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Based on observation during the life safety validation survey completed on 10/24/13, the hospital did not provide integrated smoke detection at all required locations.

Findings:

The 2nd story wheelchair custom seating area is open to the exit corridor, yet lacks integrated smoke detection inside the area as required by 19.3.6.1, Exception 1. This deficiency has the potential to affect two smoke compartments.

This observation was made in the presence of hospital engineering staff.

Based on observation during the life safety validation survey completed on 10/24/13, the hospital did not provide ready access from rooms to egress corridors at all times. 19.2.1

Findings:

The following doors on rooms that directly access an egress corridor were observed to have keyed/thumb-latch deadbolts installed that require a double action to release:

1. Inpatient Room 8
2. Inpatient Room 20
3. Operating Room #3

These observations were made in the presence of hospital engineering staff.

Based on a review of smoke detector testing during the life safety code validation survey completed on 10/24/13, the hospital did not conduct sensitivity testing of smoke detectors as required per NFPA 72.

Findings:

A review of contracted fire alarm system certification documents revealed that there was no documentation to verify that all smoke detectors have been sensitivity tested at least every two years as required.

This observation was reviewed with the Director of Engineering.

Based on interview and a review of hospital smoking policies and procedures, the hospital did not have an assessment protocol in place to determine whether patients require assistance and/or supervision while smoking. 19.7.4(2)

Findings:

A review of hospital smoking policies revealed that smoking is not permitted inside the hospital and that patients who wish to smoke must smoke outside in the designated smoking area. In an interview with hospital administration on 10/24/13, it was revealed that there was no policy or assessment protocol in place to determine if patients who smoke require assistance or supervision while smoking.

Based on observation during the validation life safety survey completed on 10/24/13, the facility did not prohibit the use of portable space heaters as required. 19.7.8

Findings:

A portable electric space heater was observed connected for use in the Acounts Payable Office area. There was no documentation to verify that the heating element did not exceed 212 degrees F.

This observation was made in the presence of the Director of Engineering.

Based on observation during the validation life safety survey completed on 10/24/13, the facility did not prohibit the vertical display of non-fire resistive fabrics as required in accordance with NFPA 701. 10.3.1

Findings:

The following vertically displayed fabrics did not have evidence or documentation that the fabric was either inherently flame retardant or treated to be flame resistant:

1. A 3' by 5' patchwork quilt displayed on the corridor wall in the P and O Hall.
2. A 3' by 4' fabric door curtain in the Inpatient Nurse Manager's Office.
3. A 3' by 4' fabric quilt in the Special Care Unit.

These observations were made in the presence of hospital engineering staff.

Based on observation during the life safety validation survey completed on 10/24/13, the hospital did not protect electrical outlets and light switch boxes in the compressed gas manifold room in accordance with NFPA 99.

Findings:

Observation of the compressed gas manifold supply room revealed that electrical outlets and light switches were installed at less than 60 inches high from the finished floor surface.

These observations were made in the presence of hospital engineering staff.

Based on observation during the life safety validation survey completed on 10/24/13, the hospital did not maintain electrical equipment and wiring in accordance with NFPA 70, The National Electrical Code.

Findings:

1. Extension cords were observed in use in the following areas: graphic arts, materials management, physician offices, volunteer office, and the wheelchair measurement room.

2. Motorized equipment (microwaves, refrigerators, a paper shredder, and an electric fan) were observed to be energized via a power strip in the following areas: medical records, improvement office area, and research office area.

3. Two power strips were observed to be interconnected in the physician office area.

These observations were made in the presence of hospital engineering staff.

Based on a review of fire watch policies and procedures during the validation life safety survey completed on 10/24/13, the hospital did not have policies in place to notify all required entities during an implemented fire watch due to an extended failure of the fire alarm system..

Findings:

Hospital fire watch policies did not include the requirement to notify the Utah Department of Health, Bureau of Health Facility Licensing and Certification in the event of a fire watch implementation.

This observation was reviewed with the Director of Hospital Engineering.

Based on a review of fire watch policies and procedures during the validation life safety survey completed on 10/24/13, the hospital did not have policies in place to notify all required entities during an implemented fire watch due to an extended failure of the fire sprinkler system..

Findings:

Hospital fire watch policies did not include the requirement to notify the Utah Department of Health, Bureau of Health Facility Licensing and Certification in the event of a fire watch implementation.

This observation was reviewed with the Director of Hospital Engineering.