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Based on observation and interview, the facility failed to maintain clear paths of egress in corridors. This was evidenced by two sets of smoke barrier doors that were obstructed by a wheelchair and a patient lift. This could delay evacuation of patients during a fire emergency affecting three of eight smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2)*Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c)*The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5)*Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)
(d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f)*The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

Findings:

During the facility tour and interview with Facilities Staff 1 on 7/13/17 , the egress corridors were observed.

1. At 1:33 p.m., there was an obstructed access to the east leaf of the opposite swinging smoke barrier doors located between the Emergency Department and the medical surgical area. There was a wheelchair stored in front of the panic hardware leaving a one foot clear width between the edge of the west leaf and the wheelchair.

2. At 1:40 p.m., there was an obstructed access to the north leaf of the opposite swinging smoke barrier doors located between the the medical surgical area north hallway and the Central Nurse Station. There was a patient lift stored in front of the panic hardware leaving a one foot clear width between the edge of the south leaf and the lift. At 1:41 p.m., Facilities Staff 1 explained that staff had left the equipment at these locations to be repaired.

Based on observation and interview, the facility failed to maintain their self closing doors. This was evidenced by a stairwell door and a set of occupancy separation doors that failed to self close. This could result in the spread of fire or smoke from one smoke compartment to another affecting four of eight smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During the facility tour and interview with Facilities Staff 1 on 7/13/17, the exit passageways were observed.

1. At 2:02 p.m., the double set of building separation doors between the F & G Building mechanical rooms were missing their door closing devices. The 90 minute fire rated doors were observed in the fully open position. At 2:03 p.m., Facilities Staff 1 explained that the closing hardware had been previously used as spares for the hospital corridor door closer repairs and new doors closers were being purchased to replace them.

2. At 2:47 p.m., the first floor stairwell door, labeled as "Central Supply" with an up arrow, failed to close completely. The door remained open two inches in all three tests from the fully open position. At 2:48 p.m., Facilities Staff 1 commented that there was airflow pushing the door open and that the closer required adjustment.

Based on observation and interview, the facility failed to maintain the fire rated enclosure for three hazardous storage areas. This was evidenced by corridor doors for Medical Records and Materials Management that failed to self close. This could result in the spread of fire or smoke during a fire emergency affecting two of eight smoke compartments.

NFPA 101 LIFE SAFETY CODE, 2012 edition
19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.4 Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (1220 mm) above the bottom of the door.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard

Findings:

During the facility tour and interview with Facilities Staff 1 on 7/13/17, the hazardous areas enclosures were observed.

First Floor

1. At 1:55 p.m., the east corridor door for the Medical Records office, with an open file storage area, was not equipped with a door closer. The door was in the fully open position. The Medical Records office was greater than 300 square feet in area and was filled with wall to wall open file storage. At 1:56 p.m., Facilities Staff 1 acknowledged that the door should have been equipped with a self closing device.

2. At 1:57 p.m., the west door was equipped with a fusible link fire-rated door which was obstructed from closing by a plastic wedge that was placed between the bottom of the door and the floor.

3. At 1:58 p.m., the door to the adjacent Medical Records Storage room failed to self-close. The room was greater than 100 square feet in area and was filled with medical records files. The fire rated door was equipped with a self closing device but was missing the closing arm.

Second Floor

4. At 2:30 p.m., the double set of corridor doors to the Materials Management area failed to self close. There were no door closers and no door sequencer attached to the doors. The area was greater than 400 square feet in area and was filled with combustible storage. At 2:31 p.m., Facilities Staff 1 acknowledged that the doors should have been equipped with automatic or self closing doors.

Based on observation and interview, the facility failed to ensure fire alarm signals could be detected at all locations. This was evidenced by no visible strobe and no audible chime in the Materials Management area when the corridor doors were closed and the fire alarm system was activated. This could result in a delay in egress during a fire emergency affecting one of eight smoke compartments.

NFPA 101. Life Safety Code, 2012 Edition
19.3.4 Detection, Alarm, and Communication Systems
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1* General.
9.6.1.1 The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.

9.6.1.2 Fire detection, alarm, and communications systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code applicable to required systems.

