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Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/24/2016 at 1:30 pm, observation revealed on the exit to the MRI truck that fire proofing was missing from the structural steel at the entrance 'canopy' which is attached to the building. In addition, the walls and roof were made of combustible material. The building is a (3,3,2) building. This situation was not compliant with NFPA 101 (2000 ed.), 18.1.6.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director Support Services), staff K (VP & CFO) and staff X (Maintenance Administration Assistant).

Based on observation and interview, the facility did not provide corridor doors with hinged doors in the egress path. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/24/2016 at 12:00 PM, observation revealed on the 1st floor in the corridor in front of the Emergency Department, that the door was installed in the path of egress access and was not side-hinged. This situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director Support Services), staff K (VP & CFO) and staff X (Maintenance Administration Assistant).



29942

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors and rated wall construction. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2016 at 1:15 PM, observation revealed on the 1st floor in the operating room 1702, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had med gas control panel approximately 2' x 2' in the rated wall of sterile supply displacing the drywall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

2. On 03/24/2016 at 1:20 PM, observation revealed on the 1st floor in the decontamination room of the operating room area, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a water outlet box that was not rated in the one hour rated wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview staff J (Director Support Services), staff K (VP & CFO) and staff X (Maintenance Administration Assistant).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

2. On 03/24/2016 at 1:05 PM, observation revealed on the 1st floor in the corridor in front of the Emergency Department, that the clear and unobstructed width of the corridor was 4 feet because when the sliding door opens from the closed position, it only opens to a 4 foot opening. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide. This condition was confirmed at the time of discovery by a concurrent observation and interview staff J (Director Support Services), staff K (VP & CFO) and staff X (Maintenance Administration Assistant).



29942

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/24/2016 at 1:10 pm, observation revealed on the 1st floor in the Emergency area corridor, that the clear and unobstructed width of the corridor was 7 feet. An ATM machine installed in the corridor reduced the corridor width. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (President and CEO), staff L (Maintenance Mechanic) and staff X (Maintenance Mechanic).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that meet permitted exceptions with unobstructed water distribution and all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

2. On 03/24/2016 at 1:45 pm, observation revealed on the 1st floor canopy (walkway) to the MRI truck, that the area under the canopy was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The canopy is made of combusible material and since it is attached to the hospital it is required to be sprinklered. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception). This condition was confirmed at the time of discovery by a concurrent observation and interview staff J (Director Support Services), staff K (VP & CFO) and staff X (Maintenance Administration Assistant).

Based on observation and interview, the facility did not provide an adequate and reliable water supply that provided a verified and adequate sprinkler water supply. This deficiency occurred in all of the smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 03/24/2016 at 1:30 pm, observation revealed on the basement floor in the boiler room, that the fire pump room was not constructed to satisfy code requirements. The fire pump was a) not enclosed with 1 hour fire rated walls (2-7.1), b) did not have lighting that was battery operated fixed light or flashlight (2-7.4); and c) did not have floors pitched away from pump & controller w/drain (2-7.6) per NFPA 20. This observed situation was not compliant with NFPA 20 (1999 ed.) 2-7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff J (Director Support Services), staff K (VP & CFO) and staff X (Maintenance Administration Assistant).