HospitalInspections.org

Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. This deficiency could affect any patients, staff, or visitors in that portion of the building because the building structure in that area could fail under fire conditions more quickly than in other parts of the building.

Findings include:

A. At 2:12 PM on May 29, 2012, unprotected steel beams and open web steel joists were observed above the ceiling in the Fourth Floor B Wing. During an interview held at that time and location, the provider's Manager of Architectural Services confirmed that, in a number of areas in the Fourth Floor B Wing, the drywall membrane that had been originally installed on the underside of the open web steel joists to complete the UL Design for the fire rated roof/ceiling assembly had been subsequently removed.

.


16339


Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. Portions of the steel structures were observed that are not covered by fire proofing materials in accordance with the designated UL Design. Locations observed include:

1. 9:10AM, 05/30/2012 C- Building, Third Floor, Toilet Room in C-318 EECP Treatment Room contains a steel beam which lacks fire proofing.

.

Based on random observation during the survey walk-through and staff interview, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A, B, or C in accordance with 19.3.3.1. This deficiency could affect any patients, staff, or visitors in the area because the material could contribute more readily to a fire.

Findings include:

A. At 10:40 AM on May 31, 2012, "masonite" peg board material was observed to be mounted on the walls of the First Floor Cast Room Storage Room. During an interview held at that time and location, the provider's Manager of Architectural Services was not able to verify that the finish material carries a Class C flame spread rating as required by the Exception to 19.3.3.2.(1).

.

Based on random observation during the survey walk-through and staff interview, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any patients, staff, or visitors in the immediate area because smoke could be permitted to pass into the building's corridors.

Findings include:

A. Waiting areas which are open to the corridors, but not visible from a constantly attended station, were observed to not be provided with smoke detectors as required by Subpart (b) of Exception 2. to 19.3.6.1. Locations observed include (All First Floor):
1. 10:50 AM May 31, 2012: Surgery Waiting Room. Smoke detectors were observed in the room, however the ceiling system does not form a complete membrane. During a radio interview conducted at that time, the provider's Equipment Technician confirmed that no smoke detectors are present within the open ceiling cavity.

2. 10:55 Am May 31, 2012: Waiting Alcove with bench in Corridor directly south of entry to Radiology Suite.

3. 11:00 AM May 31, 2012: Waiting Alcove with bench in former Main Lobby, across from the elevators.

.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. 2:10PM, 05/29/2012 E-Building, Fourth Floor-The Communication Closet corridor door was observed with a transfer grille that does not comply with 19.3.6.4.

.

Based on random observation during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect any patients, as well as any staff and visitors becaues the failure to provide dampers and proper installation of shaft could result in smoke or fire passing from one part of the building to another.

Findings include:

A. 2:45PM, 05/29/2012, C and E Building Third Floor, A ventilation shaft near the Exit Stair was observed with two round ducts and other penetrations through the corridor shaft wall which are not equipped with access panels to verify fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.2

.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the smoke compartments on either side of the cited wall by permitting smoke to pass between them.

Findings include:

A. Pipe and conduit penetrations were observed, above the cross-corridor doors in the smoke barrier at the east end of the Fourth Floor A Wing, that are not sealed against the passage of smoke as required by 19.3.7.3. and 8.3.6.1.

.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. This deficiency could affect any patients, staff, or visitors in the smoke compartment housing the Servery because smoke could be permitted to enter the adjacent corridor.

Findings include:

A. At 10:30 AM on May 31, 2012, the First Floor Cafeteria Servery, which includes commercial cooking equipment including a grill and a kitchen hood suppression system, was observed to not be separated from the adjacent Corridor because the east wall and door of the Servery are not resistant to the passage of smoke, as required by 19.3.2.1., because they include glass panes with gaps between them and a chain link gate.

.


16339


A. Sprinklered hazardous areas are not provided with smoke-resistant enclosure including self-closing, positive latching doors to comply with the requirements of 19.3.2.1. Locations include:

1. C and E Link, Second Floor - Office near Janitor's Closet: The door to this room which is being used for storage is not self-closing.

