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Based upon observation and staff interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could potentially affect all patients, staff and visitors at the time of an incident to be injured if the doors failed to operate as designed during a fire emergency.

Findings Include:

On 12/2/19 at approximately 1:52pm, by observation and interview of the Director of Facilities (DOF) and Manager of Regulatory Compliance (MRC), the smoke barrier doors on the 3rd floor of the North Tower failed to properly close when tested. This finding was verified with the DOF and MRC at the time of discovery.

On 12/3/19 at approximately 10:02am, by observation and interview of the DOF and MRC, the door from the corridor to the laundry room in the basement of the North Tower failed to properly close and latch when tested. This finding was verified with the DOF and MRC at the time of discovery.

On 12/3/19 at approximately 1:14pm, by observation and interview of the DOF and MRC, the door to the storage room across from Operating Room #3 on the 2nd floor of the Wizmer Building failed to properly close and latch when tested. This finding was verified with the DOF and MRC at the time of discovery.

On 12/4/19 at approximately 1:06pm, by observation and interview of the DOF and MRC, the door from the corridor to the chute room in the basement of the South Tower failed to properly close and latch when tested. This finding was verified with the DOF and MRC at the time of discovery.

On 12/4/19 at approximately 1:11pm, by observation and interview of the DOF and MRC, the door from the corridor to the Histology Room in the basement of the South Tower failed to properly close and latch when tested. This finding was verified with the DOF and MRC at the time of discovery.

Based upon observation and staff interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could potentially affect all patients, staff and visitors at the time of an incident to be injured in a fire emergency.

Findings Include:

On 12/3/19 at approximately 9:56am, by observation and interview of the DOF and MRC, penetrations of the smoke barrier wall in the kitchen storage room located in the basement of the North Tower failed to be properly sealed. This finding was verified with the DOF and MRC at the time of discovery.

On 12/4/19 at approximately 11:03am, by observation and interview of the DOF and MRC, penetrations of the smoke barrier wall in the IT/Communications closet on the 2nd floor ICU South Tower failed to be properly sealed. This finding was verified with the DOF and MRC at the time of discovery.

On 12/4/19 at approximately 11:07am, by observation and interview of the DOF and MRC, penetrations of the smoke barrier wall in the IT/Communications closet on the 1st floor Emergency Department South Tower failed to be properly sealed. This finding was verified with the DOF and MRC at the time of discovery.

On 12/4/19 at approximately 1:37pm, by observation and interview of the DOF and MRC, penetrations of the smoke barrier wall in the electrical room on the 1st floor of the KCI Building failed to be properly sealed. This finding was verified with the DOF and MRC at the time of discovery.

Based upon observation and staff interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could potentially affect all patients, staff and visitors at the time of an incident to be injured if the facilities fire suppression system fails to operate as designed during a fire emergency.

Findings Include:

On 12/3/19 at approximately 10:40am, by observation and interview of DOF and MRC, there were wires attached to fire suppression system hangers in the Penthouse of the Wizmer Building. This finding was verified with the DOF and MRC at the time of discovery.

Based upon observation and interview, the facility failed to ensure that portable space heating devices were used only in non-sleeping staff and employee areas as required by 19.7.8. This deficient practice could potentially affect an isolated number of residents, staff and visitors in the event of an incident with the device.

Findings Include:

On 12/4/19 at approximately 1:43pm, by observation and interview of the DOF and MRC a space heater was in operation in a office on the 2nd floor of the KCI Building. This finding was verified with the DOF and MRC at the time of discovery.

Based upon observation and staff interview, the facility failed to ensure that electrical receptacles are maintained and tested as required by 6.3.4 of NFPA 99. This deficient practice could potentially affect all patients, staff and visitors at the time of an incident to be injured during a fire emergency.

Findings Include:
On 12/2/19 at approximately 12:55pm, by observation and interview of the DOF and MRC, the facility failed to properly secure an electrical panel (LP-C6A) in the corridor on the 6th floor of the North Tower. This finding was verified with the DOF and MRC at the time of discovery.

On 12/2/19 at approximately 1:25pm, by observation and interview of the DOF and MRC, the facility failed to properly cover open-wiring above the ceiling at the smoke barrier doors (DS.04.01) on the 4th floor of the North Tower. This finding was verified with the DOF and MRC at the time of discovery.

On 12/2/19 at approximately 1:59pm, by observation and interview of the DOF and MRC, the facility failed to properly secure an electrical panel (PB-212) in the corridor on the 2nd floor of the North Tower. This finding was verified with the DOF and MRC at the time of discovery.

On 12/3/19 at approximately 10:38am, by observation and interview of the DOF and MRC, the facility failed to properly cover an open electrical junction box in the Penthouse of the Wizmer Building. This finding was verified with the DOF and MRC at the time of discovery.