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Based on observation during the survey walk-through, not all egress doors are installed and maintained as required. This deficiency could affect any staff using them because their egress under emergency conditions could be impeded.

Findings include:

On January 26, 2017 at 9:04 AM, while accompanied by the DF, the south door from the First Floor Kitchen was observed to be equipped with a thumbturn deadbolt, thus requiring two operations for egress as prohibited by 7.2.1.5.3.

Based on observation during the survey walk-through, not all designated horizontal exist or fire barriers are constructed and maintained as required. This deficiency could affect any patients, staff, or visitors on the building because fire could pass between adjacent fire compartments.

Findings include:

On January 25, 2017 at 1:12 PM, while accompanied by the DF, the Basement door between the Hospital and the adjacent business occupancy, which is located in a designated 2 hour fire rated wall, was observed to not carry a minimum 1-1/2 hour fire rating as required by Table 8.3.4.2.

Based on observation during the survey walk-through and record review, not all exit signs are installed and maintained as required. These deficiencies could affect any patients, staff, or visitors in the building because their egress under emergency conditions could be impeded.

Findings include:

On January 25, 2017 at 2:50 PM, while accompanied by the DF, an exit sign in the First Floor Surgical Corridor was observed that is not continuously illuminated, as required by 7.10.5.2, because the lamp had burned out.

Based on observation during the survey walk-through, not all enclosures for hazardous areas are constructed and maintained as required. These deficiencies could affect any patients, staff, or visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building.

Findings include:

A. On January 25, 2017 at 1:23 PM, while accompanied by the DF, a pipe penetration was observed, in the south wall of the Basement Elevator Equipment Room (a designated hazardous area), which is not sealed against the passage of fire as required by 19.3.2.1 and 8.3.5.1.

B. On January 25, 2017 at 1:27 PM, while accompanied by the DF, the door to the Basement Food Storage Room was observed to not be self-closing as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

Based on observation during the survey walk-through, not all corridor doors are installed and maintained as required. This deficiency could affect any patients, staff, or visitors in the area because smoke or fire could move from the separated rooms to the corridor.

Findings include:

On January 25, 2017 at 2:34 PM, while accompanied by the DF, the the south door from the First Floor Surgical Department (immediately south of the PACU) was observed to not be positive latching as required by 19.3.6.3.5.

Based on observation during the survey walk-through, not all smoke barriers are constructed and maintained as required. These deficiencies could affect any patients, staff, or visitors in the building because smoke could pass between adjacent smoke compartments.

Findings include:

While accompanied by the DF, pipe or other penetrations were observed in smoke barrier walls which are not sealed against the passage of smoke as required by 8.5.6.2. Locations observed include:

A. January 25, 2017 at 2:24 PM: Above cross-corridor doors at First Floor smoke barrier located directly south of the entry to the New Beginnings Unit.

B. January 26, 2017 at 8:40 AM: Above cross-corridor doors at First Floor smoke barrier located directly west of the Admitting Department and directly south of the entry to the Radiology Department.

Based on document review, not all fire drills are conducted in the manner required. This deficiency could affect any patients, staff, or visitors in the building because staff could fail to perform as required under fire alarm conditions.

Findings include:

On January 26, 2017 at 9:11 AM, while accompanied by the DF, it was determined through document review that fire drills are not conducted at varying times as required by 21.7.1.6. Fire drills conducted at similar times include:

A. January 28, 2016: 7:12 PM.

B. April 29, 2016: 7:45 PM.

C. August 26, 2016: 7:46 PM.

D. November 30, 2016: 7:20 PM.

Based on observation during the survey walk-through, not all basic electrical components are installed and maintained as required. This deficiency could affect any patients, staff, or visitors in the building because the electrical system could fail to operate properly when needed.

Findings include:

On January 25, 2017 at 1:25 PM, while accompanied by the DF, a Basement electrical panel was observed, on the south wall of the corridor directly west of the Food Storage Room, which was observed which is not labeled as required by NFPA 70 2011 480-4.

Based on observation during the survey walk-through, extension cords are utilized within the facility in a prohibited manner. These deficiencies could affect any patients in the immediate area because the equipment supported by the extension cords could fail to operate when needed.

Findings include:

While accompanied by the DF, extension cords were observed in the rooms listed below for which compliance with NFPA 99 2012 10.2.4 could not be demonstrated because no listing markings are visible on the cords or the receptacles, and because the extension cords appear to not be a pre-manufactured item. Locations observed include:

A. January 25, 2017, 2:48 PM: Operating Room 1, 3 extension cords.

B. January 25, 2017, 2:49 PM: Operating Room 2, 4 extension cords.