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During the survey walk-through, it was observed that not all doors in exit access corridors are provided with positive latching hardware. This deficiency could affect any patients, staff, or visitors in the immediate area by allowing smoke or fire to enter the egress corridor.

Findings include:

On 12/28/2015, accompanied by the Director of Facilities and a Maintenance Technician, the following corridor doors were observed to lack positive latching hardware as required by 19.3.6.3.2 and could be opened with minimal effort. Locations include:

1. At 2:06 PM, the north corridor doors at the OR suite
2. At 2:25 PM, the corridor door into the lower level IT suite
3. At 11:05 AM, the corridor door at the radiology suite

On May 31, 2016 at 11:15 AM, while in the company of the Facilities Manager, the exterior egress paths to the public way did not contain any illumination beyond the coverage of the one lamp fixture located over the exit door. The current arrangement does not meet with NFPA 101, Section 7.8.1.2 and 7.8.1.3 the entire exit egress path to the public way is to be illuminated. Locations include:
1. Administrative area on main level
2. End of corridor near the Infusion unit on the main floor
3. All exterior exit doors in the inpatient care wing

This STANDARD is not met as evidenced by:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-thru, the provider shall institute the appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to the Plan of Correction (POC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measure are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of the POC progresses.

During the survey walk through, it was observed that not all electrical work was in compliance. This deficiency could affect any patients if a transfer switch failed.

Findings include:

On 12/28/2015, accompanied by the Facility Electrician, it was observed that the following areas are not equipped with normal power receptacles as is required by NFPA 70 1999 517-18(a) and 517-19(a).

1. Corrected 05/31/2016
2. Corrected 05/31/2016
3. At 11:20 AM, the C-section room
4. At 1:15 PM, some of the patient rooms (example: 30, 35 and 40)

On May 31, 2016 at 11:15 AM, while in the company of the Facilities Manager, the exterior egress paths to the public way did not contain any illumination beyond the coverage of the one lamp fixture located over the exit door. The current arrangement does not meet with NFPA 101, Section 7.8.1.2 and 7.8.1.3 the entire exit egress path to the public way is to be illuminated. Locations include:
1. Administrative area on main level
2. End of corridor near the Infusion unit on the main floor
3. All exterior exit doors in the inpatient care wing