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Based on observation and interview, the facility failed to have its fire safety planning and training address the relocation of wheeled equipment in the corridors during a fire or similar emergency. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 11/28/16 at 3:30 PM a tour was conducted of the third floor with Staff Q and R.

During the tour, patient carts and wheelchairs were observed in the corridor.

On 12/01/16 at 9:22 AM observation in the exit access corridor in radiology revealed a housekeeping cart in place without staff nearby.

On 12/01/16 at 2:56 PM in an interview, Staff R stated there was not a policy addressing the relocation of wheeled equipment in the corridors during a fire or similar emergency.

Based on observation and interview, the facility failed to ensure each path of egress was marked with an exit sign. This had the potential to affect all patients receiving services from the facility.

Findings include:

1.On 12/01/16 at 9:10 AM observation of the fire evacuation plan for the emergency department revealed a path of egress leading out the emergency department exit discharge doors, and another path traveling north through a corridor, turning east through a door down to the waiting area then turning north again and out outside doors. The observation did not reveal an exit sign at the door where the path turned east.

On 12/01/16 at 9:10 AM in an interview, Staff Q confirmed the finding.

2. On 12/01/16 at 9:22 AM observation of the fire evacuation plan for the radiology department revealed a path of egress out to Stair C, and another opposite Stair C that led through a corridor to an outside door. Observation of the latter revealed the path of egress was not readily apparent as seen from the south end of the department.

On 12/01/16 at 9:22 AM in an interview, Staff R confirmed the finding.

3. On 12/01/16 at 9:45 AM observation of the fire evacuation plan for the laboratory revealed one path of egress that traveled west through a corridor to an outside door. The plan revealed another path that went down the same corridor and then turned south down a set of stairs and then ultimately to an outside door. However, there was not an exit sign directing occupants to go down the stairs, and the stairs ran through a three hour fire barrier. The three hour fire barrier was protected by a drop down fire shutter that was only engaged by a fusible link. Therefore, in the event this door was triggered, this path of egress would be cut off.

On 12/01/16 at 9:45 AM in an interview, Staff R confirmed the finding.

Based on observation and interview, the facility failed to maintain the stated protection level surrounding its vertical openings. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 11/28/16 at 2:15 PM a tour was conducted of the fourth floor of the facility with Staff Q and R.

1. On 11/28/16 at 2:26 PM observation above the drop down ceiling of the two hour barrier protecting the east side of stairway 02 revealed a two inch by two inch opening in the cinderblock.

On 11/28/16 at 2:26 PM in an interview, Staff Q confirmed the finding.

2. On 11/28/16 at 3:21 PM observation above the drop down ceiling of the two hour barrier on the north side of the shaft next to Stair C revealed two heating, ventilation, and cooling ducts open and running through the barrier that were not capped off.

On 11/28/16 at 3:21 PM in an interview, Staff Q confirmed the finding.

3. On 11/28/16 at 3:30 PM a tour was conducted of the third floor with Staff Q and R.

On 11/28/16 at 4:04 PM observation of the door near Stair C and leading to a mechanical space revealed it was within a two hour fire barrier, but was not rated.

On 11/28/16 at 4:04 PM in an interview, Staff Q confirmed the finding.

4. On 11/28/16 at 4:25 PM observation of the door to the shaft perpendicular to the double doors leading to the east wing of the floor revealed it was in a two hour fire barrier and was unrated.

On 11/28/16 at 4:25 PM in an interview, Staff Q confirmed the finding.

5. On 11/30/16 at 10:15 AM observation above the drop down ceiling of the two hour barrier just south of the door leading to Stair C revealed a half inch conduit open to air.

On 11/30/16 at 10:15 AM in an interview, Staff Q confirmed the finding.

6. On 11/30/16 at 9:25 AM a tour was conducted of the second floor with Staff Q and R.

On 11/30/16 at 10:53 AM observation above the drop down ceiling of the two hour barrier surrounding the double bank of elevators revealed an oval penetration above where the elevator doors were located.

On 11/30/16 at 10:53 AM in an interview, Staff Q confirmed the finding.

