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Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that smoke barriers were in full compliance with NFPA 101, 19.3.7.3 and 8.3.

The following conditions were found:-

(1) There were conduit, sleeves, and cable penetrations through the smoke compartment walls above two sets of cross corridor door openings, adjacent to the nursing unit nurses' station, that were not fire sealed to prevent the passage of smoke and the products of combustion.

(2) There were conduit and cable penetrations through the 2-hour fire, above the fire door separating the hospital from the adjacent clinic, that were not sealed to prevent the passage of the products of combustion.

Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that door openings in smoke barriers were in full compliance with NFPA 101, 19.2.2.2.6.

Cross corridor smoke compartment doors did not close fully on alarm.

Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that fire rated doors to hazardous areas were in full compliance with NFPA 101, 19.3.2.1.

The doors to the soiled utility rooms in the surgical suite and in the emergency department were fire rated but not self-closing.

Based on observations made during a review of policies and procedures on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that fire drills were being conducted in full compliance with NFPA 101, 19.7.1.2.

The logs showed that fire drills were being conducted once or twice quarterly, but not on every shift.

Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the oxygen system was protected in fullcompliance with NFPA 99, Chapter 4.

The emergency oxygen connection at the exterior wall of the building was not padlocked to prevent unauthorized access.

Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the Type I essential electrical system (EES) was in full compliance with NFPA 99, 3.4.2.2.

The generator annunciator panel located at the nursing unit nurses' station was not operationl. The signal lights did not light up on lamp test mode.

Based on observations made during a review of policies and procedures on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the following procedures were being implemented:-

(1) Grounding system testing in patient care areas was not being performed in accordance with NFPA 99, 3.3.2. There were no logs showing that electrical receptacles in patient care areas were being tested at least annually.

(2) Reports showed that disaster drills were being only being performed annually. Disaster drills were not being performed semi-annually in accordance with NFPA 99, 11.5.3.9.

Based on observations made during a review of policies and procedures on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the emergency generator was being tested in full compliance with NFPA 99, 3.4.4.1 and NFPA 110, 8.4.2.

The emergency generator was not being tested under load monthly.

Based on observations made during the tour of the facility on the morning and afternoon of 04/07/10 with the maintenance supervisor/safety officer, the facility failed to assure that the Type I essential electrical system (EES) was in full compliance with NFPA 99, 3.4.2.2.2.

The following conditions were found:-

(1) There were two 'PA' panels in the boiler room that appeared to have items belonging on the EES, but it was not clear if they were emergency panels.

(2) The nursing unit medicine preparation room did not appear to have emergency lighting, an above counter emergency receptacle, and an emergency receptacle for the medication refrigerator. None of these plates were color coded to identify them as being a part of the emergency system.

(3) The central sterile autoclave was circuited to a normal power panel, 'NM', inatead of to the equipment branch of the EES.

(4) The fire alarm booster panel was circuited to critical branch panel 'CE', instead of to the life safety branch of the EES.

Based on observations made during the tour of the facility on the morning and afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the electrical wiring and equipment was in full compliance with NFPA 70, 700.9 or 517.19.

The following conditions were found:-

(1) Emergency panels and automatic transfer switches throughout the facility were not labeled 'LIFE SAFETY', 'CRITICAL', or 'EQUIPMENT' as applicable to identify which branch of the essential electrical system they served.

(2) Emergency receptacles in the emergency treatment rooms, the recovery room, the nursery, and LDR rooms had labels. The labels identified which panel served them, but did not identify which circuit supplied power to them.

Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that smoke barriers were in full compliance with NFPA 101, 19.3.7.3 and 8.3.

The following conditions were found:-

(1) There were conduit, sleeves, and cable penetrations through the smoke compartment walls above two sets of cross corridor door openings, adjacent to the nursing unit nurses' station, that were not fire sealed to prevent the passage of smoke and the products of combustion.

(2) There were conduit and cable penetrations through the 2-hour fire, above the fire door separating the hospital from the adjacent clinic, that were not sealed to prevent the passage of the products of combustion.

Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that door openings in smoke barriers were in full compliance with NFPA 101, 19.2.2.2.6.

Cross corridor smoke compartment doors did not close fully on alarm.

Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that fire rated doors to hazardous areas were in full compliance with NFPA 101, 19.3.2.1.

The doors to the soiled utility rooms in the surgical suite and in the emergency department were fire rated but not self-closing.

Based on observations made during a review of policies and procedures on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that fire drills were being conducted in full compliance with NFPA 101, 19.7.1.2.

The logs showed that fire drills were being conducted once or twice quarterly, but not on every shift.

Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the oxygen system was protected in fullcompliance with NFPA 99, Chapter 4.

The emergency oxygen connection at the exterior wall of the building was not padlocked to prevent unauthorized access.

Based on observations made during the tour of the facility on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the Type I essential electrical system (EES) was in full compliance with NFPA 99, 3.4.2.2.

The generator annunciator panel located at the nursing unit nurses' station was not operationl. The signal lights did not light up on lamp test mode.

Based on observations made during a review of policies and procedures on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the following procedures were being implemented:-

(1) Grounding system testing in patient care areas was not being performed in accordance with NFPA 99, 3.3.2. There were no logs showing that electrical receptacles in patient care areas were being tested at least annually.

(2) Reports showed that disaster drills were being only being performed annually. Disaster drills were not being performed semi-annually in accordance with NFPA 99, 11.5.3.9.

Based on observations made during a review of policies and procedures on the afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the emergency generator was being tested in full compliance with NFPA 99, 3.4.4.1 and NFPA 110, 8.4.2.

The emergency generator was not being tested under load monthly.

Based on observations made during the tour of the facility on the morning and afternoon of 04/07/10 with the maintenance supervisor/safety officer, the facility failed to assure that the Type I essential electrical system (EES) was in full compliance with NFPA 99, 3.4.2.2.2.

The following conditions were found:-

(1) There were two 'PA' panels in the boiler room that appeared to have items belonging on the EES, but it was not clear if they were emergency panels.

(2) The nursing unit medicine preparation room did not appear to have emergency lighting, an above counter emergency receptacle, and an emergency receptacle for the medication refrigerator. None of these plates were color coded to identify them as being a part of the emergency system.

(3) The central sterile autoclave was circuited to a normal power panel, 'NM', inatead of to the equipment branch of the EES.

(4) The fire alarm booster panel was circuited to critical branch panel 'CE', instead of to the life safety branch of the EES.

Based on observations made during the tour of the facility on the morning and afternoon of 04/07/10 with the maintennce supervisor/safety officer, the facility failed to assure that the electrical wiring and equipment was in full compliance with NFPA 70, 700.9 or 517.19.

The following conditions were found:-

(1) Emergency panels and automatic transfer switches throughout the facility were not labeled 'LIFE SAFETY', 'CRITICAL', or 'EQUIPMENT' as applicable to identify which branch of the essential electrical system they served.

(2) Emergency receptacles in the emergency treatment rooms, the recovery room, the nursery, and LDR rooms had labels. The labels identified which panel served them, but did not identify which circuit supplied power to them.