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Based on observation and staff interview the facility failed to ensure corridor doors were smoke resistant in 1 of 13 smoke compartments. The findings were:

Observation on 1/06/10 at 2:10 PM showed the corridor door to patient room #6205 was not smoke resistant. The door could not be latched into its frame because the bottom of the door rubbed against the threshold. At the time of observation the engineering manager reported the threshold and carpet were replaced two months prior. He also reported the doors should have been inspected after the new installation. He staed that the current preventative maintenance rounds occurred semi-annually.

Based on observation and staff interview the facility failed to ensure corridor doors were smoke resistant in 3 of 18 smoke compartments. The findings were:

1. Observation on 1/06/10 between 9 AM and 11 AM showed the corridor doors to patient room #5013 and labor room #6 were not smoke resistant. The doors were not able to latch into the frames, with three attempts. At the time of observation the engineering manager reported all corridor doors were inspected semi-annually.

2. Observation on 1/06/10 at 10:58 AM showed the corridor door to the UPS (uninterrupted power system) room #6024 was not smoke resistant. The door had three unsealed circular penetrations, the largest hole was 3/4 of an inch in diameter. At the time of observation the engineering manager reported the lock was replaced 6 months ago and the holes should have been filled at that time.

Based on observation and staff interview the facility failed to ensure 1 of 6 stairwells were smoke resistant. The findings were:

Observation on 1/05/10 at 10:10 AM showed the southwest stairwell had an unsealed pipe penetration on the first floor landing. The gap was 1 inch larger than the pipe. At the time of observation the director of facilities reported he was aware that stairwells were required to have a 1-hour fire rating.

Based on observation and staff interview the facility failed to ensure 1 of 8 smoke barriers was smoke resistance. The findings were:

Observation on 10/07/10 at 9:16 AM showed the fourth floor "4-1" smoke barrier wall was not smoke resistant. The wall above the ceiling tiles had an unsealed 4 inch by 8 inch gap above water pipes . At the time of observation the director of facilities reported he was aware smoke barriers were required to be smoke resistant. He further reported all smoke barriers were inspected semi-annually. He was not able to explain why this gap was not previously found.

Based on observation and staff interview the facility failed to ensure all staff members were familiar with emergency actions. The findings were:

Observation of the fire drill on 1/06/10 at 11:29 AM showed the first responder entered the "fire" room and was not sure what the red flashing light indicated. She asked engineering staff if this was a drill, and they told her it was a fire drill. She called the main hospital operator with a cell phone and started to shut corridor doors. The charge nurse activated the alarm a full two minutes after the fire was discovered. A housekeeping cart was observed to be in the corridor throughout the entire drill. The first responder reported that she was not aware that she was supposed to activate the alarm during a drill. She further reported that she had worked at the facility for one year.

Based on observation and staff interview the facility failed to ensure alarm notification appliance were provided throughout 1 of 18 smoke compartments. The findings were:

Observation on 1/05/10 at 11:02 AM showed the mechanical room on the second floor "2-0" was not equipped with an alarm notification appliance. At the time of observation the engineering manager reported that he was not aware notification appliance were required in existing mechanical rooms.

Based on observation and staff interview the facility failed to ensure sprinklers were not damaged in 1 of 4 smoke compartments. The findings were:

Observation on 1/07/10 at 10:15 AM showed the sprinkler deflector in patient room #316 was bent. At the time of observation the facility director reported the sprinkler sytem was inspected annually, but that the noted sprinkler was not indentified as being damaged on the last contractor report.

Based on observation and staff interview the facility failed to ensure sprinklers were not obstructed or damaged in 2 of 18 smoke compartments. The findings were:

1. Observation on 1/06/10 at 9:37 AM showed the sprinkler deflector in the bathroom of patient room #5127 was missing on one side. At the time of observation the engineering manager reported the sprinkler system was inspected annually by an outside contractor and the noted sprinkler was not cited in the contractors last report.

2. Observation on 1/06/10 at 10:44 AM showed the sprinkler in the blood gas room #6021 was obstructed by the ceiling mounted light. The sprinkler was installed 8 inches from the light and the bottom of the deflector was 2 inches above the bottom of the light. At the time of observation the engineering manager reported he was aware of the spacing requirement.

