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Based on observation and interview, it was determined the facility failed to maintain one (rear exit corridor of the gift shop) of two means of egress in the gift shop free from all obstructions and impediments to full and instant use in case of fire or other emergency. The failed practice had the potential to affect all visitors and staff to the gift shop because rapid egress through the exit corridor was blocked. Findings follow:

A. While on tour of the facility on 11/30/2016 at 0955, one of three tables was observed blocking the exit door from the exit corridor in the rear of the gift shop to the adjacent corridor in the hospital.
B. While on tour of the facility on 11/30/2016 at 0955, it was observed the exit door at the end of the exit corridor in the rear of the gift shop was latched.
C. During the tour, the Director of Plant Operations verified the means of egress was blocked.

Referenced code: NFPA 101, 2012 edition, Section 7.1.10.1. See K211.

Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in two (in the basement above door B020 near room ME014 and above the fire-rated doors outside of the gift shop) of twelve areas observed by protecting penetrations in the barrier with a system or material capable of restricting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility on 11/30/2016 at 0910, a wire penetrating the smoke and fire barrier above the door designated as B020 near room ME014 was not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
B. While touring the facility on 11/30/2016 at 1005, the space around three of eight electrical conduits and one of one electrical junction box penetrating the fire and smoke rated wall above the door near the front of the gift shop was not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
C. During the tour, the Director of Plant Operations verified the penetrations were not sealed with a material capable of restricting the transfer of smoke from one side of the barriers to the other.

Referenced code: NFPA 101, 2012 edition; Section 8.4.4.1