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Based on observation and interview, the facility failed to provide operational positive latching corridor doors in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.6.2, 19.3.6.3.1, 19.3.6.3.2 and 19.3.6.3.3. This deficiency had the potential to affect all of the 4 inpatients and an undetermined number of outpatients, staff and visitors within the hospital.

Findings include:

1. On 9/13/16 at 12:26 pm, observation revealed the corridor door to the oxygen storage room would not close and positively self-latch. The door coordinator did not work correctly and held the door open approximately 2".

2. On 9/13/16 at 01:32 pm, observation revealed the emergency department suite corridor double doors, located adjacent to the emergency department waiting room would not fully close and latch. The doors were being held open by air flow through the door.

3. On 9/13/16 at 01:40 pm, observation revealed the emergency department suite corridor double doors, located across from the computed tomography (CT) scanner room would not fully close and latch. The doors were being held open by air flow through the door.

These findings were confirmed by Staff AA ( Manager of Plant Operations) at the time of discovery.

Based on observation and interview the facility failed to provide operational doors in smoke barrier walls that were self-closing as required by NFPA 101 - 2000 edition, section 19.3.7, 19.3.7.1, 19.3.7.6, 8.3 and 8.3.4. This deficiency had the potential to affect all of the 4 inpatients and an undetermined number of outpatients, staff and visitors within the hospital.

Findings include:

On 9/13/16 at 12:30 pm, observation revealed the smoke barrier door between the hub reception area and the nurse station would not fully close, as the door was rubbing on the door frame.

These findings were confirmed by Staff AA ( Manager of Plant Operations) at the time of discovery.

Based on observation and interview, the facility did not provide doors that were unlocked in the egress path and egress paths with proper signage in accordance with the requirements of NFPA 101 - 2000 edition, Sections 18.2.2.2.4 and 7.2.1.6.1. This deficiency had the potential to affect all of the 4 inpatients and an undetermined number of outpatients, staff and visitors within the hospital.

FINDINGS INCLUDE:

1. On 09/13/16 at 12:51 pm, observation revealed the exit discharge doors in the Obstetrics / Pediatrics wing had doors equipped with delayed egress locks and did not have the required signage on the doors.

2. On 09/13/16 at 01:24 pm, observation revealed the double doors across from the hub into the radiology department were signed as an exit and the doors were locked from the egress side.

3. On 09/13/16 at 01:32 pm, observation revealed the exit discharge doors from the hub corridor into zone 3, adjacent to the hospital elevator, were equipped with delayed egress locks and did not have the required signage on the doors.

These findings were confirmed by Staff AA ( Manager of Plant Operations) at the time of discovery.

Based on record review and interview, the facility did not maintain a written fire safety plan that contained all required elements in compliance with NFPA 101 (2000 ed.), 19.7.2.2. This deficiency had the potential to affect all of the 4 inpatients and an undetermined number of outpatients, staff and visitors within the facility.

FINDINGS INCLUDE:

1. On 09/13/16 at 11:05 am, it was noted during a review of the fire safety and evacuation plan that the plan was not updated for the new building. During an interview Staff AA ( Manager of Plant Operations) confirmed that the written fire safety plan, has not been updated due to technology issues with the new computer system, however he did state that all staff members where in-serviced on fire emergency and evacuation procedures for the new building the week the building was occupied.

Based on observation and interview, the facility did not maintain the sprinkler system, with compliant fire department connections, and unobstructed sprinkler heads, as required by NFPA 101 (2000 ed.) 9.7.5, NFPA 13 (1999 ed.), 5-6.5 and NFPA 25 (1998 ed.), 9-7.1. This deficiency had the potential to affect all of the 4 inpatients and an undetermined number of outpatients, staff and visitors within the facility.

FINDINGS INCLUDE:

1. On 09/13/16 at 12:05 pm, observation revealed in the 4 electrical closets(1360, 1362, 1634, & 1366) located in the clinic corridor 1350 that the sprinkler heads still had the construction covers in place.

2. On 09/13/16 at 01:11 pm, observation revealed, the fire department connection, located outside of the emergency department entrance, did not have proper caps to protect the sprinkler system.

These findings were confirmed by Staff AA ( Manager of Plant Operations) at the time of discovery.