.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. This deficiency could affect any patients, staff, or visitors using the exit stair because smoke could be permitted to enter the exit stair enclosure.

Findings include:

A. At 1:15 PM on May 29, 2012, a series of pipe penetrations were observed, above the door to the Fifth Floor Mechanical Room from the Exit Stair adjacent to the ABC Elevators, that are not sealed against the passage of fire as required by 8.2.5.4. and 8.2.3.2.4.2.

.


16339


A. Based on random observation during the survey walk-through, not all exit stairs are arranged to provide a continuous path of escape and provided protection against fire or smoke from other parts of the building.

Findings include:

1. 2:15PM, 05/29/2012: E-Building, Fourth Floor: The Exit Stair stair enlosure was observed to contain electrical conduits and a junction box with labels " Feed From LP-A4C-33 which this utility does not directly serves this stair to comply with 7.1.3.2.1(e). This deficiency could affect patients, as well as any staff and visitors because the exit has other uitility that is not serving the exit stair under fire conditions.

.

A. Exit stair shaft walls 3 stories in height were observed that are not complete to comply with 19.3.1.1., 8.2.5.4.(2). Locations observed include:

1. Second Floor - West Exit Stair.

B. Based on random observation during the survey walk-through, not all exit stairs are arranged to provide a continuous path of escape and provided protection against fire or smoke from other parts of the building.

Findings include:

1. 11:10AM, 05/31/2012-Third Floor: The West Exit Stair stair enclosure was observed to contain electrical panel which this utility does not directly serves this stair to comply with 7.1.3.2.1(e). This deficiency could affect patients, as well as any staff and visitors because the exit has other uitility that is not serving the exit stair under fire conditions.

2. 11:15AM, 05/31/2012- Third Floor: The West Exit enclosure which is four stories in height was observed that contained an access panel that is not one hour and a half fire rated to comply with 8.2.5.4(1), 8.2.3.2.3(1).

3. 11:00AM, 05/31/2012- Fourth Floor (non sprinklered Area): Designated West Exit Stair was observed with a duct penetration that is not provided with a combination of fire and smoke dampers to comply with 8.2.3.2.4.1.

.

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors attempting to use these egress paths because the locking devices could prevent their egress.

The surveyor notes that, due to the nature of the deficiencies described under Items A. and B. below, the provider immediately implemented interim life safety measures including (but not limited to) a fire watch conducted every two hours and the notification of staff of the conditions. The interim life safety measures were terminated by the provider at 1:15 PM on May 31, 2012, when it was demonstrated that the conditions had been corrected.

Findings include:

A. During a test of the building fire alarm system conducted at 1:45 PM on May 30, 2012, and again at 11:45 AM on May 31, 2012, delayed egress locks were observed that did not release upon activation of the building fire alarm system as required by 7.2.1.6.1. Locations observed include (all Second Floor):
1. Pair of cross-corridor doors at the southeast egress path from the NICU.

2. Pair of cross-corridor doors between the NICU and the Labor and Delivery Unit.

3. Pair of cross-corridor doors immediately east of On Call Room A222.

B. During a test of the building's infant abduction system conducted at 11:40 AM on May 31, 2012, delayed egress locks were observed that did not release within 30 seconds after the application of force to the release device as required by Subpart (c) of 7.2.1.6.1. The surveyor notes that, since there is more than 1 delayed egress locking mechanism in the tested egress path (see Exception 2. to 19.2.2.2.4.), the doors listed below were confirmed by the provider's Manager of Architectural Services (at the time of the test) to be interlocked so that all delayed egress locking mechanisms in a path will release together. Doors at which this condition was observed include (all Second Floor):

1. Pair of cross-corridor doors between the NICU and the Labor and Delivery Unit.

2. Door to Exit Stair at the northeast corner of the Mother/Baby Unit (adjacent to Patient Sleeping Room B-211).

C. The signage and activating devices for a series of delayed egress locking assemblies were observed to not be located on the doors themselves as required by 7.2.1.6.1. The surveyor notes that this condition was observed at numerous doors on the Second and Third Floors of the building; the following are examples of this condition:
1. 3:10 PM May 29, 2012: Third Floor pair of cross-corridor doors at the south end of the B Wing.

