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Based on observation and interview the facility failed to provide a smoke resistant enclosure for hazardous areas protected by automatic sprinkler system. The deficient practice would allow smoke and fire to extend beyond the hazardous areas into exit corridors and other areas of the building.

Findings are:

Observtion on 10-17-17 between 1:50 PM. and 3:15 P.M. revealed the following:
1. The East wall between the Boiler Room and Central Supply was not intact and had a void space in it.
2. The North wall between Central Supply and the Main Basement Corridor was not intact and had a void space in it that extended above the ceiling.
3. Void spaces were located in the North Wall of the Elecrical Control Room adjacent to the Emergency Room corridor.
4. Void spaces were located in the North wall of the Physical Therapy area.
5. Void spaces were located around electrical conduit along the North wall of the Elevator Control Room.

During the exit interview on 10-18-17 at 11:30 AM, Maintenance Supervisor A verified the findings.

Based on observation and interview the facility failed to provide smoke detection in room or spaces open to the corridor. The deficient practice would delay detection and notification of a fire emergency within the area and delay emergency response.

Findings are:

Observation on 10-17-17 at 3:30 P.m. revealed the Nourishment Center located on the main floor in the patient care area was open to the corridor. Further observation revealed there was no smoke detection provided in the area.

During the exit interview on 10-18-17 at 11:30 AM Maintenance Supervisor A verified the findings.

Based on record review and interview the facility failed to have a written policy or the documentation for staff response for a fire or emergency hazards that could be encountered during surgical procedures. The deficient practice did not provide staff education and training for a fire or other emergency that could occur in the Operating Room during surgical procedures

Findings are:

Record review on 10-17-17 at 3:25 PM. revealed the facility did not have a policy or procedures detailing emergency response to a fire emergency that could be encountered during surgical procedures, including fire alarm activation, evacuation of patients, equipment shutdown, and control operations, control of chemical spills, extinguisment of drapery, clothing, and equipment fires.

During the exit interview on 10-18-17 at 11:30 AM Maintenance Supervisor A verified the findings.