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Based on observation and interview, the facility failed to ensure egress doors are not equipped with a latch or lock that requires the use of a tool, key or special knowledge to open in accordance with 2012 NFPA 101 19.2.2.2.1 and 7.2.1.5.3. This deficient practice could affect 20 occupants in the event of an evacuation from the emergency department. Findings Include:

On January 9, 2023 at approximately 12:25 PM, observation revealed a 270 degree thumb-turn claw deadbolt style lock installed in the emergency department lobby sliding exit doors. The emergency exit doors are equipped with a push to open emergency breakaway function. The lock on the doors will prohibit the breakaway release doors from releasing and also prohibit evacuation from occupants who do not have the special knowledge to unlock the 270 degree deadbolt claw style lock. These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure exit and directional signs are displayed, continuously illuminated, and served by the emergency lighting system as required by 19.2.10.1. This deficient practice could affect approximately 13 occupants in the event of an emergency requiring evacuation. Findings Include:

On January 9, 2023, at approximately 2:43 PM, observation revealed areas of the emergency department where the exit access is not readily apparent and there is no clearly visible EXIT sign to direct occupants to the exit per NFPA 101, 7.10. This could prevent occupants from safely exiting during an emergency. These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to provide Hazardous areas protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. This deficient practice could affect 20 occupants in the event of a fire. Findings Include:

On January 9, 2023 at approximately 2:45 PM, observation revealed the dirty linen storage room located in the first floor staff service area does not have a door that closes and latches. The door does not latch when closed. This could potentially allow heat smoke and fire to escape the hazard room and enter the emergency egress corridor.

On January 9, 2023, at approximately 1:40 PM, observation revealed patient room 202 has been converted into a storage space containing linen carts, chairs, and large boxes. The space is not rated to a 1 hour fire resistance rating.

On January 9, 2023, at approximately 2:43 PM, observation revealed the facility failed to maintain the maintenance shop door, it would not close with positive latch when tested per NFPA 101, 19.3.2.

These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96. This deficient practice could result in harm to all occupants in the event of a fire emergency. Findings Include:

On January 9, 2023, at approximately 2:26 PM, observation revealed the fire alarm pull station located in the kitchen was blocked by a wheeled table and cart.

These findings were confirmed through interview with the Manager of Corporate Facilities at the time of record review.

Based on observation and interview, the facility failed to ensure a fire alarm system was installed in accordance with NFPA 70 and NFPA 72, as required by 19.3.4.1, 9.6 and 9.6.1.8. This deficient practice could affect all occupants in the event of a fire or smoke event. Findings Include:

On January 9, 2023, at approximately 1:00 PM, observation revealed a smoke detector in direct airflow of an air supply diffuser adjacent from room T117 in violation of 2010 NFPA 72 17.7.6.3.2. This could potentially force smoke away from the smoke detector delaying activation and notification of occupants in the event of a fire or smoke.

On January 9, 2023, at approximately 1:21 PM, observation revealed the fire alarm electrical breaker located in electrical panel #2 mechanical room M1-2 did not have a breaker lock per NFPA 72, 10.5.5.2.2.

On January 10, 2023, at approximately 12:00 PM, observation revealed a smoke detector installed in the OB/GYN On-Call room. The room is equipped with a smoke detector however, it was not verifiable as sounding an alarm within the individual space to alert sleeping occupants 2012 NFPA 101 9.6.2.10.4.

These findings were confirmed with the Director of Corporate Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72. This deficient practice could affect all occupants in the event of a fire or smoke event. Findings Include:

On January 9, 2023 at approximately 1:10 PM, observation revealed the facility smoke detector adjacent from room T 127 ultrasound mechanical room #M1-1 is broken and disconnected from the bracket hanging from the ceiling not maintained in accordance with 2010 NFPA 72 10.3.2. This could potentially allow the smoke detector to not function as designed when needed.

These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with 2011 NFPA 25. This deficient practice could affect all occupants in the event of a fire. Findings Include:

On January 9, 2023 at approximately 12:30 PM, observation revealed the sprinkler head located in the emergency room waiting area is loaded with dust in violation of 2011 NFPA 101 5.2.1.1.2, and may not function as designed when needed during a fire.

