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Based on observation and interview, the provider failed to meet the minimum construction standards of the Life Safety Code. Findings include:

1. Observation on 11/02/11 at 9:30 a.m. revealed the building was a five story, protected ordinary, Type III (211) structure with a wood roof. Interview with the facility engineer at the time of the observation revealed the fifth floor and wood roof were constructed in the 1940s when steel was scarce during World War II.

The facility meets FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to install positive latching hardware on two randomly observed doors (the Projects room corridor door 1464 and corridor door 2450 to therapy) and one randomly observed room (3495) had tape over the strike plate. Findings include:

1. Observation at 10:15 a.m. revealed corridor door 1464 for the Projects room was not equipped with positive latching hardware. Interview with the facility service manager at the time of the observation confirmed that finding.

2. Observation at 11:00 a.m. revealed room 3495 electrical closet corridor door had the strike plate covered with masking tape which prevented the door from latching into the frame. Interview with the facility service manager confirmed that finding. He removed the masking tape from the strike plate during the survey.

3. Observation at 1:15 p.m. revealed corridor door 2450 to therapy was not equipped with positive latching hardware. Interview with the facility service manager at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The one hour fire-rated double-doors between the emergency department and the ambulance garage were not provided with positive latching hardware. Findings include:

1. Observation at 10:50 a.m. on 11/01/11 revealed the south leaf of the double one hour fire-rated doors was missing the latching hardware. Interview with the facility maintenance supervisor at the time of the observation indicated the latching portion of the panic hardware had been damaged. The door hardware was different than other panic hardware throughout the hospital, so replacement parts were on order. The maintenance supervisor indicated several parts were ordered, so further damages could be corrected in a timely fashion.

Based on measurement and interview, the provider failed to maintain clear door widths of at least 32 inches for three of five sets of exit access doors. Findings include:

1. Measurement on 11/01/11 at 10:30 a.m. revealed the leaves for the double-doors between building 01 and building 02 were between 21 inches and 29 inches wide. The horizontal exit door on the fourth floor was 29 inches in clear width while the clear width on the first and second floors measured 21 inches. Interview with the facility engineer at the time of the measurement confirmed those conditions.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation, testing, and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition for two randomly observed doors (the 90 minute cross-corridor doors directly to the west of the elevator on first floor and the 90 minute horizontal exit doors to the west of room G356) at the separation between building 01 and building 02 on the first floor. Findings include:

1. Observation and testing at 9:40 a.m. revealed the south leaf of the cross-corridor horizontal exit doors on the first floor to the west of the elevators did not completely latch when closed with the automatic door closer. Those doors were equipped with fire rated door hardware that had both top and bottom latching mechanisms. In order for those doors to meet their original fire rating both top and bottom latches must engage. Testing of that door revealed the bottom latch of the south leaf did not engage the strike in the floor when closed. Interview with the director of facility engineering at the time of the observation and testing confirmed that finding.

2. Observation and testing at 10:04 a.m. revealed both leaves of the horizontal exit doors on the first floor to the west of room G356 would not completely latch when closed with the automatic door closers. Those doors were equipped with fire rated door hardware that had both top and bottom latching mechanisms. In order for those doors to meet their original fire rating both top and bottom latches must engage. Testing of that door revealed the bottom latch of both leaves did not engage into any strikes in the floor when closed. Observation at the time of testing revealed no floor strikes were visible due to installation of different flooring materials. Interview with the director of facility engineering at the time of the observation and testing confirmed that finding.

Based on observation, testing, and interview, the provider failed to maintain the rating of hazardous areas for the four soiled linen holding rooms in each of the nursing towers. Findings include:

1. Observation and testing beginning at 8:30 a.m. through 4:00 p.m. on 11/01/11 revealed the corridor doors to the soiled linen holding rooms at the following locations would not close and latch with the operation of the closer:
*Adjacent to patient room 3-123 in the bone marrow unit.
*Adjacent to patient room 1-155.
*Adjacent to patient room 1-222.

The soiled linen carts were over 32 gallons in size with a density of over 0.5 gallon/square foot of area; the soiled linen holding rooms must be maintained as hazardous areas. Testing of the doors at those locations during the observation period revealed the soiled linen cart wheels were free-wheeling and would obstruct the active door from closing fully and prevent latching if not perfectly aligned with the corridor opening.

Interview with the facility service manager at the time of the observations confirmed those findings. He stated it appeared the doors would close and latch if the soiled linen carts were placed in the space flush with the back wall and with the wheels parallel to the corridor.

Based on observation and interview, the provider failed to maintain fire-rated doors in fire-rated walls in operating condition in accordance with Life Safety Code (LSC) 4.6.12.1. One randomly observed 90 minute fire-rated double-door assembly adjacent to the morgue in the two hour fire-rated wall between building 04 (main street) and building 06 (ancillary) in the basement did not have floor strike plates. Findings include:

1. Observation at 3:15 p.m. on 11/01/11 revealed the 90 minute fire-rated double door assembly adjacent to the morgue in the two hour fire-rated wall between building 04 (main street) and building 06 (ancillary) in the basement did not have floor strike plates for the hardware in accordance with LSC 4.6.12.1. The 90 minute fire-rated doors were equipped with top and bottom latching hardware. Interview with the facility service manager at the time of the observation confirmed that finding. Interview at 1:00 p.m. with the facility engineer during the exit interview revealed the two hour fire-rated wall at that location had other openings on the same floor and upper floors that were not protected with corresponding fire-rated opening protectives. Further discussion revealed revision of the facility fire-rated separation walls had been planned but had not been completed at the time of the survey.

The Provider must comply with the National Fire Protection Association (NFPA 99), Medical Facilities section 3-4.2.2.2 Emergency System.

Based on observation and interview, the provider failed to install an emergency battery powered lighting unit at the location of automatic transfer switches (ATS) 20 and 21 in the basement room B631. Findings include:

1. Observation at 3:30 p.m. revealed the provider failed to install an emergency battery powered lighting unit at the location of automatic transfer switches (ATS) 20 and 21 in the basement room B631. Interview with the facility service manager at the time of the observation confirmed that finding. He stated it appeared the location had never had a battery powered emergency light installed.

Based on observation and interview, the provider failed to maintain three feet of clear working space in front of the electrical panels in four of six randomly observed rooms with electrical panels. The provider must comply with the National Fire Protection Association (NFPA 70), National Electrical Code (NEC) article 110.26(A)(1) Depth of Working Space (see attachment). Findings include:

1. Observation beginning at 4:00 p.m. on 10/31/11 and ending at 11:00 a.m. on 11/02/11 revealed the following electrical panels had obstructed access:
*Panels ECRPL4-4-02A and ECRFU4-4-02A disconnect had four plastic storage totes containing halloween decorations stored on the floor in front of the electrical equipment. The floor was marked and a sign posted to keep the space in front of the electrical panels clear.
*Room 3132 (electrical closet) panels NGEPL-3-1-011, NGEPL-3-1-111, ELSPH-3-1-01, and NGEPH-3-1-011 had supplies stored in front of the panels.
*Room 2133 had a fiberglass ladder stored in front of the electrical panels.
*Electrical panel NGEPL-1-1-411 was obstructed by box storage. There was not a minimum three feet of clear working space provided at any electrical panel in the room.

Interview with the facility service manager at the time of the observations confirmed those findings. He further revealed none of the items obstructing the electrical panels were acceptable storage practices at the facility.