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Based on observation and record review, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

On July 9, 2019 at 10:15 AM, while accompanied by the FMD, document review determined that exit signs are not visually inspected at least once every 30 days, as required by 7.10.9.1, because no records of such attests are available.

Based on observation, not all commercial cooking equipment is installed and maintained as required. This deficient practice 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 July 9, 2019 at 9:45 AM, while accompanied by the FMD, observation determined that a manual activator for the kitchen hood suppression system is not located in the egress path more than 10 feet from the protected appliances as required by NFPA 96 2011 10.5.1.1.

Based on observation, not all corridor walls are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke or fire could pass into corridors from adjacent rooms if the corridor walls are not properly constructed.

Findings include:

On July 9, 2019, while accompanied by the FMD, observation determined that openings through corridor walls, in non-sprinklered smoke compartments, are not sealed against the passage of fire as required by 19.3.6.2.3 and 8.4.4.1. Locations observed include:

A. 9:02 AM: Above ceiling at Patient Sleeping Room 23.

B. 9:05 AM: Above ceiling at Patient Sleeping Room 19.

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 July 9, 2019 at 9:10 AM, while accompanied by the FMD, observation determined that the door to the Kitchenette between the Emergency and Imaging Departments is not positive latching, as required by 19.3.6.5(1), because the door is out of adjustment.

Based on document review, not all fire door assemblies are inspected, tested, and maintained on an annual basis. This deficient practice could affect patients, staff, and visitors in the building because the doors may fail to operate when needed if they are not periodically inspected, tested, and maintained.

Findings include:

On July 9, 2019 at 10:04 AM, while accompanied by the FMD, document review determined that fire door assemblies are not inspected and tested annually as required by NFPA 80 2010 5.2.1.

Based on observation, not all basic electrical components are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical system could fail to operate properly when needed if the electrical components are not properly installed and maintained.

Findings include:

A. On July 9, 2019 at 8:45 AM, while accompanied by the FMD, observation determined that the Operating Room lacks a battery-powered emergency light required by NFPA 99 2012 6.3.2.2.11.1 and NFPA 70 2011 517-63(A).

B. On July 9, 2019, while accompanied by the FMD, observation determined that electrical junction boxes lack cover plates required by NFPA 70 2011 314-28(C). Locations observed include:

1. 9:03 AM: Above ceiling at Patient Sleeping Room 23.

2. 9:06 AM: Above ceiling at Patient Sleeping Room 19.

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 July 9, 2019, while accompanied by the FMD, 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. 9:31 AM: Emergency Department Exam Room 4.

B. 9:32 AM: Emergency Department Exam Room 5.

Based on document review, the facility failed to inspect, test, and maintain its emergency generator in the manner required. This deficient practice could affect patients, staff, and visitors in the hospital because the emergency generator could fail to operate under emergency conditions if it is not properly inspected, tested, and maintained

Findings include:

On July 9, 2019 at 10:13 AM, while accompanied by the FMD, document review determined that weekly visual inspections of the Emergency Power Supply System (EPSS) are not conducted as required by NFPA 110 2010 8.4.1.