2. 1:10 PM May 30, 2012: Second Floor pair of cross-corridor doors at the south end of the B Wing.

3. 1:25 PM May 30, 2012: Second Floor pair of cross-corridor doors between the NICU and the Labor and Delivery Unit.
C. At 10:43 AM on May 31, 2012, the Corridor from the First Floor Cardiac Rehab Suite, as well as from the south door from the Pediatric Outpatient/Cardiac Function Suite, was observed a dead end corridor of excessive length (as measured to the corridor intersection at the northeast corner of the Pain Center waiting Room) as prohibited by 19.2.5.9.

D. At 8:51 AM on May 31, 2012, the pair of cross-corridor doors at the northeast corner of the First Floor Emergency Department were observed to be equipped with a magnetic locking device, which can prevent egress toward the south, as prohibited by 19.2.2.2.4.

.



16339


Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. 9:45AM, 05/30/2012 - C Building, Third Floor: Doors were observed to be equipped with slide bolts and capable to be locked against egress which do not comply with 7.2.1.5.1.
Locations inclde:

1. Toilet Room for C-301 and C-302.

2. Toilet Room for C-323 and C-322.

3. Toilet Room for C-305 and C-304.

4. Toilet Room for C-319 and C-320.


B. Doors were observed that are equipped with a keyed deadbolt hardware from outside the room, and do not comply with 7.2.5.1. These deficiencies could affect patients receiving treatment, as well as any staff and visitors present, by preventing them from exiting the building under emergency conditions. Locations observed include:

1. 10:30 AM 05/30/2012, E-Building, 2nd Floor: The Patient / Office Room doors #227-230 are equipped with keyed deadbolt.
C. Exit stair that continue beyond the level of exit discharge was observed that is not equipped with interrupter gates which does not comply with 7.7.3. . Location(s) observed:

1. First floor Stair adjacent to the Gift Shop.

.

Based on random observation during the survey walk-through and document review, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 39.2.1.

Findings include:

A. At 8:30 AM on May 31, 2012, it was determined that the (undated) Rated Wall Master Plan for the First Floor of the building indicates that at least 1 exit stair (equaling 50 per cent of the total number of exit stairs serving other building stories) does not discharge exterior to the building as required by 7.7.2. This determination was confirmed during the survey walk-through at 9:30AM on that date.

.

Based on random observation during the survey walk-through and document review, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 39.2.1.

Findings include:

A. At 8:30 AM on May 31, 2012, it was determined that the (undated) Rated Wall Master Plan for the First Floor of the building indicates that the West Exit Stair discharges interior to the building as prohibited by 7.7.1. because the building is not fully covered by an automatic sprinkler system. This determination was confirmed during the survey walk-through at 10:45AM on that date.

.

Based on random observation during the survey walk-through and document review, not all designated suites are provided with exits in accordance with 19.2.5.2. This deficiency could affect any patients, visitors, or staff in the suite because access to a corridor will require a longer travel distance than in a suite of complaint size.

Findings include:

A. At 10:57 AM on May 30, 2012, the Second Floor NICU Suite was observed to be in excess of 5,000 square feet in area as prohibited by 19.2.5.6. The Rated Wall Master Plan for the facility, dated April 20, 2012, identifies the area of the suite as 8,878 square feet.

.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any staff or visitors in the area because smoke and fire could be permitted to cross the fire barrier.

Findings include:

A. At 11:30 AM on May 29, 2012, 2 duct penetrations through the required 2 hour rated fire barrier at the west wall of Ground Floor Classroom 5/6 (at the corridor wall to the Ingersoll Building) were observed to not be equipped with fire dampers as required by 8.2.3.2.4.1.

.

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 18.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

1 Exit discharge from some exits use HID type light fixtures that require a warmup period before the lights operate which does not meet the requirements of NFPA-101, Section 7.9.1.2, for lighting to be of instantaneous operation so as not to leave the exit path in darkness.