Based on observation and staff interview the facility failed to ensure sprinklers were unobstructed in 1 of 13 smoke compartments. The findings were:

Observation on 1/05/10 between 3 PM and 5 PM showed one of two sprinklers in soiled utility rooms #3249 and #4249 were obstructed by the ceiling mounted lights. The sprinklers were installed within 12 inches of the lights and the bottom of the lights were below the bottom of the sprinkler deflector. At the time of the observation the engineering manager reported he was aware of the spacing requirement. He further reported that the sprinkler system was inspected annually to ensure the sprinklers were not obstructed; howevver, he could not explain why these obstructions had not been identified.

Based on observation and staff interview the facility failed to ensure receptacles in wet locations were protected with GFCI (ground fault circuit interrupter) receptacles, failed to ensure permanent wiring was not replaced with temporary wiring and failed to ensure damaged receptacles were replaced in 3 of 18 smoke compartments. The findings were:

1. Observation on 1/05/10 at 8:24 AM showed the computer in the cobalt office near the north wall was plugged into an extension cord. At the time of observation the engineering manager reported he was aware extension cords were prohibited. He further reported the electrical system was inspected semi-annually to ensure permanent electrical wiring was not replaced with temporary wiring.

2. Observation on 1/05/10 between 8 AM and 11 AM showed the electrical receptacles in the radiation therapy exam room #1 and #2, Mammography exam room #7, Endoscopy room #1 and sitz bath #5016 were located within 6 feet of the sink. The closet receptacle was located 10 inches from the sink. The receptacles were not protected with GFCI receptacles. At the time of observation the engineering manager reported he was not aware existing electrical receptacles within 6 feet of a water source were required to be GFCI protected. He also confirmed the receptacles were unprotected.

3. Observation on 1/05/10 at 9:39 AM showed the computer in the director of radiology office was plugged into a surge protector which was, itself, plugged into another surge protector. At the time of observation the engineering manager reported he was aware surge protectors were prohibited from being chained in-line.

4. Observation on 1/06/10 at 10:12 AM showed an electrical receptacle on the head wall in labor room #6 was damaged. The electrical cord to the bed was plugged into the damaged receptacle. The top electrical port of the duplex extended out of the face plate 1/4 inch while the bottom port was flush with the face plate. At the time of observation the engineering manager reported that the damaged receptacle should have been noticed by nursing staff and a work order submitted to the engineering department.

Based on observation and staff interview the facility failed to ensure wet locations were protected with GFCI (ground fault circuit interrupter) receptacles and failed to ensure permanent wiring was not replaced by temporary wiring in 3 of 13 smoke compartments. The findings were:

1. Observation on 1/05/10 at 11:49 AM showed the computer in the linen transport office was plugged into a surge protector which was, itself, plugged into another surge protector/UPS (uninterrupted power supply). At the time of observation the engineering manager reported he was aware that surge protectors were not supposed to be attached in-line. He further reported the electrical system was inspected semi-annually.

2. Observation on 1/05/10 at 3:01 PM showed the electrical receptacle in the ante-room #3201 was located 40 inches from the sink; however the receptacle was not protected with a GFCI receptacle. At the time of observation the engineering manager reported he was aware electrical receptacles within 6 feet of a water source were required to be GFCI protected. He also confirmed the receptacles were unprotected.

3. Observation on 1/06/10 at 9:14 AM showed the electrical receptacle in the soiled utility room #5121 was located 10 inches from the sink. The receptacle was not protected with a GFCI receptacle. At the time of observation the engineering manager reported he was unaware that existing receptacles were required to have GFCI protection.

Based on observation and staff interview the facility failed to ensure wet locations were protected with GFCI (ground fault circuit interrupter) receptacles in 1 of 4 smoke compartments. The findings were:

Observation on 1/07/10 at 10:03 AM showed the electrical receptacle in the patient room #300 was located 40 inches from the sink. It was noted that the receptacle was not protected with a GFCI receptacle. At the time of observation the engineering manager reported he was aware electrical receptacles within 6 feet of a water source were required to be GFCI protected. He confirmed this particular receptacle was not protected.

