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Based on observation and interview, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2 to resist the passage of smoke into corridors or patient rooms, and potentially affecting the staff, visitors and as many as 32 patients on the fourth floor. The facility census was 169 patients.

Findings included:

1. Observation on 04/12/11 at 10:30 AM the door to room 461 failed to latch securely when pulled closed. The latch bolt did not eject to engage the strike plate and hold the door closed.

During an interview on 04/12/11 at 10:30 AM, the Maintenance Engineer in charge of the floor said he would have to remove the mechanism, apply lubrication and check to ensure trouble-free operation. He said that was the only way he could be sure it was repaired and would be unlikely to stick or bind up again.

2. Observation on 04/12/11 at 2:30 PM the door to room 431 failed to latch securely into the door frame when pulled closed and was prevented from closing by a screw embedded in the rabbet of the door frame.

During an interview on 04/12/11, at 2:30 PM, the Plant Services Director and Maintenance Engineer said they were unsure of the origin of the screw, but it appeared to have been intentionally placed there and required a screwdriver for extraction.

Based on observation, the facility failed to ensure penetrations between smoke barriers and roof deck were sealed in accordance with 8.2.5, potentially affecting the occupants and essential facility services to include administration, maintenance and housekeeping operations. The facility census was 169 patients.

Findings included:

Observation on 4/13/11 at 4:08 PM showed a three by four-inch hole in the monolithic ceiling above a set of doors in a two-hour fire wall located in a service corridor that separated plant services, housekeeping and storage (former laundry) rooms.

Based on observation, the facility failed to provide a smoke barrier of a minimum one-half-hour fire resistance rating in accordance with 8.3 in a smoke barrier wall between the Emergency Department and hospital corridor at Door #13303, potentially affecting staff, visitors and patients in the corridor and emergency waiting areas and other essential hospital operations. The facility census was 169 patients.

Findings included:

1. Observation on 04/13/11 at 3:50 PM showed a one-half-inch opening under an electrical conduit and one-half-inch opening under a sprinkler pipe in a smoke wall outside of the pedestrian entrance to the Emergency Department. The holes had been filled with fire caulk but it had dried and contracted or fallen out, leaving openings in the smoke wall separating the two smoke zones.

2. Observation on 04/13/11 at 4:08 PM showed a one-half-inch hole in the smoke wall above a service corridor that separated plant services, housekeeping and storage (former laundry) rooms.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99 (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs. This deficient practice potentially affects staff, visitors and the facility census of 169 patients. The facility census was 169 patients.

Findings included:

Observation on 04/13/11 at 4:00 PM showed six groups of "H" size cylinders of compressed nitrogen, nitrous oxide gases located in the facility manifold room, where they are piped into surgery and other locations in the hospital. The groups of cylinders (as many as 18 cylinders in one free standing group) were chained to the wall with single lengths of chain rather than individually secured or restrained to prevent them from tipping over.

During an interview on 04/13/11 at 4:00 PM, the Plant Services Director said they would correct the problem to ensure the cylinders were individually secured by racks or chains.

Based on observation and interview, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2 to resist the passage of smoke into corridors or patient rooms, and potentially affecting the staff, visitors and as many as 32 patients on the fourth floor. The facility census was 169 patients.

Findings included:

1. Observation on 04/12/11 at 10:30 AM the door to room 461 failed to latch securely when pulled closed. The latch bolt did not eject to engage the strike plate and hold the door closed.

During an interview on 04/12/11 at 10:30 AM, the Maintenance Engineer in charge of the floor said he would have to remove the mechanism, apply lubrication and check to ensure trouble-free operation. He said that was the only way he could be sure it was repaired and would be unlikely to stick or bind up again.

2. Observation on 04/12/11 at 2:30 PM the door to room 431 failed to latch securely into the door frame when pulled closed and was prevented from closing by a screw embedded in the rabbet of the door frame.

During an interview on 04/12/11, at 2:30 PM, the Plant Services Director and Maintenance Engineer said they were unsure of the origin of the screw, but it appeared to have been intentionally placed there and required a screwdriver for extraction.

Based on observation, the facility failed to ensure penetrations between smoke barriers and roof deck were sealed in accordance with 8.2.5, potentially affecting the occupants and essential facility services to include administration, maintenance and housekeeping operations. The facility census was 169 patients.

Findings included:

Observation on 4/13/11 at 4:08 PM showed a three by four-inch hole in the monolithic ceiling above a set of doors in a two-hour fire wall located in a service corridor that separated plant services, housekeeping and storage (former laundry) rooms.

Based on observation, the facility failed to provide a smoke barrier of a minimum one-half-hour fire resistance rating in accordance with 8.3 in a smoke barrier wall between the Emergency Department and hospital corridor at Door #13303, potentially affecting staff, visitors and patients in the corridor and emergency waiting areas and other essential hospital operations. The facility census was 169 patients.

Findings included:

1. Observation on 04/13/11 at 3:50 PM showed a one-half-inch opening under an electrical conduit and one-half-inch opening under a sprinkler pipe in a smoke wall outside of the pedestrian entrance to the Emergency Department. The holes had been filled with fire caulk but it had dried and contracted or fallen out, leaving openings in the smoke wall separating the two smoke zones.

2. Observation on 04/13/11 at 4:08 PM showed a one-half-inch hole in the smoke wall above a service corridor that separated plant services, housekeeping and storage (former laundry) rooms.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99 (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs. This deficient practice potentially affects staff, visitors and the facility census of 169 patients. The facility census was 169 patients.

Findings included:

Observation on 04/13/11 at 4:00 PM showed six groups of "H" size cylinders of compressed nitrogen, nitrous oxide gases located in the facility manifold room, where they are piped into surgery and other locations in the hospital. The groups of cylinders (as many as 18 cylinders in one free standing group) were chained to the wall with single lengths of chain rather than individually secured or restrained to prevent them from tipping over.

During an interview on 04/13/11 at 4:00 PM, the Plant Services Director said they would correct the problem to ensure the cylinders were individually secured by racks or chains.