.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because staff may not be properly prepared for a fire event.

Findings include:

A. Based on document review conducted at 9:35 AM on May 30, 2012, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2011 and 2012, fire drill records for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. February 22, 2011: 3:30 PM.

b. June 29, 2011: 3:30 PM.

c. September 13, 2011: 3:10 PM.

d. December 30, 2011: 3:10 PM.

e. February 22, 2012: 3:30 PM.

2. Third Shift:
a. March 10, 2011: 6:10 AM.

b. May 12, 2011: 5:00 AM.

c. September 20, 2011: 6:00 AM.

d. October 11, 2011: 6:30 AM.

e. March 21, 2012: 6:00 AM.

.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 39.3.4.

Findings include:

A. At 9:23 AM on May 31, 2012, the exterior exit door from the shared vestibule between the First Floor Education Wing and the North Office Building was observed to lack a fire alarm pull manual stations within 5'-0" of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2. The surveyor notes that this condition exists within an existing business occupancy which serves as an egress path for the existing health care occupancy.

.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

A. 10:35AM, 05/29/2012 - E-Building, Second Floor -The wardrobe top shelf obstructs sprinkler protection was observed located in the Alcove across the Nurse Station.

.


17659


Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

1. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

2. The fire pump room does not have a battery operated emergency light as required by NFPA 20-2-7.4.

3. The transfer switch for the fire pump is not located at the pump location as required by NFPA 20-6-6.4.

.



26665


A. Fifth floor stairwell 4 " stand pipe was observed without a pressure gauge at the top in accordance with NFPA 14 2000.

.

Based upon random observation, the surveyor finds that sprinkler systems are not installed and maintained in accordance with NFPA 13:

1. First Floor - Fire Sprinkler/Mechanical Room, it was observed that the sprinkler head in this room which has an open cavity and exposed ceiling is not properly installed to comply with NFPA 13.

2. Second Floor (Sleep Lab Cardiac Floor)- Shell Space (Unassigned Room 263) The spacing for sprinkler heads in this room do not meet the spacing requirements of NFPA 13.

.

A. During the survey walk- through on the morning of May 30, 2912, the Dietary department " K " fire extinguishers were observed without a placard identifying their use only after the hood suppression had discharged in accordance with NFPA 96. Areas observed:

1. Dining room

2. Kitchen food prep area

This deficiency could cause injury to patients or staff due to a depleted secondary means after re-ignition of the grease fire,

.

Based on random observation during the survey walk-through, staff interview, and document review, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the immediate area because fire could be permitted to pass between building stories.

Findings include:

A. The Rated Wall Master Plans for the building, dated April 20, 2012, indicate that a ventilating shaft serving at least 4 building stories is located at the southeast corner of the A Wing, immediately west of a pair of elevators. At 1:57 PM on May 29, 2012, the ceiling of the adjacent Hopper Room (next to Patient Sleeping Room A401) was observed to form a portion of the shaft enclosure but was observed to not carry a minimum 2 hour fire rating, as required by NFPA 90A 1999 3-3.4.1., because the ceiling assembly consists of metal studs with drywall or plaster on the bottom side only. During an interview held at that time and location, the provider's Project Coordinator was not able to identify the limits of the shaft or to confirm that the shaft enclosure is complete.

B. At 3:02 PM on May 29, 2012, a series of pipe penetrations were observed, in the south wall of a ventilating shaft on the north side of the Third Floor corridor adjacent to the pair of doors leading to the C Wing, which are not sealed against the passage of fire as required by 8.2.3.2.4.2.

C. At 10:41 AM on May 30, 2012, a gap was observed between the side of a duct and the adjacent fire rated wall assembly, at the shaft described in Item A. above (within a Second Floor Janitor's Closet). The duct penetration is thus not sealed against the passage of fire as required by 8.2.3.2.4.2.

.