7. On 11/30/16 at 11:22 AM a tour was conducted of the facility ' s first floor with Staff Q and R.

On 11/30/16 at 3:45 PM observation of the door in the two hour fire rated barrier surrounding the shaft immediately to the east of the double bank of elevators revealed its rating was unable to be determined because its label was painted over.

On 11/30/16 at 3:45 PM in an interview, Staff Q confirmed the finding.

8. During the tour of the fourth floor on 11/28/16 from 2:15 PM till 4:30 PM the following was observed:

The wall for Stairway A from the corridor side, above the drop ceiling was a black wire passing through a half inch conduit that was not sealed with fire stop material.

9. From within room 4001A nursing office above the drop ceiling, there was a four inch and a one inch conduit that was not sealed with fire stop material. Further, HVAC ducting that passed through the same wall annual space was not sealed with fire stop material.

10. Above the drop ceiling from the corridor side to the right of the double elevator shaft was an uncovered junction box.

11. The wall surrounding the C staircase above the drop ceiling across from the soiled utility room was found to have two HVAC ducts passing through the wall. The space surrounding the ducts were not sealed with fire stop material.

12. From within room 405 above the drop ceiling for the south wall into the vertical opening, were two HVAC ducts open to the air space above the ceiling, not sealed. Further, it was noted a sprinkler supply line passing through the wall also failed to have fire stop around the pipe as it passed through the wall.

13. During the tour of the Third Floor from 4:30 PM till 5: 20 PM on 11/28/16 the following was observed:

From in the nourishment room above the drop ceiling along the south wall, there were two one inch conduits that were not sealed at the end with fire stop material.

14. From the corridor above the drop ceiling above the electrical panel #3 through the vertical opening for the double elevator, there was a one inch conduit where the end was not sealed with fire stop material.

15. At the end of the corridor on the corridor side at Stair B above the drop ceiling, there was a half inch conduit with two red wires for the fire alarm system passing through that were not sealed at the end. There were two one inch holes at the leave of the drop ceiling that were not sealed with fire stop material.

16. During the tour of the second floor on 11/29/16 starting at 9:25 AM the following was observed:

From the corridor above the Exit doorway above the drop ceiling for Stair A, there were two brown wires passing through the wall that were not sealed with fire stop material.

17. Along the East wall of Staircase A from within the back room above the drop ceiling, there was a half inch and a one inch copper pipe that had been cut off and the ends were not sealed with fire stop material.

18. From the corridor in front of the double elevator doors to the left side of the elevators above the drop ceiling, there was a one inch hole that had been filled with polyurethane foam and not a fire stop material. Further, along the same wall above the drop ceiling there were rectangular holes in the wall where a possible older supported ceiling was attached that were not sealed with fire stop material.

19. From within room 203 on the West wall into the vertical opening above the drop ceiling above the nurse call box, there were three three quarter inch conduits with the ends not sealed with fire stop material and not sealed around the penetration of the wall.

20. From the corridor side above the doorway for staircase B above the drop ceiling, there was a single brown wire passing through the wall with the hole not sealed with fire stop material.

21. During the tour of the first floor on 11/29/16 starting at 11:30 AM the following was observed:

Above the doorway to room 1002 above the drop ceiling, there was a half inch conduit with one black and one white wire passing out if it where the end was not sealed with fire stop material.

22. From the elevator lobby side above the double doorway, there were six conduits where the ends were not sealed with fire stop material. Further, a two inch conduit with multiple data lines passing through was not sealed with fire stop material.

Based on observation and interview, the facility failed to ensure doors to hazardous areas were on a self-closer. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 11/30/16 at 11:22 AM a tour was conducted of the facility's first floor with Staff Q and R.

On 11/30/16 at 1:54 PM a storage room was observed in room 1013. Observation within the storage room revealed it to contain several shelves containing stacks of paper files. The door to this storage closed was not observed to have a self-closer.

On 11/30/16 at 1:54 PM in an interview, Staff Q confirmed the finding.

Based on record review and interview, the facility failed to ensure its alarm system was tested in accordance with NFPA 72, 2010 edition. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 12/01/16 a review of the facility's fire safety documentation was completed. The review did not reveal where the fire alarm had been inspected in 2014.

On 11/28/16 at 3:25 PM a horn/strobe apparatus was observed in the sitz bath room to not have an address.

