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Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This failure affected 2 of 2 smoke compartments and could result in the spread of smoke and fire from one room to another, in the event of a fire.

Findings:

During a tour of the facility with the Facilities Manager on 3/18/14 and 3/19/14, the facility walls and ceilings were observed.

On 3/18/14:
1. At 10:42 a.m., there was a 1 inch penetration in the ceiling where a conduit was removed and a 1 inch conduit that was penetrating the ceiling that was unsealed around the conduit. This was located in the auto calve room.

2. At 10:44 a.m., there was a 1 inch penetration in the wall next to the auto calve in the sterilization room.

3. At 10:46 a.m., there was a 1/4 inch penetration in the wall below the electrical outlet in the surgery break room.

4. At 11:18 a.m., there were two 1/4 inch each penetrations in the wall below the clock in the emergency department exam room 2.

5. 11:45 a.m., there were unsealed communication wires penetrating the ceiling in the server room located near the nurse station.

Based on observation, the facility failed to maintain doors on self-closure devices to latch and resist the passage of smoke as evidenced by a door that failed to latch upon self-closure. This affected 1 of 2 smoke compartments and could result in the failure to contain smoke to a room in the event of a fire.

NFPA 101, Life Safety Code (2000) Edition
7.2.1.8 Self-Closing Devices.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During a tour of the facility with the Facilities Manager on 3/18/14 and 3/19/14, the doors were observed.

On 3/18/14:
At 11:00 a.m., the door to Operating room one failed to latch upon self-closure. The door was open to its fullest extent and released twice, both times failing to latch.

Based on observation, the facility failed to maintain the fire rated construction of its smoke barrier walls as evidenced by an unsealed penetration in 1 of 2 smoke barrier walls. This affected 2 of 2 smoke compartments and could result in the spread of smoke and fire from one compartment to the next compartment.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of 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:
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 the Facilities Manager on 3/18/14, the smoke barrier walls were observed.

At 11:30 a.m., there was a 1 inch penetration around cable wires in the smoke barrier wall located above the East fire doors and next to the EVS (environmental services)closet.

Based on observation, the facility failed to maintain its battery powered emergency lighting, as evidenced by emergency lights that failed to illuminate when tested. This failure affected 2 of 2 smoke compartments, resulting in no emergency lighting in 1 of 2 operating room and other areas of the facility.

NFPA 99, Standard for Health Care Facilities (1999) Edition
3-3.2.1.2 All Patient Care Areas.
5. Wiring in anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During a tour of the facility with Facilities Manager on 3/18/14 and 3/19/14, the emergency lighting and battery back up emergency lights were observed through out the facility.

On 3/18/14:
1. At 11:02 a.m., the battery powered emergency light located in operating room one failed to illuminate when tested by staff. This deficiency was also cited in the last LSC (Life Safety Code) survey dated 5/17/12.

2. At 11:40 a.m., the battery powered emergency light located in the Tub room next to room 30 failed to illuminate when tested by staff.

3. During document review on 3/18/14, between 2:00 p.m., and 4:00 p.m., the facility provided documentation for the monthly testing and annual 90 minute testing of the emergency lighting.

Based on observation and interview, the facility failed to provide effective warning of fire in all areas of the facility, as evidenced by no audible or visible device in the dietary/kitchen area. This failure could result in the delay of evacuation in the event of a fire and affected 1 of 2 smoke compartments.

NFPA 101 Life Safety Code (2000) edition
9.6.3 Occupant Notification.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

Findings:

During the testing of the fire alarm system with the Facilities Manager on 3/19/14, the fire alarm system was observed.

At 10:32 a.m., during fire alarm testing, there was no audible or visible device in the kitchen area and when interviewed, staff stated they could not hear the fire alarms. There was a strobe in the cafe that was not visible from the kitchen area.

Based on observation, the facility failed to maintain the automatic sprinkler system, as evidenced by sprinklers that had gaps and were not flush with the ceiling and a missing escutcheon ring. This could result in the failure of the sprinkler system in the event of a fire and affected 2 of 2 smoke compartments.

NFPA 13, Installation of Sprinkler Systems 1999, edition
Chapter 12 System Inspection, Testing, and Maintenance
12-1 General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water- Base Fire Protection Systems, 1998 edition
Chapter 2 Sprinkler Systems
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g. upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with the Facilities Manager on 3/18/14 and 3/19/14, the facility sprinkler system was observed.

On 3/18/14:
1. At 10:43 a.m., there was an unsealed penetration next to the sprinkler escutcheon ring in the surgery suite janitors closet.

2. At 10:45 a.m., the sprinkler escutcheon ring was not flush with the ceiling in the Decontamination room.

3. At 10:48 a.m., the sprinkler escutcheon ring was not flush with the ceiling in the women's surgery locker room.

4. At 11:06 a.m., the sprinkler escutcheon ring in the corridor outside of the Mammography room was not flush with the ceiling.

5. At 11:00 a.m., the sprinkler escutcheon ring in the emergency department break room was not flush with the ceiling.

6. At 11:16 a.m. the sprinkler escutcheon ring located above the pixis in the emergency department had a 2 inch gap and revealed an unsealed penetration around the sprinkler pipe.

7. At 11:19 a.m., the sprinkler escutcheon ring was not flush to the ceiling in the emergency department storage room.

8. At 11:52 a.m., the sprinkler escutcheon ring was missing in the case management office.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70. This was evidenced by appliance that was plugged into a power strip, by the use of a damage six outlet wall adapter with no overcurrent protection. This affected 1 of 2 smoke compartments and could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
400-8. Uses not permitted.
Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

NFPA 70, National Electrical Code (1999) Edition
110-12(c) Integrity of Electrical Equipment and Connections.
Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, 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 the Facilities Manager on 3/18/14 and 3/19/14, the electrical wiring and equipment was observed.

On 3/18/14:
1. At 10:27 a.m., there was a 6 outlet wall adapter in use that showed signs of damage. The cash register and the toaster was plugged into the adapter that was located next to the kitchen tray line area. There was a sticker on the adapter documenting the last inspection date of 5/2012.

2. At 11:11 a.m., in the emergency department break room the refrigerator was plugged into a multiple outlet power strip and not directly into a wall receptacle.

Based on observation, the facility failed to ensure that Alcohol Based Hand Rub (ABHR) dispensers were installed away from ignition sources. This was evidenced by an ABHR dispenser that was installed above an ignition source. This affected 1 of 2 smoke compartments and could result in an increased risk of a fire.

Findings:

During a tour of the facility with the Facilities Manager on 3/18/14 and 3/19/14, the Alcohol Based Hand Rub (ABHR) dispensers were observed.

On 3/18/14:
At 11:14 a.m., the ABHR in the emergency department reception - check in area was installed approximately 3 feet above an electrical outlet. There was evidenced of spills on the wall below the dispenser leading to the electrical outlet.