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Based on observation and interview, the facility failed to ensure doors in its two hour fire barrier that separated itself from business occupancies closed completely and the barrier itself was free of penetrations. This has the potential to affect all patients, staff, and visitors to the facility. The hospital census was 192 patients.

Findings include:

1. On 02/19/15 at 11:41 A.M. observation of the double doors in the two hour rated barrier between the main building and medical office building two revealed they did not close and shut because of a bent coordinator.

On 02/19/15 at 11:41 A.M. in an interview, Staff M confirmed the observation.

2. On 02/19/15 at 1:45 P.M. observation above the drop down ceiling of the two hour rated barrier over the double doors between the main hospital and the business occupancy, medical office building 2, revealed a sprinkler pipe with an annular space that had one red and one blue wire passing through.

On 02/19/15 at 1:45 P.M. in an interview, Staff M confirmed the observation.

Based on observation and interview, the facility failed to have doors with self closer's protecting corridor openings to be free of impediments such that the self closer's could fully close the doors. This has the potential to affect all patients, staff, and visitors to the facility. The hospital census was 192 patients.

Findings include:

On 02/17/15 at 1:38 P.M. a tour was conducted of the eighth floor with Staff M and S.

1. At 1:40 P.M. the door to patient room 811 was observed to be on a self closer; however, a walker and a wheel chair was observed to impede the self closing door from fully closing.

On 02/17/15 at 1:40 P.M. in an interview, Staff M confirmed the finding.

2. At 1:42 P.M. the door to patient room 810 was observed to be on a self closer; however, a computer cart was observed to impede the self closer door from fully closing.

21521

Based on observation and interview, the facility failed to ensure the integrity of the fire barriers surrounding its vertical openings and to ensure doors in vertical openings were rated. The hospital census was 192 patients.

Findings:

On 02/17/15 at 3:12 P.M. a tour was taken of the seventh floor with Staff M and S.

1. At 3:52 P.M. observation from the corridor above the drop down ceiling of the two hour fire barrier surrounding stairwell FM revealed an open one inch conduit with a red wire traveling through it.

On 02/17/15 at 3:52 P.M. in an interview, Staff M confirmed the observation.

2. At 4:00 P.M. observation from the corridor above the drop down ceiling of the two hour barrier surrounding stairwell FF revealed a one inch open conduit with a red wire passing through the barrier.

On 02/17/15 at 4:00 P.M. in an interview, Staff M confirmed the observation.

On 02/18/15 at 8:54 A.M. the tour of the seventh floor resumed with Staff M and S.

3. On 02/18/15 at 8:54 A.M. observation of the soiled linen chute door revealed no fire rating label and it failed to close and latch shut.

On 02/18/15 at 8:54 A.M. in an interview, Staff M confirmed the observation.

On 02/18/15 at 9:20 A.M. a tour was conducted of the fifth floor with Staff M and S.

4. At 9:34 A.M. observation above the drop down ceiling of the two hour rated wall for stairway FK revealed a junction box with an open knock out hole having two red wires passing through it. The junction box had a conduit connected to it coming from the two hour rated stairway wall.

On 02/18/15 at 9:34 A.M. in an interview, Staff M confirmed the observation.

5. At 9:35 A.M. observation of the data closet on the fifth floor revealed an open one inch conduit that traveled between the fifth and sixth floor.

On 02/18/15 at 9:35 A.M. in an interview, Staff M confirmed the observation.

On 02/18/15 at 10:12 A.M. a tour was conducted of the third floor with Staff M and S.

6. On 02/18/15 at 10:22 A.M. observation of the two hour rated barrier on the visitor side of elevator #1 revealed a half inch open conduit that passed through the barrier.

On 02/18/15 at 10:22 A.M. in an interview Staff M and S confirmed the observation.

7. On 02/18/15 at 10:35 A.M. observation in the third floor data closet revealed an open one inch orange flex conduit that was connected to a large junction box which was fed by a grey plastic conduit that traveled to the fourth floor.

On 02/18/15 at 10:35 A.M. in an interview, Staff M confirmed the observation.

8. On 02/18/15 at 11:41 A.M. observation above the drop down ceiling of the two hour rated barrier of the northeast stairwell of the third floor revealed a half inch open conduit with two grey wires passing through.

On 02/18/15 at 11:41 A.M. in an interview, Staff M confirmed the observation.

9. On 02/18/15 at 11:48 A.M. observation above the drop down ceiling of the two hour rated barrier of the southeast stairwell of the third floor revealed three open conduits with grey and white wires passing through.