On 11/28/16 at 4:08 PM a horn/strobe apparatus was observed in the mechanical room on the third floor to not have an address.

On 11/28/16 at 4:40 PM a horn/strobe apparatus was observed in waiting area of the third floor to not have an address.

On 12/01/16 at 10:45 AM in an interview, Staff Q confirmed certain horn/strobe apparatuses were not addressed and the results of their testing were unknown. Also, Staff Q confirmed there were no testing documents for 2014.

Based on record review and interview, the facility failed to ensure its sprinkler system was inspected in accordance with NFPA 25. This had the potential to affect all patients receiving services from the facility.

Findings include:

A review of the facility's fire safety documentation was completed on 12/01/16. It revealed the sprinkler system was last inspected on 10/30/15 and did not reveal any inspections for 2014.

On 12/01/16 at 10:45 AM in an interview, Staff Q confirmed there were not any sprinkler system inspection documentation to be found for 2014 and the next scheduled sprinkler system inspection was scheduled for this month.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings had a means suitable for keeping them closed. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 11/28/16 at 2:15 PM a tour was conducted of the fourth floor of the facility with Staff Q and R.

On 11/28/16 at 2:45 PM observation of the corridor door to the supply room perpendicular to the elevator shaft revealed it was held closed with a roller latch.

On 11/28/16 at 2:45 PM in an interview, Staff Q confirmed the finding.

On 11/30/16 at 9:10 AM a tour was conducted of the third floor with Staff Q and R.

On 11/30/16 at 9:23 AM observation of the door to patient room 306 revealed it had latching hardware that did not latch the door.

On 11/30/16 at 9:23 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the protective construction of it's smoke barriers. This had the potential to affect all patients receiving services from the facility.

Findings include:

1. On 11/28/16 at 3:30 PM a tour was conducted of the third floor with Staff Q and R.

On 11/28/16 at 3:46 PM observation above the drop down ceiling of the one hour smoke barrier northwest of the double elevators and containing a door leading to the labor and delivery revealed a one inch conduit open to air.

On 11/28/16 at 3:46 PM in an interview, Staff Q confirmed the finding.

2. On 11/30/16 at 9:25 AM a tour was conducted of the second floor with Staff Q and R.

On 11/30/16 at 10:00 AM observation above the drop down ceiling of the north side of the one hour barrier (seen from within the physician's practice) revealed three heating, ventilation, and cooling and three conduits running through an opening.

On 11/30/16 at 10:00 AM in an interview, Staff Q confirmed the finding.

3. On 11/30/16 at 11:22 AM a tour was conducted of the facility's first floor with Staff Q and R.

On 11/30/16 at 11:51 AM observation above the drop down ceiling of the three hour barrier as seen from within the gift shop and above the door leading to room 1300b revealed a brown speaker wire traveling through an unfilled penetration in the barrier.

On 11/30/16 at 11:51 AM in an interview, Staff Q confirmed the finding.

4. On 11/30/16 at 2:20 PM observation above the drop down ceiling of the one hour smoke barrier as seen from post anesthesia care unit curtain area two revealed nine open one inch conduits with three of them located above the stenciled word "FIRE" in the stenciled words "FIRE WALL."

On 11/30/16 at 2:20 PM in an interview, Staff Q confirmed the finding.

5. On 11/30/16 at 2:31 PM observation above the drop down ceiling of the one hour smoke barrier as seen from post anesthesia care unit curtain area four revealed six open one inch conduits.

On 11/30/16 at 2:31 PM in an interview, Staff Q confirmed the finding.

6. On 11/30/16 at 3:22 PM observation above the drop down ceiling of the one hour barrier at the corridor corner south and west of the double bank of elevators revealed it contained one layer of drywall.

On 11/30/16 at 3:22 PM in an interview, Staff Q confirmed the finding.

7. On 11/30/16 at 4:01 PM observation above the drop down ceiling of the one hour smoke barrier as seen from within the back southwest section of the laboratory revealed a two inch by two inch penetration.

On 11/30/16 at 4:01 PM in an interview, Staff Q confirmed the finding.

