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Based on observation and interview with the Maintenance Director, the hospital failed to maintain their fire alarm system in accordance with NFPA 72. Failure to maintain initiating devices could result in a smoke detector failing to activate the alarm system resulting in the potential endangerment of the occupants of the building in the event of a fire.

The findings include:

During the Fire & Life Safety tour of the facility with the Director of Maintenance on 09/23/2020 between 1:00pm-4:00pm , the fire alarm panel was indicating 177 trouble alarms. This could result in the system not functioning as required. The facility was placed on fire watch after this discovery.

The Maintenance Director verified these findings at the times observed. NFPA 72 (2010 edition) Chapter 14.

Based on observation and interview with the Maintenance Director, the hospital failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.

The findings include:

A Fire & Life Safety tour was conducted with the Director of Maintenance on 09/23/2020 between 1:00pm-4:00pm. Sprinkler heads located in the operating rooms and adjacent rooms were corroded and showing signs of chemical damage. The Maintenance Director verified these findings at the times observed.

According to NFPA 25 (2011 edition) 5.2.1.1.1; "Sprinklers 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." and 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 sprinkler manufacturer."

Based on observation and interview with the Maintenance Director, the hospital failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) Smoke Compartments to become involved in a Fire/Smoke situation. This could allow fire, smoke and fire gasses to enter the compartment, which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency.

The findings include:

During the Fire & Life Safety tour of the facility with the Director of Maintenance on 09/23/2020 between 1:00pm-4:00pm, it was observed that several 1 hour rated Fire/Smoke doors were not closing properly,
1. Door to Operating Room #1 was sticking
2. Door to Records room not closing properly
3. Doors to both mechanical rooms in maintenance wedged open and one was missing handle.
4. Door to maintenance director's office wedged open.
The Maintenance Director verified these findings at the times observed.

NFPA 101, (2012 edition,) Chapter 19, 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on observation and interview with the Maintenance Director, the hospital failed to properly maintain the required Fire/Smoke barrier penetrations, which have not been fire stopped or smoke sealed per the requirements of NFPA 101(2012 edition). This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

The findings include:

During the Fire & Life Safety tour of the facility with the Director of Maintenance on 09/23/2020 between 1:00pm-4:00pm, it was found that penetrations through the wall above the ceiling have not been fire stopped or smoke sealed. Above the ceiling in operating room #1 penetrations were observed that were not properly protected with the required fire caulk. The Maintenance Director verified these findings at the times observed.

According to NFPA 101(2012 edition) 8.4.4 & 8.4.4.1 and 19.3.7.6

Based on observation and interview with the Maintenance Director, the hospital failed to maintain electrical equipment and wiring in accordance with NFPA 70 the National Electric Code (N.E.C.), and NFPA 99 Health Care Facilities Code and to provide a facility free from electrical hazards. Failure to maintain electrical devices, equipment, and wiring in accordance with the applicable standards can result in the hazards of electric shock, electrocution, energized equipment and fire resulting from electric sources.

The findings include:

During the Fire & Life Safety tour of the facility with the Director of Maintenance on 09/23/2020 between 1:00pm-4:00pm, it was discovered above ceiling in Operating Room #1 there was wiring not protected by conduit and was wrapped with green tape on the bare ends. The Maintenance Director verified these findings at the times observed. Facility must maintain electrical equipment and wiring in accordance with NFPA 70 the National Electric Code (N.E.C.) and NFPA 99 Health Care Facilities Code.