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

9.6.1.4 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

Findings:

During the facility tour and interview with Facilities Staff 1 on 7/13/17, the fire alarm system was observed.

1. At 2:35 p.m., in the center of the Materials Management area, there was no audible or visual indication that the fire alarm system had been activated. At 2:36 p.m., Facilities Staff 1 concurred that there was no detectible alarms for that area when the corridor doors were closed.

Based on observation and interview, the facility failed to maintain clear access to electrical panels. This was evidenced by storage of miscellaneous items against two electrical breaker panels in the Information Technology area. This could result in delays restoring power during an emergency power outage. This affected one of eight smoke compartments.

NFPA 101 Life Safety Code 2012 edition
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70 National Electrical Code, 2011 Edition
110.2 Approval. The conductors and equipment required or permitted by this Code shall be acceptable only if approved. Informational Note: See 90.7, Examination of Equipment for Safety, and 110.3, Examination, Identification, Installation, and Use of Equipment. See definitions of Approved, Identified, Labeled, and Listed.

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (A)(1)(b), or A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.

Table 110.26(A)(1) Working Spaces
Nominal Voltage to Ground 0-150 Condition 1 Condition 2 Condition 3
Minimum Clear Distance 914 mm (3 ft) 914 mm (3 ft) 914 mm (3 ft)

Nominal Voltage to Ground 151-600
Minimum Clear Distance 914 mm (3 ft) 107 mm (3 ft 6 in) 122 mm (4 ft)

Note: Where the conditions are as follows:
Condition 1 - Exposed live parts on one side of the working space and no live or grounded parts on the other side of the working space, or exposed live parts on both sides of the working space that are effectively guarded by insulating materials.
Condition 2 - Exposed live parts on one side of the working space and grounded parts on the other side of the working space. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the working space.

Findings:

During the facility tour and interview with Facilities Staff 1 on 7/13/17, the electrical panels were observed.

1. At 3:15 p.m., there were miscellaneous storage items stacked against electrical Panels K1 and K2 in the Information Technology area. At 3:16 p.m., Facilities Staff 1 confirmed that there should have been a minimum of three feet clear space in front of the panels.

Based on observation, the facility failed to maintain wiring connections on electrical equipment. This was evidenced by appliances plugged into extension cords and surge protectors and computer servers plugged into surge protectors that were plugged into other surge protectors. This affected affected two of eight smoke compartments and could result in an increased risk of electrical shock or an electrical fire.

NFPA 99 Health Care Facilities 2012 edition
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70 National Electrical Code 2011 edition
240.5 Protection of Flexible Cords, Flexible Cables, and Fixture Wires. Flexible cord and flexible cable, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either 240.5(A) or (B).
(A) Ampacities. Flexible cord and flexible cable shall be protected by an overcurrent device in accordance with their
ampacity as specified in Table 400.5(A)(1) and Table 400.5(A)(2). Fixture wire shall be protected against overcurrent
in accordance with its ampacity as specified in Table 402.5. Supplementary overcurrent protection, as covered in
240.10, shall be permitted to be an acceptable means for providing this protection.
(B) Branch-Circuit Overcurrent Device. Flexible cord shall be protected, where supplied by a branch circuit, in accordance with one of the methods described in 240.5(B)(1), (B)(3), or (B)(4). Fixture wire shall be protected, where supplied by a branch circuit, in accordance with 240.5(B)(2).

400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

Findings:

During the facility tour with Facilities Staff 1 on 7/13/17, the electrical devices and wiring connections were observed.

1. At 2:59 p.m., in the Acute Nursing Breakroom, there was a refrigerator plugged into an extension cord which was plugged into a surge protector which was plugged into a wall outlet on the opposite side of the room.

2. At 3:00 p.m., in the Acute Nursing Breakroom, there was a toaster and a microwave oven plugged into a surge protector which was plugged into the wall outlet

3. At 3:04 p.m., in the Nurse's Office, there was a coffee maker plugged into a surge protector which was plugged into a wall outlet.

4. At 3:25 p.m., in the Information Technology area, there were computer servers plugged into a surge protector which was plugged into a second surge protector which was plugged into an electrical outlet.