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Based on the review of the E.P.P. (Emergency Preparedness Plan) it was determined the facility failed to have a readily available emergency preparedness plan.

Findings include:

During interview on 07/19/22 at 9:30 a.m. with hospital administrative staff members, a copy of the E.P.P. was requested. Additional requests were made at 10:10 a.m., 10:30 a.m., 11:05 a.m. and 11:25 a.m. At 11:30 a.m., a 43 page hardcopy outline was presented for review. At approximately 2:00 p.m. a more inclusive hard copy was presented by Staff J (Director of Emergency Management) upon Staff J's arrival to the facility.

During interview on 7/20/2022 between 8:00 a.m. and 9:00 a.m. with Staff J, the electonric Emergency Preparedness files were reviewed. Staff J revealed a comprehensive computerized EPP; however, actual hard copies covering the E.P.P. failed to be available in case of a computer system failure, malware, ransomware attacks, or any interruptions that could impede full instant access.

Interview on 07/21/22 with Staff J and Staff H (Director of Facilities) confirmed that hard copies should be accessible.

Based on observations and interview, it was determined the facility failed to ensure two fire rated door assemblies, protecting hazardous areas, could automatically close to a latched position, and one storage room door could resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 07/20/22 between 9:00 a.m. and 1:45 p.m. with Staff H (Director of Facilities) revealed the following three door assemblies' conditions and locations that failed to meet the 2012 Life Safety Code requirements:
1. The 90-minute fire rated door assembly to the Chemo Supply Storage room, exceeding 50 sq. ft., was blocked in the open position with a large rolling supply cart. The door assembly is equipped with a magnetic hold-open device that will release in an alarm condition but the rolling cart will not allow the fire rated door assembly to close to a latched position.
2. The 45-minute fire rated door assembly, protecting the ground level Hyperbaric Treatment room, had the automatic door closing device disconnected from the top of the door panel and will not automatically close to a latched position.
3 The clean storage room door, located next to room # 240 East, has four small holes completely through the top of the door panel from the replacement of an automatic door closing device. The door does close to a latched position, however will not resist the passage of smoke.

Interview on 07/20/22 with Staff H confirmed the above findings, locations, and existing conditions.

Based on observations and interview, it was determined the facility failed to ensure proper placement of ABHS (Alcohol Based Hand Sanitizer) dispenser's in multiple locations throughout the facility.

Findings include:

Observations during tour on 07/20/22 between 7:30 a.m. and 3:00 p.m. with Staff H (Director of Facilities) revealed multiple locations where ABHS dispensers are installed above an electrical ignition source or installed to close in proximity to another ABHS dispenser (less than the minimum 48" horizontal spacing).
The locations and existing conditions are as follows:
1. ABHS dispensers are mounted directly inside and directly outside of individual room doorways, less than the required 48" horizontal spacing, at room's numbered # 350, # 351, # 352, # 355, # 356, # 357, # 362, # 364, # 365, # 368, and the Emergency Department X-ray room.
2. In the corridor outside CCU # 248, two ABHS dispensers are mounted approximately 42" apart.
3. In the corridor between Exam room # 2 and # 4, three ABHS dispensers are mounted approximately 42" apart.
4. In the corridor across from the Day room # 11, one ABHS dispenser is mounted directly above an electrical outlet.
5. In the Ultrasound exam room # 1, one ABHS dispenser is mounted directly above an electrical light switch.
6. In the Ultrasound exam room # 3, one ABHS dispenser is mounted directly above an electrical light switch.

Interview on 07/20/22 with Staff H confirmed the above findings, locations, with less than the required 48" horizontal spacing between the ABHS dispensers.

NFPA 101 Life Safety Code (2012 edition)
8.5 Smoke Barriers
8.5.2.1 Smoke barriers required by this code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof.
8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Based on observations and interview, it was determined the facility failed to ensure four smoke barrier wall locations could resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 07/21/22 between 10:00 a.m. and 12:15 a.m. with Staff H (Director of Facilities) and Staff I (Facilities Staff) revealed four locations where the smoke barrier walls had small unsealed penetrations through the smoke barrier wall.
The following unsealed penetrations were all located above the suspended ceiling in the second floor East building compartment:
1. The smoke barrier wall across from the Elevator bank has a 3" sleeve with a heat pipe passing through the barrier, which failed to be completely sealed.
2. Directly above the Gerophyschyitry main entrance doors, has two small metal conduit sleeves, for "IT" wires passing through the barrier wall, that failed to be completely sealed.
3 Above the Spaulding II stretcher alcove, there is a 1" metal conduit passing through the wall that failed to be completely sealed.
4. Above the smoke barrier doors directly outside room # 221 E, has one small unsealed penetration through the barrier wall.

Interview on 07/21/22 with Staff H and Staff I confirmed the above findings and locations.
All penetrations were immediately sealed (witnessed) with approved industry standard materials.