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Egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

A. On January 28, 2020 while in the company of the FEM it was observed that locking devices are not installed in accordance with 19.2.2.2.4:

1. At 10:05am the north magnetically locked doors of the Radiology suite were observed to lack a functional sensor to comply with 19.2.2.2.4(3) and 7.2.1.6.2(1).

2. At 10:10am the south exterior door from the corridor between the Emergency Dept. suite and the Same Day Surgery Dept. suite was observed to be a pair of 3'-0" doors equipped with manual flush bolts and a release device only on the active leaf. This arrangement does not permit the minimum clear width of 41.5" to be obtained with a single releasing operation to comply with 19.2.2.2.4 and 7.2.1.5.11.

3. At 10:15am the west exterior door of the Emergency Dept. was observed to be equipped with a Delayed Egress magnetic locking device which does not comply with 19.2.2.2.4(2) and 7.2.1.6.1.1 because the building is not protected throughout by the automatic sprinkler system.

4. At 10:25am the south exterior doors of the Emergency Dept. were observed to be marked as an exit and are continually locked with magnetic locking devices which are not installed in accordance with 19.2.2.2.4(1), (2) or (3) because they are not connected to the "lock-down" system in accordance with 19.2.2.2.5.2 or not provided with a sensor to release in accordance with 7.2.1.6.2(1) and do not cease to function during fire alarm activation to comply with 19.2.2.2.5.2(5) or 7.2.1.6.2(6).

Based upon observation, healthcare occupancy exits which traverse non-healthcare occupancies are not in compliance with requirements for horizontal exits. Failure to provide compliant horizontal exits can compromise the safety of occupants if required to use the exit during a fire/smoke emergency.

Findings include:

On January 28, 2020 at 9:05am while in the company of the FEM it was observed that the east exit access from the corridor leading toward the Chapel through the business occupancy was not a designated horizontal exit as required by 19.1.3.6 & 19.1.3.7 and lacked a fire alarm manual pull station to comply with NFPA 72-2010, 17.14.6.

Based upon observation, exit signs are not provided to identify access to two remote exits from the building. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire condition.

Findings include:

A. On January 28, 2020 while in the company of the FEM it was observed that corridors and passages within designated suites lacked exit signs to identify access to at least two remote means of egress from the building to comply with 19.2.10 and 7.10.

Locations include:

1. At 8:20am it was observed that the SE corridor serving the 2nd floor Sleep Study/Cardiac Rehab suite and the supply room which leads to the exit stair lacked identification of a 2nd exit from the designated corridor to comply with 19.2.5.4. Surveyor notes that this corridor and supply room are not currently designated as part of the suite, but must be within the suite to meet the requirements of 19.2.5.4 if exit signage is added at the west door accessing the current suite boundary.

2. At 8:40am it was observed that the Cardiac Rehab portion of the designated Sleep Study/Cardiac Rehab suite lacks identification of a 2nd exit access from the designated suite to comply with 19.2.5.7.3.2(A). Doors between the Sleep Study area and the Cardiac Rehab area are not available for exiting for Rehab occupants due to access control systems. The Rehab area is not defined as a separate smaller suite to permit a single exit access in accordance with 19.2.5.7.3.2.

3. At 8:50am it was observed that the corridor serving the elevators and the Sleep Study suite lacks identification of a 2nd exit access to comply with 19.2.5.4. Surveyor notes that the stair at this location has been identified as only a convenience stair due to its interior discharge not complying with 7.7.2(4)A sprinklering requirements.

4. At 10:00am it was observed that the designated Surgery Dept. suite lacked sufficient exit signage to direct occupants to the two required exit access doors of the suite to comply with 19.2.5.7.3.2(A) because the PACU, non-restricted and semi-restricted corridors lacked visibility of at least two exit signs to identify the two remote exits from the suite.

Based upon observation, vertical openings are not constructed and maintained to provide separation of floor levels in accordance with requirements. This condition could affect patients, staff and visitors if vertical openings would permit the effects of a fire/smoke to expose and compromise the safety of occupants on adjacent floors.

