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Based on observations and interview it was determined that the facility failed to maintain integrity of fire rated separations. This resulted in the potential for fire spread that could jeopardize the facility's building construction features and/or fire/smoke separation. Findings include:

1. On 5/17/2010 at 1:56 p.m., a ceiling panel had been removed in the equipment store room in the Mt Emily East conference room.

Based on observations and interview it was determined that the facility failed to maintain doors that are capable of resisting the passage of fire/smoke. This resulted in the potential for the passage of fire/smoke into the means of egress in the event of a hostile fire event. Findings include:

1. During the facility tour on 5/17/2010 from 1:00 p.m. to 4:30 p.m., the lower one-third of all patient room doors on 3rd floor Labor and Delivery had the smoke gasketing removed from the frames and 3rd party plastic protectors had been installed.

Based on observations and interview it was determined that the facility failed to maintain approved fire doors. This resulted in the potential for the spread of fire/smoke to other smoke compartments. Findings include:

1. On 5/17/2010 at 1:55 p.m., the Solarium fire doors failed to latch closed when released from the hold-open device.

2. On 5/18/2010 at 8:35 a.m., the fire door coordinator between the dining room and the service area was binding and did not coordinate the doors properly.

Based on observations and interview it was determined that the facility failed to provide complete sprinkler coverage for all portions of the building. This resulted in the potential for limited effectiveness of the fire sprinkler system. Findings include:

1. During the facility tour on 5/17/2010 from 1:00 p.m. to 4:30 p.m., there was a lack of complete sprinkler protection noted in X-ray, Surgery, and Med Surg Patient rooms. Also, in house supervisor's office closet containing the lockers.

2. On 5/18/2010 at 8:30 a.m., the janitor's room at the loading dock lacked sprinkler protection.

Based on observations and interview it was determined that the facility failed to maintain automatic sprinkler system free from obstructions. This resulted in the potential for limited effect on efficiency of sprinkler system. Findings include:

1. On 5/17/2010 at 3:55 p.m., the sprinkler was obstructed by storage on the top shelf in the Lab Specimen storage room.

Based on observations and interview it was determined that the facility failed to maintain access to fire extinguishers. This potentially delays a quick response to contain a fire from spreading, exposing patients and staff to fire in the environment. Findings include:

1. On 5/17/2010 at 3:35 p.m., the fire extinguisher in Cysto Room was sitting on the floor.

2. On 5/17/2010 at 3:37 p.m., the fire extinguisher in Operating room 2 was obstructed by a cart.

Based on observations and interview it was determined that the facility failed to ensure that exit egress remained clear and unobstructed. This resulted in the potential for injury and panic to patients and staff attempting to relocate/evacuate during emergency conditions. Findings include:

1. On 5/17/2010 at 3:14 p.m., the corridor in Day Surgery was obstructed with the storage of computers, carts, wheelchairs, and other items reducing the corridor width to less than 4 feet.

Based on observations and interview it was determined that the facility failed to maintain electrical wiring and equipment. This resulted in the potential for equipment failure, which could result in starting a fire or injury to patients and staff. Findings include:

1. On 5/17/2010 at 1:53 p.m., there was a box fan with a modified electrical cord that was plugged in located in the 3rd floor roof communication room.

Based on observations and interview it was determined that the facility failed to provide all wiring in a contained physical barrier. This resulted in the potential for fire and/or electrical shock hazard to patients and staff. Findings include:

2. On 5/17/2010 at 3:47 p.m., there was an open junction box with energized electrical wires inside located in the OR storage room.

3. On 5/17/2010 at 4:05 p.m., there was a metal junction box sitting on the floor being used as temporary wiring behind the information desk at the main entrance.

4. On 5/18/2010 at 8:18 a.m., there was an open junction box with energized electrical wires in mechanical room #6 near the chilled water flow control valve B384.

Based on observations and interview it was determined that the facility failed to provide approved multi-plug adapters. This resulted in the potential for appliance failure, which could result in starting a fire or injury to patients and staff. Findings include:

5. On 5/18/2010 at 8:15 a.m., there was a relocatable power tap without overcurrent protection in the MRI control room.

Based on observations and interview it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition. This resulted in the potential for injury to patients and staff. Findings include:

1. On 5/17/2010 at 2:42 p.m., there was an alcohol based hand rub dispenser mounted above the light switch in the nurse's break room on the 2nd floor.

2. On 5/17/2010 at 3:50 p.m., there was an alcohol based hand rub dispenser mounted above telecom wall plate #2-B-B24 in the Lab.

3. On 5/17/2010 at 3:19 p.m., there was an alcohol based hand rub dispenser mounted on the wall behind the television in Surgery waiting room.

4. On 5/18/2010 at 8:12 a.m., there was an alcohol based hand rub dispenser mounted above the electrical outlet in the basement Mammography room.

Based on observations and interview it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition. This resulted in the potential for injury to residents and staff. Findings include:

1. During the facility tour on 5/18/2010 from 7:30 a.m. to 8:00 a.m., all procedure and exam rooms had alcohol based hand rub dispensers mounted above light switches.