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Based on observations and interview, it was determined that the facility failed to ensure one 45-minute fire rated door assembly, and one 90-minute fire rated door assembly could automatically close to a latched position.

Findings include:

Observations during tour on 09/22/21 between 8:00 a.m. and 10:30 a.m. with Staff B (Maintenance Supervisor) revealed the basement level generator room door (labeled N0012) that has a 90-minute fire assembly rating, failed to automatically close to a full latched position when released from the full open position. The latch and the strike plate failed to align properly. Additionally, the 45-minute fire rated door assembly, located between the main lobby and the gift shop, failed to automatically close to a latched position when released from the magnetic hold-open device. The left hand door panel has a metal cap installed on the top of the door that was preventing the double doors on the meeting edges to achieve a full closed and latched position.

Interview on 09/22/21 with Staff B confirmed the above findings, door conditions, and locations.

Based on observations and interview, it was determined that the facility failed to ensure one large PPE (Personal Protective Equipment) storage room, that exceeds 50 sq. ft., was equipped with an automatic door closing device.

Findings include:

Observations during tour on 09/22/21 between 11:00 a.m. and 11:15 a.m. with Staff B (Maintenance Supervisor) revealed one storage room (approximately 75 sq. ft.), located behind the back wall of the wound care center, at the bottom of the stairwell, was full of PPE supplies. The rated storage room door assembly failed to be equipped with an automatic door closing device.

Interview on 09/22/21 with Staff B confirmed the above findings, location, and the quantities of PPE in the storage room.

Based on observations, record review and interview, it was determined that the facility failed to ensure the fire department connection received it's 5-year hydrostatic testing and that at least 6 sprinkler heads were not "loaded" with dust/debris.

Findings include:

Professional standard:
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

5.2.1 Sprinklers.
5.2.1.1 Sprinklers shall be inspected from floor level annually.
5.2.1.1.1 Sprinkler shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (upright, pendant, or side-wall)
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the manufacturer

A.5.2.1.1.2(5) In lieu of replacing sprinklers that are loaded with a coating of dust, it is permitted to clean sprinklers with compressed air or by vacuum provided that the equipment doesn't touch the sprinkler.

Table 13.1.1.2 Hose connections Testing: Every 5-years
13.7 Fire Department Connections.
13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper is in place and operating properly.
13.7.2 If fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the fire department connection clapper is operational over it's full range.

13.8.1 Inspections, Tests, and Maintenance procedures
Table 13.8.1 Fire Department Connection (FDC)
(1) Isolate and hydrostatic test for 2-hours at 150 psi
(2) Main drain test (Only when a control valve has been closed)

Observations and record review on 09/22/21 between 8:00 a.m. and 2:00 p.m. with Staff B (Maintenance Supervisor) revealed the following locations with loaded sprinkler heads (full of lint and dust/debris):
1. At least 2 sprinkler heads in the Main Laboratory are "loaded" with dust/lint (in close proximity to the ventilation ducts).
2. At least 3 sprinkler heads in the Main Kitchen are "loaded" with dust/lint/grease.
3. At least 1 sprinkler head in the Patient Registration waiting area is "loaded" with Dust/lint (in close proximity of the ventilation ducts).
The documentation for the Fire Department Connection, located along the main entrance driveway, outside the administration wing, was labeled 11/21/2011 (almost 10 years) from the last hydrostatic testing date. Additional documentation was requested from Staff A (Facility Services Director), Staff B, and the appropriate vendors with no additional records being located.

Interview on 09/22/21 with Staff B and email responses on 09/24/21 with Staff A confirmed the above findings, locations, and available documentation.

Based on observations and interview, it was determined that the facility failed to ensure that at least 3 smoke barrier walls are maintained to resist the passage of smoke.

Findings include:

Observations during tour on 09/22/21 between 12:30 p.m. and 2:15 p.m. with Staff A (Facility Services Director) and Staff B (Maintenance Supervisor) revealed the 3 following locations and conditions of the identified smoke/fire barrier walls:
1. Above the suspended ceiling, over the 45-minute fire rated door assembly, between the administration wing and the corridor to the main lobby, has a 3" hole in the drywall that is filled with a non-rated yellow Kraft insulation and one unsealed penetration around a red fire alarm wire.
2. Above the suspended ceiling, above the right side of the main doors to the birthing suite (2nd floor), has a 3/4" unsealed hole through the wall.
3. Above the suspended ceiling, in the 3-hour fire rated, brick wall assembly, outside the emergency department waiting room, has multiple unsealed penetrations through the brick wall consisting of at least 3 steel trusses penetrating the wall, one 6" piece of brick missing, and 2 hot water pipes. These unsealed penetrations will not resist the passage of smoke or the effects from fire.

