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Based on observation, the facility failed to ensure instant closure of a fire rated door. This was evidenced by a door to a patient room that failed to instantly release manually and swing close. This failure affected 1 of 5 smoke compartments and 1 of 1 patients in Room 104 in the Medical Surgical unit, and had the potential to allow the spread of smoke in the event of a fire.

NFPA 101, 2000 Edition, Life Safety Code.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with Operations Staff 1 on 4/22/14 the doors protecting corridor openings were observed.

At 2:04 p.m., the door to Patient Room 104 was manually pulled from the magnetic hold open device to initiate closing. The closing device created a 15 second delay while manually being pulled closed.
At 2:08 p.m., the door was pulled again to observe the time to close on its own. It took 35 seconds for the door to close and latch.

Based on observation, the facility failed to provide an inspector test valve with an orifice that was equal to the smallest size of the installed system. This was evidenced by the use of a one inch opening on the Inspectors Test Valve. This affected 5 of 5 smoke compartments and could result in incorrect pressure reading and response time during sprinkler system testing.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-6.2* Initiation of the alarm signal shall occur within 90 seconds
of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a tour of the facility with Operations Staff 1 on 4/23/14, the automatic sprinkler system was observed.

At 2:10 p.m., the Inspectors Test Valve was equipped with a pipe with an orifice opening that was approximately one inch in diameter. The sprinkler system was equipped with sprinklers with one half inch orifices, which was the smallest size of the installed system.

Based on observation, the facility failed to maintain their smoke barrier walls to resist the passage of smoke. This was evidenced by unsealed penetrations in smoke barrier walls. This affected two of five smoke compartments, and could result in the spread of smoke and fire from one compartments to another.

NFPA 101 Life Safety Code, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Operation Staff 1 on 4/23/14, the smoke barrier walls were observed.

1. At 9:36 a.m., there was an 1/8 inch penetration above an electrical conduit in the smoke barrier wall between Anesthesia Services and Operating Room 3.
2. At 9: 37 a.m., there was an approximately 1 inch penetration were the fire chalking was separated around a pipe in the smoke barrier wall between Anesthesia Services and Operating Room 3.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70. This was evidenced by the use of power cords to connect appliances to wall outlets and a broken faceplate cover. This affected 1 of 4 smoke compartments and 1 of 1 off site locations. This failure had the potential to increase the risk of an electrical fire.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electric Code 1999 Edition.
Section 400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.
Article 110-12) (c) Integrity of Electrical Equipment and Connection. Internal parts of electrical equipment, including busbars, wiring terminal, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

Findings:

During a tour of the facility with Operations Staff 1 on 4/22-23/14, the electrical equipment was observed.

1. On 4/22/14 the Medical Surgical unit was observed to have surge protectors in 17 of 17 patient rooms. Where occupied, the surge protectors were powering hospital beds, feeding pumps, and nebulizers.

2. On 4/23/14 the Off Site Rehabilitation building was observed to have a broken faceplate cover, with 1/4 of the cover missing, in the rehab gym.