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Based on observations, schematic review and staff interview, the facility failed to ensure corridors were separated from use areas by walls constructed with at least a half hour fire resistance rating. In fully sprinklered smoke compartments, partitions were only required to resist the passage of smoke. In non-sprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to corridor under certain conditions specified in the Code. This could affect all patients in the facility. The facility census was 140 patients.

Findings include:

On 09/28/16 between 12:30 P.M. and 4:00 P.M. and on 09/29/16, 09/30/16 and 10/03/16 from 8:45 A.M. until 4:15 P.M. tours of the facility were conducted with Staff A and/or B.

Review of the second floor facility schematic revealed the operating room corridors had 30 minute fire rated barrier walls. The operating rooms and corridors surrounding the operating rooms were not provided automatic sprinkler protection. The facility had ten operating rooms.

On 09/29/16 between 8:45 A.M. and 11:30 A.M., interviews were conducted with Staff A and B. Both staff confirmed that penetrations in fire barrier walls above the ceiling tiles in the operating room areas remained. Both staff revealed it was determined that application of an automatic sprinkler system in the operating rooms and surrounding corridors would be best, but that preliminary work for the automatic sprinkler project was initiated but installation had not started.

Staff A confirmed the finding identified above the ceiling tiles in the main corridor of the surgical area of multiple penetrations of various sizes in the 30 minute fire rated barrier were still present. The penetration approximately 8" by 6" observed above the main operating room doors remained.

On 09/29/16 between 1:30 P.M. and 4:00 P.M., tour of the first floor was conducted with Staff A and B. Observation above the ceiling tiles in South corridor beside Women's Health radiology area revealed a ten inch hole and white pipe with open space around them penetrating the Film room wall. A penetration approximately 18 inches wide and 30 inches long was observed.

Interview of Staff B during tour regarding the space above the ceiling tiles in the corridor above CT Scan 1 room, revealed the corridor wall was not in place. Staff B confirmed that a section of wall, approximately two feet wide and ten feet long was missing. Staff B noted that in order to repair the corridor wall, a large piece of duct work had to be moved which was an extensive project and not completed.



31007

Based on facility observations, review of architectural drawings, and staff interviews, the facility failed to ensure that vertical openings between floors such as ventilation shafts maintained the identified fire resistance rating as required in the code at 8.2.5. This could affect all patients in the facility. The facility census was 140 patients.

Findings include:

On 09/29/16, 09/30/16 and 10/03/16 from 8:45 A.M. until 4:15 P.M. tours of the facility were conducted with Staff A and B. The following observations were noted on the second floor of the facility:

1. Observation of the second floor intensive care area was conducted on 09/29/16 with Staff A and B. Review of facility schematic indicated a large chase with one hour fire rated separation which extended through the upper floors. On 09/29/16, staff present on tour confirmed the one hour fire rated separation for the chase had not been completed.

2. On 09/29/16 observation of the second floor with Staff A and B of a chase located near the operating room storage area was conducted. Review of the facility schematic revealed the chase was to be separated by two hour fire rated construction. Staff A and B revealed that penetrations in the two hour fire rated barrier had not been repaired. Observation of the two hour fire rated barrier wall from the corridor side of the chase revealed a large duct in the chase. A chipped, broken piece of gypsum was visible at the corner, floor level, just inside the door to the chase.

3. On 09/29/16 at 10:25 A.M., observation of a one hour fire rated barrier wall was conducted above the ceiling tiles within the x-ray storage room with Staff A and B. The observation revealed the presence of a chase used for electrical services. Observation of the chase revealed at least eight conduits which penetrated the one hour fire rated barrier. The penetrations were not sealed with any fire rated sealant. Staff A and B confirmed the observation.

Based on observation and staff interview, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating and were constructed in accordance with 8.3. This could affect all patients in the facility. The facility had a census of 140 patients.