26665


A. During document review process, fire, smoke and combination dampers inspection were identified with deficiencies and no corrective repairs since April and May 2012. Items identified were;

1. Not fully closing

2. No access panel

3. Could not reach access panels

4. Pipes obstructing opening of access panels

.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the immediate area because the gases could contribute to a fire condition.

Findings include:

A. Medical gas tanks were observed being stored, in sprinklered portions of the building, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). Locations observed include:

1. 2:46 PM May 29, 2012: 9 medical gas tanks in the Third Floor D Wing Storage Room adjacent to Patient Sleeping Room D327.

2. 9:12 AM May 31, 2012: 12 medical gas tanks in First Floor PACU Soiled Utility Room.

.

Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients served by the associated medical gas outlets because it may be difficult to close the medical gas valves under emergency conditions.


A. At 2:51 PM on May 30, 2012, the medical gas zone (shut-off) valves serving the Second Floor Caesarian Section Recovery Room were observed to be located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d).

B. At 2:06 PM on May 29, 2012, a set of medical gas zone (shut-off) valves was observed behind a door, on the Fourth Floor, which leads from the ABC Elevators to the C Wing. These valves are thus not visible and accessible at all times as required by NFPA 99 1999 4-3.1.2.3(i).

.


26665


A. During the survey tour of the nitrous oxide manifold room on the morning of May 30, 2012, the ground floor in the mechanical room the low wall exhaust appeared to be connected to a general area exhaust/return air duct and not a dedicated exhaust to the outside in accordance NFPA 99 1999 Chapter 4.

This deficiency could cause injury to patients and staff by allowing nitrous oxide to other areas.

B. During the survey tour of the ground floor mechanical room, three vacuum pumps were observed to be supplying the patient vacuum system. Two pumps were piped to the receiver with a common source isolation valve for the system and the third pump was piped into the system after the source valve with a valve connecting it to the main line without a durable tag identifying what areas were served in accordance with NFPA 99 1999 Chapter 4.

This deficiency could cause injury to patients requiring medical vacuum.

C. During the survey tour of the medical air location on ground floor mechanical room the three medical air systems was observed without a CO monitor in accordance with NFPA 99 1999 Chapter 4.

This deficiency could cause injury to patients due to high level of carbon monoxide it the air.

.

Based on random observationduring the survey walk-through the generator equipment does not meet all requirements of NFPA-110.

Findings include:

1. The generators were located in the same room as the 12470 Volt primary power service equipment which does not comply with NFPA-110, Section 5-2.1. This deficiencies could affect all building occupants because a failure of the generators could also effect the normal power service.

2. The generator annunciator panels were not monitored at a constantly attended location and were not arranged with a derangement alarm which did not meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

3. Each generator did not have an individual remote shut down switch to comply with NFPA-110, Section 3-5.5.6.

.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Life Safety, Critical and Equipments branches of power were not separated throughout the building. The E-wing of the building had no separation at all, all branches were served by a single transfer switch. Areas of the building where modernization projects had been performed had some separation , but there were still emergency panels throughout that had mixtures of critical and equipment such as panel LPEMA4 and EMB4 which served patient rooms but also served room heating and cooling equipment, and panels such as LPEM4, EMB3, LPEMA3, EC3, ELS, LPEMA2, and 2CLR2 which were serving critical and life safety loads. The loads served by the emergency power system should be separated into three branches to comply with NFPA-70, Sections 517-32 through 34, and NFPA-99, Section 3-4.2.2.2 and 3-4.2.2.3.

.

Based on random observation during the survey walk-through, not all portions of the facility's electrical system are installed in accordance with NFPA 70. These deficiencies could affect any patients being treated in the Operating Rooms because power and light may not always be available to provide treatment.

Findings include:

A. A series of First Floor Operating Rooms were observed to lack electrical receptacles served by the building's normal power system as required by NFPA 70 1999 517-19(a). Locations observed include:
1. 10:50 AM May 31, 2012: Operating Room 1.

2. 10:55 AM May 31, 2012: Operating Room 3.

