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Based on observation, the facility failed to ensure that all corridor doors were free of impediments to closure.

Findings include:

The following corridor door could not close to resist the passage of smoke:

Second Floor:
- In the Intensive Care Unit, consult room corridor door was held open by a chair.

Based on observation, the facility failed to ensure that all smoke barrier, cross-corridor doors closed properly.

Findings include:

Second Floor:

- The fire rated (1 hour) barrier cross-corridor doors between the lobby and the Intensive Care Units failed to close properly.

NFPA 13, Chapter 4-4.1.6 states: A minimum of 18 inches (457 mm) clearance shall be maintained between the top of storage and ceiling sprinkler deflectors.

Based on observations, the facility failed to ensure a minimum of 18 inches clearance was maintained between top of storage and ceiling sprinklers.

Findings include:

First Floor:
- In the Kitchen, two large walk-ins ( #2, #3) contained stored boxes of food stored above the ceiling sprinkler deflectors.
- In the Marketing Office, a closet contained stored baskets and vases staked above the ceiling sprinkler deflectors.
- In the Gift Shop, a storage room/office contained boxes stored above the ceiling sprinkler deflectors.

Based on observation, the facility failed to ensure portable fire extinguishers were checked annually and tagged.

Findings include:

First Floor:
- In the Women's Center, the Cesarean section room #2 contained a portable carbon dioxide fire extinguisher that wasn't tagged and the pin was pulled from the handle.

Based on observation, the facility failed to ensure that all smoke barrier penetrations were protected.

Findings include:

Second Floor:
In Communications Room, on the Intensive Care Unit, there were unprotected conduits openings for computer cables at the ceiling.

NFPA 101
Chapter 18-5.1.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction.

NFPA 70

EXTENSION CORDS:
NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure
NFPA 70, Section 305-4(h) Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protections shall be provided to avoid damage.

BRANCH CIRCUIT, FEEDER, AND SERVICE CALCULATIONS
NFPA 70, Section 220-3 Computation of Branch Circuit Loads. Branch circuit loads shall be computed as shown in (a) through (c).
(a) Lighting Loads for Specified Occupancies.
(b) Other Loads - All Occupancies.
(c) Loads for Additions to Existing Installations.

Based on observation, the facility failed to ensure that the electrical installations within the building conformed to NFPA 70, National Electrical Code.

Findings include:

The below listed locations had the following electrical problems:

First Floor:
- In the Loss Control Office, a surge protector was utilized as permanent wiring to plug in a portable radio.
- In the Director of Imaging's Office, a surge protector was utilized as permanent wiring to plug in a portable radio.
- In the Gift Shop, a surge protector was utilized as permanent wiring to plug in night lights for a window display.

Second Floor:
- In the Respiratory Workroom, a surge protector was utilized as permanent wiring to plug in a portable radio, coffee pot and refrigerator.

Note: The facility must be mindful to ensure that the capacity for the circuits do not get overloaded. Mapping of the circuits within the building is strongly recommended for monitoring and re-assigning electrical appliances as needed.