On January 9, 2023 at approximately 12:35 PM, observation revealed the sprinkler head located above the main reception desk at the main hospital entrance is loaded with dust in violation of 2011 NFPA 101 5.2.1.1.2, and may not function as designed when needed during a fire.

On January 9, 2023 at approximately 12:40 PM, observation revealed the sprinkler head located in the emergency department in room T144 exam room 1 is loaded with dust in violation of 2011 NFPA 101 5.2.1.1.2, and may not function as designed when needed during a fire.

On January 10, 2023 at approximately 11:55 AM, observation revealed the sprinkler head located in the obstetrics and gynecology Nursery room number T236 is loaded with dust in violation of 2011 NFPA 101 5.2.1.1.2. and may not function as designed when needed during a fire.

On January 10, 2023 at approximately 12:00 PM, observation revealed the sprinkler head located in the obstetrics and gynecology lounge, room number T219, is loaded with dust in violation of 2011 NFPA 101 5.2.1.1.2 and may not function as designed when needed during a fire.

On January 9, 2023 at approximately 12:55 PM, observation revealed the Recycle room located adjacent from the emergency department double doors has a sprinkler head installed in the space that has a manufacturer date of 1969. Sprinkler heads over 50 years old must be in accordance with 2011 NFPA 25 5.3.1.1.1. This could potentially allow the sprinkler head to fail when needed during a fire.

On January 9, 2023 at approximately 12:55 PM, observation revealed the sprinkler heads located in the purchasing supply area have a manufacturer date of 1969. Sprinkler heads over 50 years old must be in accordance with 2011 NFPA 25 5.3.1.1.1. This could potentially allow the sprinkler head to fail when needed during a fire.

On January 9, 2023 at approximately 2:00 PM, observation revealed the sprinkler heads located in the Chapel have a manufacturer date of 1969. Sprinkler heads over 50 yrs old must be in accordance with 2011 NFPA 25 5.3.1.1.1. This could potentially allow the sprinkler head to fail when needed during a fire.

These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure doors in smoke barriers are self-closing or automatic-closing as required by 19.3.7.6, 18.3.7.8 and 19.3.7.9. This deficient practice could affect all occupants in the event of a fire emergency. Findings Include:

On January 9, 2023, at approximately 3:14 PM, observation revealed the facility failed to maintain the cross-corridor smoke doors near room #204 per NFPA 101, 8.5.4. The cross-corridor doors failed to close to a reasonable smoke tight fit when tested because the door synchronizer was broken.

These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure portable space heating devices were prohibited or only used in non-sleeping staff areas where the heating elements do not exceed 212 degrees Fahrenheit as required by 18.7.8, 19.7.8. This deficient practice could affect 15 occupants in the event of a space heater related fire. Findings Include:

On January 9, 2023 at approximately 1:45 PM, observation revealed a space heater in the medical records office plugged into a powerstrip and running under a desk. The temperature of the heating element for the space heater could not be verified to be less than 212 degrees.

On January 9, 2023 at approximately 3:30 PM, observation revealed a space heater in the Consultation office running under a desk. The temperature of the heating element for the space heater could not be verified to be less than 212 degrees. The consultation office is located within a sleeping compartment.

These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure power receptacles comply with the requirements of 6.3.2.2.6.2(F) and 6.3.2.4.2 of NFPA 99. This deficient practice could affect approximately 13 occupants in the event of an electrical failure. Findings Include:

On January 9, 2023, at approximately 3:21 PM, observation revealed the 2nd floor diet kitchen had electrical outlets within 6 feet of a water source that was not GFCI protected per NFPA 70, Chapter 210.8(B)(1)(2)(5).

These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.

Based on observation and interview, the facility failed to ensure power strips are listed for the area in which they are used and extension cords are only used temporarily. This deficient practice could affect 10 occupants in the event of an electrical fire. Findings Include:

On January 9, 2023 at approximately 1:40 PM, observation revealed a power strip connected to an extension cord connected into another power strip in the Hospitalist office on the second floor. This could potentially allow an overloaded electrical circuit and start a fire.

These findings were confirmed with the Corporate Director of Facilities and Energy at the time of observation.