B. Critical care patient beds were observed at which electrical receptacles served by the building emergency electrical system are not labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a). Locations observed include:

1. 10:50 AM May 31, 2012: Operating Room 1.

2. 10:55 AM May 31, 2012: Operating Room 3.

C. At 11:27 AM on May 30, 2012, 1 of 2 Second Floor Caesarian Section Rooms was observed to lack a battery-powered emergency light required by NFPA 99 1999 3-3.2.1.2(a)(5)(e) and NFPA 70 1999 517-63(a). The other Caesarian Section Room was not accessible to the surveyor due to an ongoing procedure

.


16339


Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. 2:30PM, 05/29/2012 Building C and E Link Fourth Floor: Electrical panels were observed at which a clear working space of 3'-0" in front of the panel is not maintained as required by NFPA 70 1999 110-26(a). Locations observed include:

1. Janitor's Closet. ( Note: This appears to be a typical situation in other floors Example: Third, Second and First Floors ).

B. 9:15AM, 05/29/2012 C- Building, 3rd Floor Corridor near C-318: Data cables above the ceiling area supported by the ceiling panel and other conduits are not adequately supported from deck above to comply with NFPA 70 1999 800-52(e).

.


17659


Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Improper grounding could create a shock hazard for all occupants of the building.

Findings include:

1. Staff was not able to locate were the med gas piping was bonded as required by NFPA-70, Section 250.104(c).

.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1 The surveyor observed that the elevator machine rooms were not equipped with a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

2. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.

3. The elevator disconnects were not properly marked in all locations with the number of the elevator and the location of the supply side overcurrent protective device as required by NFPA-70, Section 620-51(d).

.

Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. This deficiency could affect any patients, staff, or visitors in that portion of the building because the building structure in that area could fail under fire conditions more quickly than in other parts of the building.

Findings include:

A. At 2:12 PM on May 29, 2012, unprotected steel beams and open web steel joists were observed above the ceiling in the Fourth Floor B Wing. During an interview held at that time and location, the provider's Manager of Architectural Services confirmed that, in a number of areas in the Fourth Floor B Wing, the drywall membrane that had been originally installed on the underside of the open web steel joists to complete the UL Design for the fire rated roof/ceiling assembly had been subsequently removed.

.


16339


Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. Portions of the steel structures were observed that are not covered by fire proofing materials in accordance with the designated UL Design. Locations observed include:

1. 9:10AM, 05/30/2012 C- Building, Third Floor, Toilet Room in C-318 EECP Treatment Room contains a steel beam which lacks fire proofing.

.

Based on random observation during the survey walk-through and staff interview, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A, B, or C in accordance with 19.3.3.1. This deficiency could affect any patients, staff, or visitors in the area because the material could contribute more readily to a fire.

Findings include:

A. At 10:40 AM on May 31, 2012, "masonite" peg board material was observed to be mounted on the walls of the First Floor Cast Room Storage Room. During an interview held at that time and location, the provider's Manager of Architectural Services was not able to verify that the finish material carries a Class C flame spread rating as required by the Exception to 19.3.3.2.(1).

.

Based on random observation during the survey walk-through and staff interview, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any patients, staff, or visitors in the immediate area because smoke could be permitted to pass into the building's corridors.

Findings include:

A. Waiting areas which are open to the corridors, but not visible from a constantly attended station, were observed to not be provided with smoke detectors as required by Subpart (b) of Exception 2. to 19.3.6.1. Locations observed include (All First Floor):
1. 10:50 AM May 31, 2012: Surgery Waiting Room. Smoke detectors were observed in the room, however the ceiling system does not form a complete membrane. During a radio interview conducted at that time, the provider's Equipment Technician confirmed that no smoke detectors are present within the open ceiling cavity.

2. 10:55 Am May 31, 2012: Waiting Alcove with bench in Corridor directly south of entry to Radiology Suite.

3. 11:00 AM May 31, 2012: Waiting Alcove with bench in former Main Lobby, across from the elevators.

.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. 2:10PM, 05/29/2012 E-Building, Fourth Floor-The Communication Closet corridor door was observed with a transfer grille that does not comply with 19.3.6.4.

