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1) Based on observation and interview with staff, the facility failed to provide a Building that meets construction type and height in accordance with the following. NFPA 101 2000 edition chapter 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1. Findings include:

a) The building is fully sprinkled, however the building is constructed with Unprotected Interior and Exterior Steel Beams and Girders. During recent construction projects, the facility did not protect the construction Type II with a one hour covering or conduct a FSES Survey for alternative method of meeting the LSC .

1) Based on observation and interview with staff, the facility failed to provide openings in corridor walls other than required enclosures of vertical openings, exits, or hazardous areas with substantial doors, that are constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Findings include:

a) The access window installed in the wall outside Medical Records is not provided with latching hardware.

b) Door to Gift shop was open and blocked with a rubber scotch block.

c) Door to Chapel was open and blocked with a rubber scotch block.

d) Door to the Kitchen/ Nourishment station was not provided with a door closure on third floor.

e) Doors latches to Soiled Utility Rooms located through out the hospital was taped closed.

f) Door to Janitor Closet, first floor was not provided with a closure.

g) Double doors to the kitchen, adjacent to the elevator would not shut tightly in its frame, the door would not latch.

h) There was no door closure to the IT Hardware room.

i) There was no door with latching hardware ,separating the kitchen from the first floor egress corridor.

j) There was no door closure to Kitchen Dry Storage

1) Based on observation and interview with staff, the facility failed to provide Smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 and windows are protected by fire-rated glazing or by wired glass panels and steel frames. Findings include:

a) The window installed a couple of month ago in Medical Records was not provided with fire rated or wired glass in a steel frame.

b) Penetrations by conduit above the new window above Medical Records was not sealed.

1) Based on observation and interview with staff, the facility failed to provide Exit access that is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1 Findings include:

a) The area used as a exit on the north west end of the kitchen was being used kitchen trash staging area.

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning equipment that complies with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) The facility could not provide a Test and Balance for all areas of the Operating Room Suite.

b) There was no exhaust fan over the sterilizer in between the Operating Room Suite.

c) The exhaust fan in the soiled utility room in the Surgery Suite was not working.

d) The HEPA Filter in The Radiology Waiting Room had never been changed or put on a Preventive Maintenance Schedule. The lights that verify condition of Filters and Fans was not working.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99 1999 edition, Standard for Health Care Facilities. Findings include:

a) Based on interview with Director of Engineering, the Humidifier was not working in conjunction with the HVAC system. NFPA 99 1999 edition chapter 5-6.1.1 requires that ventilating and humidifying equipment for anesthetizing locations be kept in operable condition and shall be continually operating during surgical procedures. The requirements/equipment was not operational.

b) The HVAC system that is installed does not have a smoke control system that will automatically vent smoke and products of combustion out of the suite or the windows installed in the operating rooms do not open to remove products of combustion from the room in accordance with 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion

c) The facility failed to adopt and post Rules and Regulations that requires authorities and professional staff to jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations in accordance with NFPA 99 12-4.1.1.4 . Upon adoption of rules and regulations, these rules shall be prominently posted in the operating room suite, there was no rules posted for Fire Loss Prevention.

d) The facility failed to log humidity levels.

e) The manometers located in the HVAC Equipment was not monitored. Staff could not verify the life or the efficiency of the HEPA Filters installed in the HVAC Equipment.

f) During the survey staff was asked to define equipment that is installed in the Operating Rooms. Surveyor pointed to the Line Isolation Monitor, staff was unable to explain what the kind of safety the equipment provided.

g) The facility failed to have a preventive maintenance program for Line Isolation Monitors.

1) Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply that is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

a) Exterior transfer switch is a single point of failure for entire EES and not allowed.
b) Branches served from the EES are not based on a reliable design and load considerations.
c) Critical, Life Safety and Equipment Branch Loads are not readily identifiable and separated. EES loads are not on one or more transfer switches as determined by the type of loads
d) The facility failed to have Interim Life Safety Policy and Procedures that deal with the Interim Generator hooked up to provide the EES for the Hospital. There is no enunciator, there is no instructions for staff if the maintenance staff is not available.

1) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building, will have to do a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions in accordance with NFPA 101 200 edition chapter 5.8.14. 5.8.14 reads; 5.8.14 Use of Performance-Based Design Option. Design proposals shall include documentation that provides anyone involved in the ownership or management of the building with notification of the following:
(1) The building was approved as a performance-based design
with certain specified design criteria and assumptions.
(2) Any remodeling, modification, renovation, change in
use, or change in the established assumptions will require
a re-evaluation and re-approval . Based on observation and interview with staff, the facility modified, changed room use in the following areas with out approval from the authority having jurisdiction.

a) The kitchen south wall and doors that separated the Kitchen from other parts of the building was removed.

b) The nurses station on the 3rd floor was removed.

c) The nurses station on 3rd floor west end was created with out nurse call, washing station, medication station, etc.

d) The Nursery was being renovated with out approval from the authority having jurisdiction.

e) Patient Room constructed as a General Care Area east of the existing nursery was being renovated and re-purposed as a New Born Nursery. HVAC ( room was being heated and cooled with recirculation of room unit), Electrical Distribution, Medical Gas Piping, and hand washing station were not installed to code.

f) Two General Care Patient Rooms were re-purposed into Labor and Delivery Rooms on third floor west end of the unit..

1) Based on observation, review of records, and interview with staff, the facility failed to inspected Generators weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The new generator log does not have the size, percent of load, fuel level log and is not provided with a remote enunciator.

1) Based on observation and interview with staff, the facility did not have Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2

a) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building shall have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, any room that is re-purposed will be submitted for approval. The two rooms on 3rd west designed as General Care Beds in accordance with blue prints provided was changed into Labor and Delivery Rooms with out approval.

b) The nursery relocated in a patient room did not have dedicated circuits to each bed Bassinet Bed location.

c) The nursery under renovation was not submitted.

d) The nurses station on the west end was not submitted for relocation and provided with nurse call.