10. On 02/19/15 observations on the first floor were made of two dumbwaiters (OR unit were observed at 9:37 AM and the OB unit were observed at 10:47 AM) which lacked labeling for fire rating of the doors. One dumbwaiter was in a clean supply area and another in a soiled room, which served the OR unit and also served the OB unit.
On 02/20/15 at 11:36 AM Staff M confirmed there were no tags on the dumbwaiters in the clean and soiled hold areas that identified the fire rating of the doors.

Based on observation and interview, the facility failed to ensure doors in vertical openings equipped with a self closer operated correctly. This has the potential to affect all patients, staff, and visitors to the facility. The hospital census was 192 patients.

Findings include:

On 02/18/15 at 10:12 A.M. a tour was taken of the third floor with Staff M and S.

On 02/18/15 at 11:48 A.M. observation of the door to the southeast stairway revealed it did not completely close when the self-closer was activated.

On 02/18/15 at 11:48 A.M. in an interview, Staff M confirmed the observation.

Based on observation and interview, the facility failed to maintain the integrity of its smoke barriers. This has the potential to affect all patients, staff, and visitors to the facility. The hospital census was 192 patients.

Findings include:

On 02/17/15 at 1:38 P.M. a tour was conducted of the eighth floor with Staff M and S.

1. At 2:05 P.M. observation of the smoke barrier above the drop down ceiling near the double doors near room 809 revealed an open 2.5 to 3 inch conduit with mostly blue cables running through it.

On 02/17/15 at 2:05 P.M. in an interview, Staff M confirmed the observation.

2. At 2:15 P.M. observation of the smoke barrier above the drop down ceiling in the corner of the supervisor office revealed red wires traveling through a penetration in the barrier.

On 02/17/15 at 2:15 P.M. in an interview, Staff M confirmed the observation.

3. At 2:24 P.M. observation above the drop down ceiling of the one hour rated wall in the clean supply room revealed an half inch conduit open to air which traveled to the ceiling then curved and traveled between two water pipes where there was a one to two inch gap.

On 02/17/15 at 2:24 P.M. in an interview, Staff M confirmed the observation.

3. At 3:00 P.M. observation of the smoke barrier above the drop down ceiling over the manager's door revealed an unsealed one inch conduit with blue wires running through it.

On 02/17/15 at 3:00 P.M. in an interview, Staff M confirmed the observation.

4. At 3:05 P.M. observation of the smoke barrier above the drop down ceiling at the back of the clinical manager's office revealed an approximate six inch by six inch annular opening around heating, ventilation and cooling duct work.

On 02/17/15 at 3:05 P.M. in an interview, Staff M confirmed the observation.

On 02/18/15 at 10:12 A.M. a tour was taken with Staff M and S of the third floor.

5. At 11:25 A.M. observation of the smoke barrier lateral to room 318 revealed a half inch open white tip conduit passing through it.

On 02/18/15 at 11:25 A.M. in an interview, Staff M confirmed the observation.

6. At 2:04 P.M. observation above the drop down ceiling of the smoke barrier between the laundry room and the conference room revealed a one inch open corrugated conduit.

On 02/18/15 at 2:04 P.M. in an interview, Staff M confirmed the observation.

On 02/19/15 at 8:48 A.M. a tour was taken of the first floor with Staff M and S.

7. On 02/19/15 at 10:22 A.M. observation above the drop down ceiling of the smoke barrier near door 1-34-sb revealed an open junction box with a one inch conduit traveling through the barrier.

On 02/19/15 at 10:22 A.M. in an interview, Staff M confirmed the observation.

On 02/19/15 at 2:18 P.M. a tour was taken of the ground floor with Staff M and S.

8. At 2:46 P.M. observation above the drop down ceiling of the one hour rated wall in the wheel chair alcove revealed a one inch conduit with an annular space.

On 02/19/15 at 2:46 P.M. in an interview, Staff M confirmed the observation.

9. At 3:05 P.M. observation above the drop down ceiling of the one hour rated wall near the scale revealed a metal chase with blue wires running through the wall.

On 02/19/15 at 3:05 P.M. in an interview, Staff M confirmed the observation.

10. At 4:03 P.M. observation above the drop down ceiling over the double doors in the corridor between areas SK-5 and SK-6 on the ground floor revealed an orange conduit passing through it. Tracing the conduit in SK-5 revealed a break in the conduit by the fire extinguisher and the sign that read main hospital.

On 02/19/15 at 4:03 P.M. in an interview, Staff M confirmed the observation.

