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Based on observation and interview, the facility failed to ensure each emergency exit discharge area was provided with emergency powered lighting.

Findings:

On 05/24/17 at 2:04 pm, each of the exit discharges of the faclity including the exit discharge area located at the main entrance and exit discharge area located near the cafeteria were observed to have lighting fixtures on normal power.

On 05/24/17 at 2:04 pm, the facility operations manager stated he did not know what existing light fixtures located at each exit discharge were wired to or were powered by the emergency generator.

Based on observation and interview the facility failed to ensure hazardous areas were protected as required.

Findings:

On 05/25/17 at 10:42 am the mechanical penthouse room was observed to have over 14 penetrations in the fire barrier walls.

On 05/25/17 at 10:42 am the facility operations manager stated he will get the penetrations fixed.

Based on observation the facility failed to ensure smoke barrier walls were free of penetrations as required.

Findings:

On 05/25/17 at 11:58 am multiple penetrations were observed in the fire wall barrier above the double doors leading into the dining area.

On 05/25/17 at 12:08 pm multiple penetrations were observed to be in the smoke barrier wall near the elevator on the 2nd floor.

On 05/25/17 at 12:16 pm horizontal penetrations were observed to be in the smoke barrier wall at the ceiling near the elevator on the 3rd floor.

On 05/25/17 at 12:20 pm two penetrations were observed to the fire wall above the fire doors on the 4th floor near the entrance to the elevator.

Based on observation the facility failed to ensure electrical wiring and equipment complied with NFPA 70, National Electric Code.

Findings:

On 05/24/17 at 11:14 am a microwave was observed to be plugged into a power tap in the staff lounge.

On 05/24/17 at 2:36 pm a hydroculator was observed plugged into a non-GFCI receptacle.

On 05/24/17 at 3:13 pm an extension cord wqas observed with a four plug receptacle in each operating room #1, #2, and #3.

Based on record review and interview the facility failed to ensure heating and air ventilation was operating per ASHRAE 170 as required.

Findings:

On 05/24/17 at 11:11 am the ante-room between patient room 444 and 446 was observed to have sterile supplies stored in the room. A tissue was placed at the bottom of the door and the tissue was pulled in towards the room indicating the room was negatively ventilated.

On 05/24/17 at 11:12 am the director of physical operations stated after seeing the tissue test the room needs to be positive since they were storing sterile supplies in it.

On 05/25/17 at 2:08 pm during an interview the faclity operations manager was asked how they determine the time to change their filters which seve the operating suite. He said they check the manometers and then change the filters. The facility operations manager failed to provide documentation showing manometer readings checked periodically for operating suite filter changes.

Reference:
ASHRAE 170
Annex A
Table 7-1
design Parameters for function of space
Clean storage - positive ventilation
A1.1 Operating Rooms
Each operating room should be tested for positive pressure semi-annualy or on an effective preventative maintenance schedule. When HEPA filters are present with the diffuser of operating rooms, the filter should be replaced based on pressure drop.

Based on interview the facility failed to ensure completing building systems risk assessment for their medical gas systems as required in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 05/23/17 at 11:37 am during an interview the faclity operations manager was asked for their building systems risk assessments to include medical gas systems. During record review facility operations manager failed to provide the medical gas risk assessment.

Based on record review and interview the facility failed to ensure completing building systems risk assessments for the facility essential electric system as required in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 05/23/17 at 10:30 am during an interview with the facility operations manager he was asked for their building systems risk assessments to include their essential electric system categories. During record review, the facility operations manager failed to provide the essential electric system risk assessment.