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Based on observation, it was determined that all fire doors do not close automatically during a Code Red fire drill and activation of the Fire Alarm System.

Findings include:

1. On 12/9/14 at 11:00 AM, Unit 4 North was toured in the presence of Staff #7, Staff #11, and Staff #15. At 11:13 AM, the fire alarm system activated and a Code Red [Fire] was called over the public address system.

a. The first set of double fire doors located at the end of 4 North [heading to 4 South] did not close during the Code Red.

b. The second set of fire doors, leading from a small hallway from 4 North to the 4 South bridge, did not close during the Code Red.

2. Staff #13 confirmed upon interview, that these doors should have closed automatically during the Code Red.

Based on observation, it was determined that the facility failed to ensure that electrical wiring and equipment are in accordance with NFPA 70, National Electric Code.

Findings include:

Reference #1: 1999 edition of NFPA 70, 70:110-26(b) Clear Spaces. Working space required by this section shall not be used for storage.

1. On 12/9/14 at 12:10 PM in the presence of Staff #4, two cardboard boxes and a plastic utility cart were located in the Electrical Room near Operating Room #4, in the Same Day Surgery Suite.

Based on observation, it was determined that all fire doors do not close automatically during a Code Red fire drill and activation of the Fire Alarm System.

Findings include:

1. On 12/9/14 at 11:00 AM, Unit 4 North was toured in the presence of Staff #7, Staff #11, and Staff #15. At 11:13 AM, the fire alarm system activated and a Code Red [Fire] was called over the public address system.

a. The first set of double fire doors located at the end of 4 North [heading to 4 South] did not close during the Code Red.

b. The second set of fire doors, leading from a small hallway from 4 North to the 4 South bridge, did not close during the Code Red.

2. Staff #13 confirmed upon interview, that these doors should have closed automatically during the Code Red.

Based on observation, it was determined that the facility failed to ensure that electrical wiring and equipment are in accordance with NFPA 70, National Electric Code.

Findings include:

Reference #1: 1999 edition of NFPA 70, 70:110-26(b) Clear Spaces. Working space required by this section shall not be used for storage.

1. On 12/9/14 at 12:10 PM in the presence of Staff #4, two cardboard boxes and a plastic utility cart were located in the Electrical Room near Operating Room #4, in the Same Day Surgery Suite.