11. On 2/20/15 at 9:49 A.M. observation above the drop down ceiling of the smoke barrier near door LL17SB revealed a half inch conduit with one red wire, a two inch pipe with an annular space, and grey wires running through a square opening.

On 02/20/15 at 9:49 A.M. in an interview, Staff M confirmed the observation.

21521

Based on observation and interview, the facility failed to ensure all doors in the smoke barriers were free of gaps, were on self closer's, or to close completely. This has the potential to affect all patients, staff, and visitors to the facility. The hospital census was 192 patients.

Findings include:

On 02/17/15 at 1:38 P.M. a tour was conducted of the eighth floor with Staff M and S.

1. Observation of the double doors in the smoke barrier by room 809 revealed a quarter inch gap between them.

On 02/03/15 at 1:38 P.M. in an interview, Staff M confirmed the observation.

2. Observation of the double doors in the smoke barrier between the supervisor office and the soiled utility room revealed a quarter inch gap between the the door leafs when in the closed position.

On 02/03/15 at 2:45 P.M. in an interview, Staff M confirmed the observation.

On 02/18/15 at 11:16 A.M. a tour was taken with Staff M and S of the third floor.

3. At 11:22 A.M. observation of the laundry room door that is a part of the floor's smoke barrier revealed it lacked a self closing device.

On 02/18/15 at 11:22 A.M. in an interview, Staff M confirmed the observation.

On 02/19/15 at 8:48 A.M. a tour was taken of the first floor with Staff M and S.

4. On 02/19/15 at 9:31 A.M. observation of the double doors in the smoke barrier between the intensive care unit waiting area and the break room revealed a quarter inch gap between the door leafs when in the closed position.

On 02/19/15 at 9:31 A.M. in an interview, Staff M confirmed the observation.

On 02/19/15 at 2:18 P.M. a tour was taken of the ground floor with Staff M and S.

5. At 2:18 P.M. observation of door LL23 in the smoke barrier revealed it failed to completely close.

On 02/19/15 at 2:18 P.M. in an interview, Staff M confirmed the observation.

6. Observations were made on 02/19/15 at 10:40 AM during a tour of the first floor maternity unit, of double doors located at the far end of the nurses' station, near delivery room #2, which failed to latch shut.

On 02/19/15 at 11:00 AM Staff N confirmed the double doors failed to latch when released from the open position.

21521

Based on observation and interview, the facility failed to ensure magnetic door locks released to allow egress from two seclusion rooms in the psychiatric intensive care unit which had the potential to affect any patient on the psychiatric intensive care unit (PICU). The hospital census was 192 patients.

Findings include:

1. Observations were made on 02/19/15 on the second floor of the main hospital in the in-patient psychiatric intensive care unit (PICU) at 9:58 AM of a fire alarm test involving the magnetic release doors on two seclusion rooms. During the test of the fire alarm the two magnetically locked seclusion rooms did not release to open. Each door was equipped with a magnetic lock that could not be released from inside the seclusion room, which should have been released by initiation of the alarm system to enable egress from the rooms.
On 02/23/15 at 10:08 AM a second test of the fire alarm was completed to test the magnetic release mechanism on the two PICU seclusion room doors and the magnetic locks did not release (unlock). On 02/23/15 at 10:11 AM Staff O confirmed the magnetic door locks on both seclusion room doors had not released (unlocked) when the fire alarm was engaged.

Based on record review and staff interview the facility failed to ensure a ninety minute test was conducted annually for battery operated emergency egress lights.

Findings include:

Review of the maintenance records for the emergency egress lighting on 02/18/15, for three years, 2012, 2013, and 2014, revealed the battery operated emergency egress lights had not been tested for ninety minutes annually. Interview with Staff P on 02/18/15 at 10:25 AM confirmed there had been no ninety minute test of the lights to ensure the equipment was fully operational for the duration of time (90 minutes), rather the batteries were changed on the units annually.

Based on observation and interview, the facility failed to ensure the buildings' sprinklers were installed in accordance with National Fire Protection Association 13, 1999 edition, Chapter 3-2. This has the potential to affect all patients, staff, and visitors to the facility. The hospital census was 192 patients.

Findings include:

On 02/19/15 at 8:48 A.M. a tour was taken of the first floor with Staff M and S. Observation of the sprinkler heads in the bathrooms to patient rooms 136, 137, 138, and 139 revealed they were blue in color and therefore of a temperature rating greater than that of ordinary.

On 02/19/15 at 11:15 A.M. in an interview Staff M confirmed the observation explaining that at one time there had been a heating element in the ceiling of the bathrooms, but not anymore.