Findings include:

A. On January 28, 2020 at 8:15am while in the company of the FEM it was observed at the 2nd floor southeast Supply room that floor penetrations in the SE corner were not sealed to comply with 19.3.1. A penetration in the north wall was also not sealed to comply with 19.3.2.1.

B. On January 28, 20202 at 9:00am while in the company of the FEM it was observed that the temporary construction barriers provided at the elevator during elevator renovation work did not have self-closing doors to comply with 19.3.2.1.3 and 19.3.1.1/NFPA 80.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

Findings include:

A. On January 28, 2020 while in the company of the FEM it was observed that sprinkler protected storage rooms failed to be provided with self-closing door assemblies to comply with 19.3.2.1.3. Locations observed include:

1. At 8:10am the Sleep Study suite "Clean Storage" room door was not self-closing.

2. At 10:30am the Same Day Surgery east storage room door was observed to be held open by a closer equipped with a hold-open feature which could not be released by the fire alarm system in accordance with 7.2.1.8.

Based upon observation the facility failed to provide the installation of smoke detection in accordance with Code requirements. Failure to properly install smoke detection can affect patients, staff and visitors if the fire alarm detection system failed to notify building occupants in a timely manner.

Finding include:

On January 28, 2020 at 8:20am while in the company of the FEM it was observed in the corridor outside Sleep Lab suite room #5 that a smoke detector was located less than a distance of 3'-0" from an air diffuser, which does not comply with 9.6, NFPA 70 and NFPA 72-2010, 17.7.3.1.

Based upon observation, spaces open to corridors are not provided with smoke detection to comply with requirements. Failure to provide smoke detection as an added degree of protection for the space open to the corridor can compromize the use of the corridor if prompt detection of a fire condition in the space is not initiated.

Findings include:

On January 28, 2020 at 8:45am while in the company of the FEM it was observed that the 2nd floor equipment alcove near the elevators lacked smoke detection within the space to comply with 19.3.4.5.2 and 19.3.6.1(1)c.

Based upon observation, smoke barriers are not maintained to subdivide the building in accordance with requirements. Failure to maintain smoke barriers can compromise the safety of occupants if a place of refuge is not provided during a fire/smoke emergency.

Findings include:

A. On January 28, 2020 at 9:45am while in the company of the FEM it was observed that the designated smoke barrier door in the Gift Shop was removed making the smoke barrier incomplete and not in compliance with 19.3.7.6.

B. On January 28, 2020 at 9:50am while in the company of the FEM it was observed at the smoke barrier wall adjacent the main lobby waiting area and at the Surgery Storage room that the top of wall was not sealed to comply with 19.3.7.3 and 8.5.7 to afford the minimum 1/2-hour fire resistance rating and smoke tightness.

Based upon observation, medical gas system piping is not installed and maintained in accordance with Code requirements. Failure to install piped medical gas systems in accordance with requirements can cause disruption of services or add to the severity and progression of fire throughout the facility.

Findings include:

On January 28, 2020 at 9:30am while in the company of the FEM it was observed that a main oxygen supply line was routed above the ceiling of the kitchen, as prohibited by NFPA 99-2012, 5.1.10.11.3.2. A hanger was also observed near the location above the cooler which appeared not to be of non-ferrous material to comply with 5.1.10.11.4.2.

Based upon observation and staff interview during the survey walk-thru, the Essential Electrical System (EES) is not installed and maintained in accordance with Code requirements. Failure to maintain the emergency generator system in accordance with Code requirements may prevent the system from operating to maintain life support and emergency lighting systems which could affect all occupants during an emergency situation.

Findings include:

On January 28, 2020 at 9:10am while in the company of the FEM, the generator set enclosure was observed not to be a conditioned space. The starting batteries for the generator were not provided with a means of maintaining battery temperatures (battery warmer) for cold start as determined by generator manufacturer to comply with NFPA 110-2010, 5.3.1.