Based on observation and staff interview the facility failed to ensure ABHR (alcohol based hand rub) dispensers were not installed over ignition sources in 2 of 13 smoke compartments. The findings were:

Observation on 1/06/10 between 9 AM and 12 PM showed the ABHR dispensers in the ante-room #3201 and in the corridor near room #3 on the sixth floor were installed over electrical receptacles. At the time of observation the engineering manager was unaware ABHR dispensers were prohibited from being installed over ignitions sources.

Based on observation and staff interview the facility failed to ensure corridor doors were smoke resistant in 1 of 13 smoke compartments. The findings were:

Observation on 1/06/10 at 2:10 PM showed the corridor door to patient room #6205 was not smoke resistant. The door could not be latched into its frame because the bottom of the door rubbed against the threshold. At the time of observation the engineering manager reported the threshold and carpet were replaced two months prior. He also reported the doors should have been inspected after the new installation. He staed that the current preventative maintenance rounds occurred semi-annually.

Based on observation and staff interview the facility failed to ensure corridor doors were smoke resistant in 3 of 18 smoke compartments. The findings were:

1. Observation on 1/06/10 between 9 AM and 11 AM showed the corridor doors to patient room #5013 and labor room #6 were not smoke resistant. The doors were not able to latch into the frames, with three attempts. At the time of observation the engineering manager reported all corridor doors were inspected semi-annually.

2. Observation on 1/06/10 at 10:58 AM showed the corridor door to the UPS (uninterrupted power system) room #6024 was not smoke resistant. The door had three unsealed circular penetrations, the largest hole was 3/4 of an inch in diameter. At the time of observation the engineering manager reported the lock was replaced 6 months ago and the holes should have been filled at that time.

Based on observation and staff interview the facility failed to ensure 1 of 6 stairwells were smoke resistant. The findings were:

Observation on 1/05/10 at 10:10 AM showed the southwest stairwell had an unsealed pipe penetration on the first floor landing. The gap was 1 inch larger than the pipe. At the time of observation the director of facilities reported he was aware that stairwells were required to have a 1-hour fire rating.

Based on observation and staff interview the facility failed to ensure 1 of 8 smoke barriers was smoke resistance. The findings were:

Observation on 10/07/10 at 9:16 AM showed the fourth floor "4-1" smoke barrier wall was not smoke resistant. The wall above the ceiling tiles had an unsealed 4 inch by 8 inch gap above water pipes . At the time of observation the director of facilities reported he was aware smoke barriers were required to be smoke resistant. He further reported all smoke barriers were inspected semi-annually. He was not able to explain why this gap was not previously found.

Based on observation and staff interview the facility failed to ensure all staff members were familiar with emergency actions. The findings were:

Observation of the fire drill on 1/06/10 at 11:29 AM showed the first responder entered the "fire" room and was not sure what the red flashing light indicated. She asked engineering staff if this was a drill, and they told her it was a fire drill. She called the main hospital operator with a cell phone and started to shut corridor doors. The charge nurse activated the alarm a full two minutes after the fire was discovered. A housekeeping cart was observed to be in the corridor throughout the entire drill. The first responder reported that she was not aware that she was supposed to activate the alarm during a drill. She further reported that she had worked at the facility for one year.

Based on observation and staff interview the facility failed to ensure alarm notification appliance were provided throughout 1 of 18 smoke compartments. The findings were:

Observation on 1/05/10 at 11:02 AM showed the mechanical room on the second floor "2-0" was not equipped with an alarm notification appliance. At the time of observation the engineering manager reported that he was not aware notification appliance were required in existing mechanical rooms.

Based on observation and staff interview the facility failed to ensure sprinklers were not damaged in 1 of 4 smoke compartments. The findings were:

Observation on 1/07/10 at 10:15 AM showed the sprinkler deflector in patient room #316 was bent. At the time of observation the facility director reported the sprinkler sytem was inspected annually, but that the noted sprinkler was not indentified as being damaged on the last contractor report.

Based on observation and staff interview the facility failed to ensure sprinklers were not obstructed or damaged in 2 of 18 smoke compartments. The findings were:

1. Observation on 1/06/10 at 9:37 AM showed the sprinkler deflector in the bathroom of patient room #5127 was missing on one side. At the time of observation the engineering manager reported the sprinkler system was inspected annually by an outside contractor and the noted sprinkler was not cited in the contractors last report.

