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Based on observation and interview the facility failed to maintain one of eight means of egress (rear corridor near Receiving) free from all obstructions and impediments to full and instant use in case of fire or other emergency. The failed practice had the potential to affect all patients, visitors, and staff because travel through the means of egress was impeded in the event of fire or other emergencies. Findings follow:

A. While on tour of the facility on 04/24/18 at 2:05 PM, observation showed a patient table, a cart with boxes loaded on it, and a hand truck obstructing the available travel space of the exit corridor near Receiving.
B. During the tour, the Director of Plant Operations verified the means of egress was obstructed.

Referenced code: NFPA 101; 2012 edition, Section 7.1.10.1

Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in three (above the fire-rated doors near Room 112, above the fire-rated doors near Room 110, and above the fire-rated near the entrance to the X-Ray Hall) of six areas observed by protecting penetrations in the barrier with a system or material capable of restricting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility on 04/24/18 at 2:30 PM, observation showed penetrations in the fire-rated barriers which were not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other in the following locations:
1) a sleeve (conduit) for wire penetrating the fire barrier above the fire-rated doors near Room 112;
2) a group of cables penetrating the fire barrier above the fire-rated doors near Room 110;
3) one of seven pipes penetrating the fire barrier above the fire-rated doors near the entrance to the X-Ray Hall.
B. During the tour, the Director of Maintenance verified the penetrations were not sealed with a material capable of restricting the transfer of smoke from one side of the barriers to the other.

Referenced code: NFPA 101; 2012 edition, Section 8.4.4.1

Based on observation and interview, it was determined the facility failed to comply with all provisions in the National Electric Code (NFPA 70, 2011 Edition.) Two of four electrical junction boxes did not have covers as required. The failed practice had the potential to affect all patients, visitors, and staff because of the potential fire hazard absence of covers presents. Findings follow:

A. While touring the facility on 04/24/18 at 2:45 PM, observation showed two electrical junction boxes with no cover in the following locations:
1) one above the drop down ceiling near the fire-rated doors at the entrance to the Emergency Room and;
2) one above the drop down ceiling near fire-rated doors near the Emergency Room waiting area.
B. During the tour, it was verified by the Facilities Management Director the electrical junction boxes did not have covers.

Referenced Codes: NFPA 99, 2012 edition, Section: 6.3.2.1; NFPA 70, 2011 edition, Article: 314.25