Interview on 09/22/21 with Staff A and Staff B confirmed the above findings, locations, and conditions that exist.

Based on record review and interview, it was determined that the facility failed to correct the same deficient findings, identified in the annual Medical Gas vendor inspection report, for the last 3 years.

Findings include:

Professional standard:
NFPA 99 Health Care Facilities Code

5.2.1.4 Medical gas and vacuum systems should be surveyed at least annually for the items that follow and deficient items corrected. Survey of medical air and instrument air sources should include, but not limited to the following:
(1) Dew point Monitor (operation and calibration).
(2) Carbon monoxide monitor (medical air only) (operation and calibration)
(3) Aftercoolers (condition, operation of drains)
(4) Operating pressures (cut-in, cut-out, and control pressures)
(5) All local alarms (verify presence of local alarms, perform electrical tests, test lag alarm)
(6) Receiver elements (auto drain, manual drain, sight glass, pressure gauge)
(7) Filters (condition)
(8) Pressure regulators (condition, output pressure)
(9) Source valve (labeling)
(10) Intake ( location and condition)
(11) Housekeeping around compressors)

Survey of the medical vacuum and the WAGD source(s) should include, but not be limited to the following:
(1) Operating vacuum (cut-in, cut-out, and control pressures)
(2) All local alarms (verify presence of local alarms, perform electrical tests, test lag alarm)
(3) Receiver elements (auto drain, manual drain, sight glass, pressure gauge)
(4) Source valve (labeling)
(5) Exhaust (location and condition)
(6) House keeping around the pump

Survey the medical gas manifold source(s) should include, but not limited to the following:
(1) Number of cylinders (damaged connectors)
(2) Cylinder leads (condition)
(3) Cascade (switching from one cylinder to another)
(4) All local alarms (verify presence of local alarms, perform electrical tests, test lag alarm)
(5) Source valve (labeling)
(6) Relief valves ( discharge location and condition)
(7) leaks
(8) Security (door, gate locks, and signage)
(9) Ventilation (general operation, housekeeping)
(10) Housekeeping around manifolds

Survey of medical gas area alarms should include, but not limited to the following:
(1) Locations (visible to the staff)
(2) Signals (audible and visual, use test function)
(3) Activation at low pressure
(4) Housekeeping around alarm

Survey of medical gas master alarms should include, but not limited to the following:
(1) Locations (visible to the staff)
(2) Signals (audible and visual, use test function)
(3) Activation at low pressure
(4) Housekeeping around alarm

Survey of zone valves should include, but not limited, to the following:
(1) Locations (relationship to terminals control)
(2) Leaks
(3) Labeling
(4) Housekeeping around alarm

Survey of the medical gas outlets/inlets, should include, but not limited to, the following:
(1) Flow and function
(2) Latching/delatching
(3) Leaks
(4) General condition (noninterchangable indexing)

The facility should retain a written or electronic copy of all findings and any corrections performed.

Record review on 09/21/21 between 12:00 p.m. and 1:00 p.m. with Staff B (Maintenance Supervisor) revealed the annual medical gas vendor reports, list the following 5 deficiencies for at least the last 3 annual surveys.

Hospital medical gas systems, annual survey inspections were conducted on:
July 16th, 2021
July 30th, 2020
March 8th. 2019

These same deficiencies and locations are as follows:
Medical Air manifold room (inside room 1104): There is no ventilation installed.

Nitros Oxide room (1st floor east): The mechanical exhaust inlet fails to be within 12" of the finished floor. There fails to be a fire-rating label on the entrance door (45-minute required).

Medical Gas System: Leaks detected after the fitting and before the final line gauge. There is a threaded connection after the source valve.

Interview on 09/22/21 with Staff B confirmed the available documentation and the above findings.

Based on observations and interview, it was determined that the facility failed to ensure that six electrical junction boxes had protective covers installed.

Findings include:

Professional standard:
NFPA 70 National Electrical Code (2011 edition)
314.28 Pull and junction boxes and conduit bodies.
Boxes and conduit bodies used as pull or junction boxes shall comply with 314.28 (A) through (E).
(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. where used, metal covers shall comply with the grounding requirements of 250.110.

Observations during tour on 09/22/21 between 9:00 a.m. and 9:10 a.m. with Staff B (Maintenance Supervisor) revealed 6 electrical junction boxes, containing the monitoring modules for the sprinkler system tamper switches. The 6 cover plates had been removed and placed behind the junction boxes in the basement level sprinkler riser room.

Interview on 09/22/21 with Staff B confirmed the above findings, location, and the cover plates had not been reinstalled after the last sprinkler vendor service.