Findings include:

On 09/29/16 between 8:45 A.M. and 11:30 A.M., tour of the second floor was conducted with Staff A and B. The following areas were noted to be included in the construction project which required extended time to complete:

1. The area above the ceiling tiles in the mens' locker room located near the critical care unit, revealed penetrations where four conduits passed through the one hour fire rated barrier.

2. The space above the ceiling tiles in the surgeons' locker room located near the critical care unit, revealed a penetration three to four inches in diameter with conduit passed through the one hour fire rated barrier.

3. The one hour fire rated barrier located outside the operating room storage room revealed multiple penetrations of varying sizes and shapes.

On 09/29/16, tour of the second floor with Staff A and B of the corridor leading to the pharmacy hall revealed the one hour fire rated barrier was not complete. Staff B revealed in an interview that an area approximately 12 to 15 feet in length and ten inches in width was in need of repair. Staff B noted that duct work needed to be removed before the one hour fire rated barrier could be repaired.

Staff B confirmed the multiple penetrations of varying sizes and shapes above the ceiling tiles remained in the one hour fire rated wall located across from the clean utility room in the post anesthesia care unit for the endoscopy unit. Staff B further stated they were not repaired due to security staff were required to be present

Tour of the first floor was conducted with Staff A on 09/30/16 between 8:30 A.M. and 3:00 P.M.

Interview of staff confirmed the observation above the door between the Cath Lab and Respiratory area as seen from the Cath Lab side revealed no wall present for about 13 foot span was not addressed. The construction required an extended period of time to complete and was not done.



31007

Based on review of facility schematic, observation and staff interview, the facility failed to ensure that one hour fire rated construction (with three quarter hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were self-closing and non-rated or field-applied protective plates that did not exceed 48 inches from the bottom of the door were permitted. This could affect all patients in the facility. The facility had a census of 140 patients.

Findings include:

On 09/29/16 and 09/30/16 tour of the first and second floors was conducted between 8:30 A.M. and 3:30 P.M. with Staff A and/or B.

Observation of the second floor schematic revealed the storage areas for surgical supplies was to be separated by one hour fire rated walls. Interview of Staff A and B revealed that operating room storage areas, had penetrations in one hour fire rated walls that were to separate the areas, were located in the smoke compartment that contained ten operating rooms. The operating rooms and the storage areas were not provided automatic sprinkler system protection. Both staff present stated the second floor operating rooms were part of an extensive project that would provide the sprinkler system to the area. Staff B confirmed that some penetrations were addressed, but not all since the sprinkler system project was initiated.

On 09/29/16 at 2:20 P.M., observation of the endoscopy and the post anesthesia care unit for same day surgery, revealed multiple penetrations of varying sizes and shapes in the fire rated wall above the ceiling tiles of the medication/supply room located on the unit. Staff B confirmed the penetrations were not addressed as security staff were required to be present when work was conducted in the medication area.

Observation on 09/30/16 at 2:00 P.M. of the first floor emergency department general storage area located across from the soiled utility room revealed no fire rated wall at the corridor, just a curtain between the space and the corridor. The storage space, approximately 14 feet long and ten feet wide, contained three metal shelving units of medical supplies in combustible wrappers, a blanket warmer and refrigerator.

Observation on 09/29/16 at 4:10 P.M. of the West wall of the storage area between the West hospital entrance and the Cath Lab as seen from in the Cath Lab revealed three open ended conduits with blue data cables passing through.

Staff present on tour confirmed the observations



31007

Based on facility observation, review of preventative maintenance documentation and staff interview, the facility failed to ensure that heating, ventilating, and air conditioning complied with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications. This could affect all patients in the facility. The facility had a census of 140 patients at the time of survey.

Findings include:

On 09/28/16 through 10/03/16, tour of the facility was conducted with Staff A and B. Observation above the ceiling tiles on each floor revealed duct work with dampers labeled as smoke dampers or fire dampers.

