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The facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

On May 12, 2010 the surveyor, accompanied by the Director of Support Services observed the following corridor doors were wedged open, not tightly close or was not smoke resistant.

1. Room 509
2. 1st floor Managers Office Room 1-043
3. Elevator doors 4th floor marked 3-019
4. Housekeeping closet Room 1-107

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

The facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. ( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Section 7.2.1.8.1 (1) "Upon release of the hold-open mechanism, the door becomes self-closing."
Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

On May 12, 2010 the surveyor, accompanied by the Director of Support Services observed smoke seals were torn or a gap of more than a 1/8 inch between smoke barrier doors when closed located on the 3rd and 4th floors.

Failure to properly adjust or repair smoke doors will allow smoke to contaminate smoke zones not directly effected by the fire, which could cause harm to the patients.

The facility failed to provide a self-closing or an automatic-closing door in a hazardous area.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "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 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

On May 12, 2010 the surveyor accompanied by Director of Support Services observed the following rooms was missing its self-closing devices on the doors.

1. Gift shop 1st floor was missing the door closure arm for the door closure assembly
2. Emergency Department storage room measured to be approximately 120 total square feet and not self closing.
3. Soiled utility room 1-056 not closing sticking to the door frame when tested by staff.

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to the patients in time of a fire.


The facility did not maintain the integrity, smoke resistance, of walls, ceilings and unfilled pipe chases in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19,. Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls, doors, and ceilings must be able to resist the passage of smoke.

On May 12, 2010, the surveyors, accompanied by the Director of Support Services and Security manager observed unsealed pipe chase holes, holes in walls or ceilings in the following rooms:

1. 3rd floor Mechanical room #3098
2. 3rd floor Electrical room #3-019
3. 1st floor Telecommunications room #1064
4. 1st floor Electrical room closet #1-163
5.1st floor Electrical room #1177
6. 4th floor Telecommunications room
7. Communications room outside of the ICU

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

The facility did not keep exits readily accessible and unobstructed at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel." NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10 " 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". Section 7.1.10.2.1 "No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof."

On May 12, 2010 the surveyor, accompanied by the Security Manager observed storage of Cardio Medical Equipment within the exit corridors of the Cardio Operating rooms and beds in the Pacu Phase 2 exit corridors. In addition, the South hallway of Operating room one Orthopedic replacement equipment was being stored in the exit corridor. The storage of equipment was reducing the corridor width and and obstructing the exit access located in these locations.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and cause harm to the patients.

The facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

On May 12, 2010 the surveyor, accompanied by the Director of Support Services observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup throughout the entire exhaust hood system.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a fire, which could cause damage to the kitchen and could cause harm to the patients.

The facility failed to provide a medical gas cylinder storage room free of combustible materials or mount receptacles outlets five feet above the floor in the oxygen storage rooms.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

On May 12, 2010 the surveyor, accompanied by the Director of Support Services and the Security Manager observed the oxygen storage rooms in the facility had storage of plastics, cardboard boxes, or medical supplies being stored within five feet of the oxygen bottles or stored next to receptacle outlets in the wall.

1. 5th floor Equipment storage room
2. 4th floor Function room (PFT)
3. 1st floor Emergency Department room #1089
4. 4th floor nurses station storage room adjacent to the nurses station
5. Anesthesia work office in the Operating room

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients. Failing to mount receptacles outlets five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.