2. Observation on 1/06/10 at 10:44 AM showed the sprinkler in the blood gas room #6021 was obstructed by the ceiling mounted light. The sprinkler was installed 8 inches from the light and the bottom of the deflector was 2 inches above the bottom of the light. At the time of observation the engineering manager reported he was aware of the spacing requirement.

Based on observation and staff interview the facility failed to ensure sprinklers were unobstructed in 1 of 13 smoke compartments. The findings were:

Observation on 1/05/10 between 3 PM and 5 PM showed one of two sprinklers in soiled utility rooms #3249 and #4249 were obstructed by the ceiling mounted lights. The sprinklers were installed within 12 inches of the lights and the bottom of the lights were below the bottom of the sprinkler deflector. At the time of the observation the engineering manager reported he was aware of the spacing requirement. He further reported that the sprinkler system was inspected annually to ensure the sprinklers were not obstructed; howevver, he could not explain why these obstructions had not been identified.

Based on observation and staff interview the facility failed to ensure receptacles in wet locations were protected with GFCI (ground fault circuit interrupter) receptacles, failed to ensure permanent wiring was not replaced with temporary wiring and failed to ensure damaged receptacles were replaced in 3 of 18 smoke compartments. The findings were:

1. Observation on 1/05/10 at 8:24 AM showed the computer in the cobalt office near the north wall was plugged into an extension cord. At the time of observation the engineering manager reported he was aware extension cords were prohibited. He further reported the electrical system was inspected semi-annually to ensure permanent electrical wiring was not replaced with temporary wiring.

2. Observation on 1/05/10 between 8 AM and 11 AM showed the electrical receptacles in the radiation therapy exam room #1 and #2, Mammography exam room #7, Endoscopy room #1 and sitz bath #5016 were located within 6 feet of the sink. The closet receptacle was located 10 inches from the sink. The receptacles were not protected with GFCI receptacles. At the time of observation the engineering manager reported he was not aware existing electrical receptacles within 6 feet of a water source were required to be GFCI protected. He also confirmed the receptacles were unprotected.

3. Observation on 1/05/10 at 9:39 AM showed the computer in the director of radiology office was plugged into a surge protector which was, itself, plugged into another surge protector. At the time of observation the engineering manager reported he was aware surge protectors were prohibited from being chained in-line.

4. Observation on 1/06/10 at 10:12 AM showed an electrical receptacle on the head wall in labor room #6 was damaged. The electrical cord to the bed was plugged into the damaged receptacle. The top electrical port of the duplex extended out of the face plate 1/4 inch while the bottom port was flush with the face plate. At the time of observation the engineering manager reported that the damaged receptacle should have been noticed by nursing staff and a work order submitted to the engineering department.

Based on observation and staff interview the facility failed to ensure wet locations were protected with GFCI (ground fault circuit interrupter) receptacles and failed to ensure permanent wiring was not replaced by temporary wiring in 3 of 13 smoke compartments. The findings were:

1. Observation on 1/05/10 at 11:49 AM showed the computer in the linen transport office was plugged into a surge protector which was, itself, plugged into another surge protector/UPS (uninterrupted power supply). At the time of observation the engineering manager reported he was aware that surge protectors were not supposed to be attached in-line. He further reported the electrical system was inspected semi-annually.

2. Observation on 1/05/10 at 3:01 PM showed the electrical receptacle in the ante-room #3201 was located 40 inches from the sink; however the receptacle was not protected with a GFCI receptacle. At the time of observation the engineering manager reported he was aware electrical receptacles within 6 feet of a water source were required to be GFCI protected. He also confirmed the receptacles were unprotected.

3. Observation on 1/06/10 at 9:14 AM showed the electrical receptacle in the soiled utility room #5121 was located 10 inches from the sink. The receptacle was not protected with a GFCI receptacle. At the time of observation the engineering manager reported he was unaware that existing receptacles were required to have GFCI protection.

Based on observation and staff interview the facility failed to ensure wet locations were protected with GFCI (ground fault circuit interrupter) receptacles in 1 of 4 smoke compartments. The findings were:

Observation on 1/07/10 at 10:03 AM showed the electrical receptacle in the patient room #300 was located 40 inches from the sink. It was noted that the receptacle was not protected with a GFCI receptacle. At the time of observation the engineering manager reported he was aware electrical receptacles within 6 feet of a water source were required to be GFCI protected. He confirmed this particular receptacle was not protected.