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Based on observation and staff interview the facility failed to ensure that the one hour fire resistance rating for vertical openings was maintained.

The finding is:

On the morning of 11/04/13, observation revealed that the vertical pipe penetrations in the Emergency Department Electrical Closet were partially sealed.

The above mentioned observation was concurrently confirmed by staff #7.

Based on observation and staff interview the facility failed to ensure that there was only one panic hardware device installed on an exit access door.

The finding is:

On the afternoon of 11/4/13 observation revealed that the Emergency Room Fast Track fire exit access door had two panic hardware devices installed on it.

The above mentioned observation was concurrently confirmed by staff #7.

Based on observation and staff interview the facility failed to ensure that their smoke barriers were maintained.

The findings were:

a) On the morning of 11/5/13 observation of the 6th. Floor smoke barrier wall, in the vicinity of the Well Baby Nursery, revealed that there were three partially sealed pipe penetrations.

b) On the morning of 11/5/13 observation of the 6th. Floor smoke barrier wall, in the vicinity of the North Wing Entrance revealed that there were 2 partially sealed pipe penetrations.

c) On the morning of 11/5/13 observation of the 5th. Floor smoke barrier wall, in the vicinity of the Sleep Center Entrance, revealed that there were two unsealed data penetrations and two unsealed holes in the wall.

d) On the afternoon of 11/6/13 observation of the 3rd. Floor smoke barrier wall, in the vicinity of the Employee Entrance to the Critical Care Unit, revealed that the was one partially sealed metal conduit and one partially sealed BX cable.

e) On the afternoon of 11/6/13 observation of the 2nd. Floor smoke barrier wall, in the vicinity of the Doctor's Lounge. revealed that there was one partially sealed data-wire penetration and one partially sealed medical vacuum pipe.

f) On the afternoon of 11/6/13 observation of the 1st. Floor smoke barrier wall, in the vicinity of Elevators #1 and #2, revealed that an air duct metal flange was not flush with the wall.

The above mentioned observations were all concurrently confirmed by staff #7.

Based on observation and staff interview, the facility failed to ensure that their required automatic sprinkler system was continuously maintained to function properly as per NFPA 13. Specifically, various supplies were stored less then 18" from the sprinkler heads.

The findings were:

a) On the morning of 11/4/13 observation in the Ambulatory Surgery Center Clean Utility Room revealed that a pillow and other supplies were being stored less then 18" from the sprinkler heads.

b) On the morning of 11/4/13 observation in the Emergency Room (ER) Housekeeping Closet revealed that miscellaneous containers and paperwork were being stored less then 18" from the sprinkler heads.

c) On the morning of 11/4/13 observation in the ER Storage Room revealed that various tape casts, cervical collars, etc. were being stored less then 18" from the sprinkler heads.

d) On the afternoon of 11/4/13 observation revealed that in the vicinity of the Electrical Closet there were linen bags and pillows stored on the top of the Linen Cart. These items were stored less then 18" from the sprinkler heads.

The above mentioned observations were all concurrently confirmed by staff #7.

Based on observation and staff interview the facility failed to ensure that the means of egress was maintained free of obstructions in case of emergency.

The finding is:

On the afternoon of 11/5/13 observation in the 4th. Floor Labor and Delivery Area revealed that there were two C-section pack carts partially blocking access to Emergency Exit Stairwell B4.

The above mentioned observation was concurrently confirmed by staff #7.

Based on record review and staff interview the facility failed to ensure that their Type 1 Emergency Electrical System was in accordance in NFPA 99.

The finding is:

On the morning of 11/7/13 record review revealed that automatic transfer switch #6 had a mixed electrical load including devices of the life safety branch, the critical branch, and the equipment branch.

The above mentioned observation was concurrently confirmed by staff #7.