8. On 11/30/16 at 4:10 PM observation above the drop down ceiling of the one hour smoke barrier perpendicular to the 4:01 PM finding revealed an eight inch by eight inch penetration with a drain pipe running through it. Below the penetration the words "1 HR FIRE WALL" were observed stenciled onto the barrier.

On 11/30/16 at 4:10 PM in an interview, Staff Q confirmed the finding.

9. On 11/30/16 at 4:20 PM a tour was taken of the basement area with Staff Q and R.

On 11/30/16 at 4:20 PM observation above the drop down ceiling of the one hour fire barrier between the mail room and the landing for Stair D, as seen from the landing, revealed the words "1 HR FIRE WALL" stenciled onto the barrier. To the left of this stenciling a two inch pipe was open to air, two half inch copper lines were open to air, and a half inch conduit holding blue wiring was open to air.

On 11/30/16 at 4:20 PM in an interview, Staff Q confirmed the finding.

10. On 12/01/16 at 9:29 AM observation of the two hour fire barrier as seen from within the boiler room revealed at approximately the midpoint a three foot by one foot opening with five large conduits traveling through one layer of drywall.

11. During the tour of the second floor 11/29/16 starting at 11:20 AM the following was observed:

Within room 2200, the surgery waiting room, on the East wall above the strobe light above the drop ceiling, there was a three quarter inch conduit with two red wires passing through that was not sealed with fire stop material at the end and where it passed through the wall.

12. During the tour of the first floor 11/29/16 starting at 11:30 AM the following was observed:

From the corridor side of the soiled holding rooms #1010 doorway in the surgical wing across from the men's locker room above the drop ceiling, to the left there was a hole with a white wire passing through and three conduits that were not sealed with fire stop material. Further to the right side there were three more conduits that were not sealed with fire stop material.

13. Within the PACU area above the open bays numbered 1, 2, and 3, above the drop ceiling were three sets of three each conduits that were not sealed with fire stop material.

14. From the PACU side above the drop ceiling outside the sterile storage room #1012 on the north wall were four ridged conduits that were not sealed with fire stop material.

15. Directly across from the last finding on the South wall outside Endo room 1 above the drop ceiling, was a three quarter inch conduit with a blue wire passing through that was not sealed with fire stop material.

16. Above bay number 4 in PACU above the drop ceiling on the East wall, there were six open conduits not sealed with fire stop material.

17. On the East wall of the PACU manager's office above the drop ceiling there was a one inch conduit with a blue wire passing through that was not sealed with fire stop material.

18. In the main corridor just outside the A staircase above the double doors above the drop ceiling, there were two pass throughs, one with multiple blue wires and a second with yellow cable passing through not sealed with fire stop material.

19. Within the lab where the blood banking is done on the East wall above the drop ceiling at the south corner, there was a half inch conduit with one green and two black wires passing through that was not sealed with fire stop material.

20. Within the Radiology Department, the Vascular room South of the waiting area on the West wall above the drop ceiling, there was a one inch square hole with a single brown wire that was not sealed with fire stop material.

21. Within the Radiology Department, within the bathroom adjacent to the waiting area on the West wall above the drop ceiling, there was a one inch square hole with a green wire passing through that was not sealed with fire stop material.

22. Within the Radiology Department, above the cabinets within the nursing station on the West wall above the drop ceiling, there was a two inch PVC pipe with multiple data lines passing through that was not sealed with fire stop material.

Based on observation and interview, the facility failed to ensure doors in smoke barriers self-closed. This had the potential to affect all patients receiving services from the facility.

Findings include:

1. On 11/28/16 at 3:30 PM a tour was conducted of the third floor with Staff Q and R.

On 11/28/16 at 3:52 PM a door in the physician's on call room was observed to be within a one hour smoke barrier. The door was not observed to have a self-closer.

On 11/28/16 at 3:52 PM in an interview, Staff Q confirmed the finding.

2. On 11/30/16 at 11:22 AM a tour was conducted of the first floor with Staff Q and R.

On 11/30/16 at 11:34 AM the door to the physician's dictation area was observed to be in a three hour barrier and propped open with a chair in such a way that the door could not self-close.

On 11/30/16 at 11:34 AM in an interview, Staff Q confirmed the finding.

3. On 11/30/16 at 3:22 PM observation of the door to storage area 1200A (near public elevator 1) revealed it was in a one hour barrier without a self-closing device.

