10 2010 6.1.3.1, because it is obstructed by a food cart.

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor doors are not properly installed and maintained.

Findings include:

On June 4, 2019 at 11:12 AM, while accompanied by the DPO, observation determined that all Patient Sleeping Room doors in the Fourth Floor former ICU are not positive latching as required by 19.3.6.5(1).

Based on observation, not all smoke barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke could pass between adjacent smoke compartments if the smoke barriers are not properly constructed.

Findings include:

On June 4, 2019 at 11:14 AM, while accompanied by the DPO, observation determined that a series of pipe or other penetrations, above the ceiling at the Fourth Floor smoke barrier wall between the Med-Surg Unit and the former ICU, are not sealed against the passage of smoke as required by 8.5.6.2.

Based on observation, not all smoke barrier doors are installed and maintained as required. This deficient practice could affect patients. staff, and visitors in the hospital because smoke could pass between adjacent smoke compartments if smoke barrier doors are not properly installed and maintained.

Findings include:

On June 4, 2019 at 11:15 AM, while accompanied by the DPO, observation determined that the Fourth Floor smoke barrier door between the Med-Surg Unit and the former ICU is not self-closing, as required by 19.3.7.8(a) and NFPA 105 2010 4.5.1, because the door is held open by an unapproved foot peg.

Based on observation, not all electrical receptacles are installed as required. this deficient practice could affect patients, staff, and visitors in the building because electrical power may not be available for use when required if they are not installed properly.

Findings include:

On June 4, 2019, while accompanied by the DPO, observation determined that critical care patient beds exist at which at least 1 branch circuit is not served by the hospital's normal power system as required by NFPA 70 2011 517-19(A). Locations observed include:

A. 1:27 PM: Second Floor Delivery Room.

B. 1:46 PM: First Floor Operating Room 3.