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Based on observation and staff interview the facility failed to ensure corridor doors were smoke resistant in 1 of 13 smoke compartments. The findings were:

Observation on 1/06/10 at 2:10 PM showed the corridor door to patient room #6205 was not smoke resistant. The door could not be latched into its frame because the bottom of the door rubbed against the threshold. At the time of observation the engineering manager reported the threshold and carpet were replaced two months prior. He also reported the doors should have been inspected after the new installation. He staed that the current preventative maintenance rounds occurred semi-annually.

Based on observation and staff interview the facility failed to ensure 1 of 6 stairwells were smoke resistant. The findings were:

Observation on 1/05/10 at 10:10 AM showed the southwest stairwell had an unsealed pipe penetration on the first floor landing. The gap was 1 inch larger than the pipe. At the time of observation the director of facilities reported he was aware that stairwells were required to have a 1-hour fire rating.

Based on observation and staff interview the facility failed to ensure 1 of 8 smoke barriers was smoke resistance. The findings were:

Observation on 10/07/10 at 9:16 AM showed the fourth floor "4-1" smoke barrier wall was not smoke resistant. The wall above the ceiling tiles had an unsealed 4 inch by 8 inch gap above water pipes . At the time of observation the director of facilities reported he was aware smoke barriers were required to be smoke resistant. He further reported all smoke barriers were inspected semi-annually. He was not able to explain why this gap was not previously found.

Based on observation and staff interview the facility failed to ensure all staff members were familiar with emergency actions. The findings were:

Observation of the fire drill on 1/06/10 at 11:29 AM showed the first responder entered the "fire" room and was not sure what the red flashing light indicated. She asked engineering staff if this was a drill, and they told her it was a fire drill. She called the main hospital operator with a cell phone and started to shut corridor doors. The charge nurse activated the alarm a full two minutes after the fire was discovered. A housekeeping cart was observed to be in the corridor throughout the entire drill. The first responder reported that she was not aware that she was supposed to activate the alarm during a drill. She further reported that she had worked at the facility for one year.

Based on observation and staff interview the facility failed to ensure alarm notification appliance were provided throughout 1 of 18 smoke compartments. The findings were:

Observation on 1/05/10 at 11:02 AM showed the mechanical room on the second floor "2-0" was not equipped with an alarm notification appliance. At the time of observation the engineering manager reported that he was not aware notification appliance were required in existing mechanical rooms.

Based on observation and staff interview the facility failed to ensure sprinklers were not damaged in 1 of 4 smoke compartments. The findings were:

Observation on 1/07/10 at 10:15 AM showed the sprinkler deflector in patient room #316 was bent. At the time of observation the facility director reported the sprinkler sytem was inspected annually, but that the noted sprinkler was not indentified as being damaged on the last contractor report.

Based on observation and staff interview the facility failed to ensure receptacles in wet locations were protected with GFCI (ground fault circuit interrupter) receptacles, failed to ensure permanent wiring was not replaced with temporary wiring and failed to ensure damaged receptacles were replaced in 3 of 18 smoke compartments. The findings were:

1. Observation on 1/05/10 at 8:24 AM showed the computer in the cobalt office near the north wall was plugged into an extension cord. At the time of observation the engineering manager reported he was aware extension cords were prohibited. He further reported the electrical system was inspected semi-annually to ensure permanent electrical wiring was not replaced with temporary wiring.

2. Observation on 1/05/10 between 8 AM and 11 AM showed the electrical receptacles in the radiation therapy exam room #1 and #2, Mammography exam room #7, Endoscopy room #1 and sitz bath #5016 were located within 6 feet of the sink. The closet receptacle was located 10 inches from the sink. The receptacles were not protected with GFCI receptacles. At the time of observation the engineering manager reported he was not aware existing electrical receptacles within 6 feet of a water source were required to be GFCI protected. He also confirmed the receptacles were unprotected.

3. Observation on 1/05/10 at 9:39 AM showed the computer in the director of radiology office was plugged into a surge protector which was, itself, plugged into another surge protector. At the time of observation the engineering manager reported he was aware surge protectors were prohibited from being chained in-line.

4. Observation on 1/06/10 at 10:12 AM showed an electrical receptacle on the head wall in labor room #6 was damaged. The electrical cord to the bed was plugged into the damaged receptacle. The top electrical port of the duplex extended out of the face plate 1/4 inch while the bottom port was flush with the face plate. At the time of observation the engineering manager reported that the damaged receptacle should have been noticed by nursing staff and a work order submitted to the engineering department.

Based on observation and staff interview the facility failed to ensure ABHR (alcohol based hand rub) dispensers were not installed over ignition sources in 2 of 13 smoke compartments. The findings were:

Observation on 1/06/10 between 9 AM and 12 PM showed the ABHR dispensers in the ante-room #3201 and in the corridor near room #3 on the sixth floor were installed over electrical receptacles. At the time of observation the engineering manager was unaware ABHR dispensers were prohibited from being installed over ignitions sources.