On 11/30/16 at 3:22 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to inspect the function of the fire dampers within the heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8 of 90A, 2012 edition and therefore 19.4.1.1 in NFPA 80. This had a potential to affect all patients receiving services from the facility.

Findings include:

On 11/30/16 at 11:43 AM observation of the three hour fire barrier at the upper landing of Stair D revealed heating, ventilation, and cooling ducting traveling through it and a fire damper in place.

On 11/30/16 at 11:51 AM in an interview, Staff Q stated none of the fire dampers in the surgical building had been inspected.

Based on record review and interview, the facility failed to ensure each fire drill included the transmission of the fire alarm signal. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 12/01/16 a review of the facility's fire drills was completed. The review revealed a drill had occurred on 03/09/16 at 3:00 AM. A review of that drill did not reveal where a signal had been sent.

On 12/01/16 at 12:25 PM in an interview, Staff Q confirmed they did not transmit the signal during the off hours.

Based on observation and interview, the facility failed to ensure mobile trash collection receptacle were kept in a room protected as hazardous. This had the potential to affect all patients receiving services from the facility.

Findings include:

1. On 11/30/16 at 9:17 AM a wheeled garbage bin of greater than 32 gallons was observed in the corridor without staff present.

On 11/30/16 at 10:15 AM the wheeled garbage bin was observed still in the corridor.

On 11/30/16 at 10:15 AM in an interview, Staff Q confirmed the finding.

2. On 11/30/16 at 4:31 PM observation within the mailroom in the basement revealed it contained a trash receptacle that was greater than 32 gallons. The door to this room lacked a self-closer.

On 11/30/16 at 4:31 PM in an interview, Staff Q confirmed the finding.

3. On 12/01/16 at 9:45 AM observation of the exit corridor by the worker station in the radiology department revealed a wheeled garbage bin that was greater than 32 gallons parked there without staff nearby.

On 12/01/16 at 9:45 AM in an interview, Staff Q confirmed the finding.

Based on interview and policy review, the facility failed to have it's systems assessed for risk in such a way as to have them meet the descriptions in NFPA 99, 2012 edition, 4.1. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 12/01/16 a review of the facility's risk assessment policy was completed on 12/01/16. The review revealed the building's risk assessment included two broad categories: high risk and non-high risk. The review revealed high risk was further subdivided into three additional categories: high risk, infection control and life safety. The review revealed non high risk was further subdivided into non high risk and run to fail.

On 12/01/16 at 2:25 PM in an interview, Staff R was unable to explain how the policy correlated to the four categories as described in NFPA 99, Chapter 4.

Based on record review and interview, the facility failed to ensure it acted upon its annual medical gas and vacuum system inspection report in accordance with NFPA 99, 2012 edition, 5.1.14.2.2. This had the potential to affect all patients receiving services from the facility.

Findings include:

A review of the facility's 2016 annual medical gas and vacuum system inspection report completed 10/13/16 to 10/14/16 revealed a defective gauge at a shutoff valve to the medical gas to an operating room, abnormal pressure to an oxygen outlet in a patient room and in the intensive care unit, and several patient rooms with abnormal pressures to the medical air outlets.

On 12/01/16 at 12:25 PM in an interview, Staff Q stated the repairs to the medical gas system had not been made.

Based on observation and interview, the facility failed to comply with NFPA 99, 2012 edition, 6.4.1.1.17. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 12/01/16 observation of the facility's emergency electrical system revealed it contained two generators, an inside and an outside generator. During the tour, an annunciator panel for the inside generator could not be located.

On 12/01/16 at 11:27 AM in an interview, Staff Q stated an annunciator panel was located in the emergency department for one generator, but the other did not have one at a constantly attended, regular work station.

Based on policy review and interview, the facility failed to comply with NFPA 99, 2012 edition, 15.13. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 12/01/16 a review of the facility's policy titled "Universal Protocol and Site Marking Procedure" revealed it contained a time out procedure that addressed correct patient identity, correct side and site, and agreement on the procedure to be done. It did not address pooling of flammable antiseptics, solution-soaked materials, or dryness of the application site.

On 12/01/16 at 11:27 AM Staff R confirmed the policy as written.