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Based on observation and interview, the provider failed to maintain the 20 minute fire resistive rating of corridor doors. One randomly observed hazardous room door was not self-closing (dirty linen room door in the emergency department). One randomly observed corridor door was held in the open position by an unapproved device (the employee break room). Findings include:

1. Observation at 9:50 a.m. on 11/30/10 revealed the door for the dirty linen room in the emergency department was not equipped with a self-closing device. Interview with the director of plant operations at the time of the observation confirmed that finding.

2. Observation at 2:30 p.m. on 12/01/10 revealed the corridor door to the employee break room was held in the open position with a plastic dust pan. That device was an impediment to closing the door in an emergency. Interview with the director of plant operations at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to install two readily visible illuminated signs to direct occupants to exits in the boiler room and three exit signs to direct occupants from the corridor south of the cafeteria in the basement. Findings include:

1. Observation at 1:00 p.m. on 11/30/10 revealed the boiler room was over 500 square feet in area and did not have illuminated exit signs for the exterior door or the corridor door from the boiler room. Interview with the director of plant operations at the time of the observation revealed the original boiler room was about 400 square feet, but a subsequent building expansion added over 300 additional square feet to the boiler room.

2. Observation at 10:00 a.m. on 12/01/10 revealed a lack of illuminated exit signs to direct occupants to reach exits in the basement corridor at the elevator location outside the cafeteria. One was needed pointing east; one was needed pointing north; and one was needed pointing east at the 90 minute fire-rated double doors through the clinic.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The ceiling of the medical surge elevator hydraulic room had an unsealed opening around a pneumatic door closer conduit. The door for the room would not self-close and latch. Findings include:

1. Observation at 4:15 p.m. on 11/30/10 revealed the ceiling of the medical surge elevator hydraulic room had an unsealed opening around a pneumatic door closer conduit. Interview with the director of plant operations at the time of the observation confirmed that finding.

2. Observation at 4:20 p.m. on 11/30/10 revealed the corridor door for the medical surge elevator hydraulic room would not self-close and latch. Interview with the director of plant operations at the time of the observation revealed the top hinge was loose on the door and prevented the door from closing.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. Magnetically locked exit doors from the LDRP wing were not equipped with signage that indicated how to open a magnetically locked door. Findings include:

1. Observation at 4:00 p.m. on 11/30/10 revealed the two stair enclosures had doors that were each equipped with a magnetic lock that activated upon close proximity of a HUGS bracelet. Interview with the staff on duty at that time revealed the doors were delayed egress and could be opened by pushing the panic bar on the door and waiting 15 seconds for the magnet to release (the door magnet would also release upon activation of the fire alarm system). Signage was not provided at either stair enclosure door stating the doors were delayed egress. On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch in stroke width on a contrasting background that reads as follows:

PUSH UNTIL ALARM SOUNDS

DOOR CAN BE OPENED IN 15 SECONDS

Interview with the director of plant operations at the time of the observation confirmed those findings.

Based on observation and interview, the provider failed to ensure staff were familiar with fire drill procedures. Findings include:

1. Observation at 1:15 p.m. revealed the nurse responding to the simulated fire in the staff breakroom did not pull the breakroom door closed to isolate the effects of the fire. Also the adjacent vending machine room and patient room 204 doors were not shut. The staff nurse was not familiar with the location of the manual fire alarm pull stations. The pull station at the southwest elevator (farthest from the simulated fire location) was used to sound the alarm. The fire alarm loudspeaker announcement stated the location of the pull station used rather than the actual simulated fire location. Also no other staff responded to the fire location. No fire extinguishers were brought to the fire drill. Interview with the director of plant operations at the time of the observations confirmed those findings.

Based on observation, measurement, and interview, the provider failed to maintain unobstructed space adjacent to the sprinkler deflector so the water discharge was not interrupted. One randomly observed sprinkler in the orthopedic patient wing small storage room was found obstructed. Findings Include:

1. Observation at 9:45 a.m. on 12/01/10 revealed the sprinkler in the orthopedic patient wing storage room was obstructed by ice-holding pad kits for patient use. Measurement at the time of the observation revealed the pad kits were stacked to within 8 inches of the sprinkler discharge. Interview with the director of plant operations at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to install permanent wiring for the janitor's closet west of the nurses station and for the ice pack freezer in the storage room on the orthopedic patient wing. (See attached (NFPA 70) Article 527 Temporary Installations. Findings include:

1. Observation at 9:00 a.m. on 12/01/10 revealed a junction box in the ceiling of the janitor's closet west of the nurse's station had exposed wiring without a cover plate. Interview with the director of plant operations at the time of the observation confirmed that finding.

2. Observation at 9:30 a.m. on 12/01/10 revealed an extension cord used for the ice pack freezer in the storage room (formerly a sitz bath) on the orthopedic patient wing. Interview with the director of plant operations at the time of the observation confirmed that finding.