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Based on observation and staff interview, it was determined the facility failed to ensure that any area having a higher degree of hazard for the hospital was sprinkler protected or protected by one hour fire resistance rating. Failure to ensure the areas within the facility are protected has potential to harm patients and staff during a fire.

NFPA 101 2012 Edition Section 19.3.2.3 "Anesthetizing Locations. Anesthetizing locations shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing." Section 8.7.1.1 " Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: (1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3. (2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7. (3) Applying both 8.7.1.1 (1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43. Section 8.3.1.2 " Fire barriers shall comply with one of the following: (1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Findings Include:

Observation on tour of the facility on October 29, 2019, revealed that the MedSurg unit was not fully sprinklered, and was not enclosed with a 1-hour fire resistance rating in accordance with Section 8.3.

The Chief Operating Officer and Support Services Manager acknowledged during the exit conference on October 29, 2019, that the MedSurg unit was not fully sprinklered, and was not enclosed with a 1-hour fire resistance rating in accordance with Section 8.3.