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Based on observation the Maintenance Department did not maintain the fire resistance rating of the fire barrier wall enclosing the exit stairway.

Findings:
On 11/16/15 at approximately 1:35 PM it was observed that there was sprinkler piping and electrical conduit penetrating the two hour fire barrier wall enclosing the exit stairway near room 203. The space between the penetration and the fire wall has not been protected with a material equal to the fire resistance rating of the fire barrier wall.

This finding was confirmed by the Director of Facility Operations and the Facilities Maintenance Specialist at the time of observation.

Observed 11/16/2015 at 1:15 PM: Rolling work carts are being stored in the corridor outside of the Operating Room nearest room 203. These carts are blocking the emergency shutoff valves serving the Operating Room medical gases, and are restricting the exit egress through this section of corridor. NFPA 101 section 18.2.3.3 states that exit access corridors must be 8 ft and maintained clear and unobstructed. Movement of the carts in order to access the shutoff valves results in further obstruction of the exit access corridor.

This finding was confirmed with the Director of Facility Operations and Facilities Maintenance Specialist at the time of observation.

A clean linen cart is being stored in the corridor outside of room 203, obstructing the exit access corridor. The cart is stored in this location throughout the day while clean linen are accessed by staff.

This finding was verified with the Executive Director during the exit interview on 11/18/15 at 2:30 PM.

Based on interview the Maintenance Department did not maintain written records of visual inspections and tests which were conducted on the emergency lighting system.

Findings include:
On 11/16/15 at approximately 10 AM Emergency light testing documentation was requested from the hospitals Executive Director at the Entrance Conference.

On 11/18/15 at 2:45 PM it was confirmed by the hospitals Executive Director that the Maintenance Department does not keep records of the emergency light testing that has been performed.

Observed 11/16/2015 at 1:15 PM: Rolling work carts are being stored in the corridor outside of the Operating Room nearest room 203. These carts are blocking ready access to the emergency shutoff valves for the medical gases serving the Operating Room.

This finding was confirmed with the Director of Facility Operations and Facilities Maintenance Specialist at the time of observation.