On 09/30/16 and 10/03/16, review of facility preventative maintenance and fire safety documentation was conducted with Staff A and C. Review of fire and smoke damper testing documentation, completed by a contracted company, revealed the facility dampers were inspected between July 2014 and December 2014. Staff C indicated that another contracted company was reviewing each deficit or inaccessible damper in the facility. Staff A and C noted that based on that review, fire/smoke dampers were either made accessible, decommissioned, repaired or replaced as applicable for the area of damper location.

A detailed report of the fire and smoke damper inspection revealed the following:

1. The first floor had 29 smoke dampers, 41 fire dampers and 45 combination dampers which were inspected between 10/07/14 and 10/29/14. Combination dampers were motorized smoke dampers and fusible link fire dampers in the same duct. The report indicated that 45 of 115 total dampers failed. Review of the deficiency report revealed a contracted company was in process of reviewing each of the deficient fire/smoke dampers. The report for the first floor noted that two dampers (one in the old QRM and one in the kitchen) did not function correctly and that three dampers were needed in a two hour fire barrier.

2. The second floor had 43 smoke dampers, 32 fire dampers and 58 combination dampers which were inspected between 10/29/14 and 12/05/14. The report indicated that 58 of 133 total dampers failed on the second floor. Review of the deficiency report revealed a contracted company was in process of reviewing each deficient damper. The second floor report noted that four dampers (one between the obstetrical operating room and Pharmacy, one in the maternity hall, one A/F operating room entrance and one at N/T operating room entrance) were not functioning. A damper located at the critical care unit nurses' station had an access panel that was obstructed.

3. The third floor had 14 smoke dampers, four fire dampers and six combination dampers which were inspected between 07/25/14 and 08/07/14. The report noted that 18 of 24 total dampers failed. Review of the deficiency report revealed a contracted company was in process of reviewing each deficient damper. The third floor report noted that two dampers (one at a nurses' station A/F room 3102 and one at DD N/T room 3001) were not functioning.

4. The fourth floor had eight smoke dampers, five fire dampers and 21 combination dampers which were inspected 07/08/14 through 07/25/14. The report indicated that 14 of 34 total dampers failed. Review of the deficiency report revealed the contracted company had repaired, replaced or made accessible all dampers on the fourth floor. All deficient dampers were re-tested and noted to have passed.

Staff A and C, present at the document review, revealed that some dampers were in need of new motors that were ordered, but had not yet arrived. Both staff confirmed that work to address the deficient dampers continued.

Based on facility observation, review of preventative maintenance documentation and staff interview, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standard for Health Care Facilities and that oxygen storage locations of less than 3,000 cu.ft. met the storage requirements of 4-3.1.1.2 (2) with regards to construction assembly with a fire resistive rating of at least one hour. This could affect all patients in the facility. The facility had a census of 140 patients at the time of survey.

Findings include:

On 09/28/16, Staff C provided a deficiency list related to the oxygen/medical air delivery system for the facility. Staff C provided a work sheet which indicated areas (second and fourth floors) where missing gauges/ports were still needed. The list included valves that needed to be installed on the vacuum system. Staff C revealed the work to be completed was assigned to an outside contractor.

Interview of Staff C on 09/28/16 revealed the facility had implemented a plan to address all deficient areas and plans for improvement related to the oxygen medical air delivery system in the facility. The implementation of the plan included ordering the oxygen alarm panels for the labor and delivery unit. Staff C confirmed the alarm panels had not yet been delivered.

On 09/29/16 between 8:30 A.M. and 2:00 P.M. observation of the second floor room 273, was conducted with Staff A. Room 273 was identified as the respiratory therapy storage room and contained 20, E-sized oxygen tanks (approximately 480 cu.ft) in a cart or on respiratory therapy equipment. The room had no fire rated separation and a door with a 20 minute fire rating. Signage outside the room noted there was medical gases stored within the room. Observations were confirmed by staff present on the tour.