.

Based on random observation during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect any patients, as well as any staff and visitors becaues the failure to provide dampers and proper installation of shaft could result in smoke or fire passing from one part of the building to another.

Findings include:

A. 2:45PM, 05/29/2012, C and E Building Third Floor, A ventilation shaft near the Exit Stair was observed with two round ducts and other penetrations through the corridor shaft wall which are not equipped with access panels to verify fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.2

.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the smoke compartments on either side of the cited wall by permitting smoke to pass between them.

Findings include:

A. Pipe and conduit penetrations were observed, above the cross-corridor doors in the smoke barrier at the east end of the Fourth Floor A Wing, that are not sealed against the passage of smoke as required by 19.3.7.3. and 8.3.6.1.

.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. This deficiency could affect any patients, staff, or visitors in the smoke compartment housing the Servery because smoke could be permitted to enter the adjacent corridor.

Findings include:

A. At 10:30 AM on May 31, 2012, the First Floor Cafeteria Servery, which includes commercial cooking equipment including a grill and a kitchen hood suppression system, was observed to not be separated from the adjacent Corridor because the east wall and door of the Servery are not resistant to the passage of smoke, as required by 19.3.2.1., because they include glass panes with gaps between them and a chain link gate.

.


16339


A. Sprinklered hazardous areas are not provided with smoke-resistant enclosure including self-closing, positive latching doors to comply with the requirements of 19.3.2.1. Locations include:

1. C and E Link, Second Floor - Office near Janitor's Closet: The door to this room which is being used for storage is not self-closing.

.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. This deficiency could affect any patients, staff, or visitors using the exit stair because smoke could be permitted to enter the exit stair enclosure.

Findings include:

A. At 1:15 PM on May 29, 2012, a series of pipe penetrations were observed, above the door to the Fifth Floor Mechanical Room from the Exit Stair adjacent to the ABC Elevators, that are not sealed against the passage of fire as required by 8.2.5.4. and 8.2.3.2.4.2.

.


16339


A. Based on random observation during the survey walk-through, not all exit stairs are arranged to provide a continuous path of escape and provided protection against fire or smoke from other parts of the building.

Findings include:

1. 2:15PM, 05/29/2012: E-Building, Fourth Floor: The Exit Stair stair enlosure was observed to contain electrical conduits and a junction box with labels " Feed From LP-A4C-33 which this utility does not directly serves this stair to comply with 7.1.3.2.1(e). This deficiency could affect patients, as well as any staff and visitors because the exit has other uitility that is not serving the exit stair under fire conditions.

.

A. Exit stair shaft walls 3 stories in height were observed that are not complete to comply with 19.3.1.1., 8.2.5.4.(2). Locations observed include:

1. Second Floor - West Exit Stair.

B. Based on random observation during the survey walk-through, not all exit stairs are arranged to provide a continuous path of escape and provided protection against fire or smoke from other parts of the building.

Findings include:

1. 11:10AM, 05/31/2012-Third Floor: The West Exit Stair stair enclosure was observed to contain electrical panel which this utility does not directly serves this stair to comply with 7.1.3.2.1(e). This deficiency could affect patients, as well as any staff and visitors because the exit has other uitility that is not serving the exit stair under fire conditions.

2. 11:15AM, 05/31/2012- Third Floor: The West Exit enclosure which is four stories in height was observed that contained an access panel that is not one hour and a half fire rated to comply with 8.2.5.4(1), 8.2.3.2.3(1).

3. 11:00AM, 05/31/2012- Fourth Floor (non sprinklered Area): Designated West Exit Stair was observed with a duct penetration that is not provided with a combination of fire and smoke dampers to comply with 8.2.3.2.4.1.

.

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors attempting to use these egress paths because the locking devices could prevent their egress.

The surveyor notes that, due to the nature of the deficiencies described under Items A. and B. below, the provider immediately implemented interim life safety measures including (but not limited to) a fire watch conducted every two hours and the notification of staff of the conditions. The interim life safety measures were terminated by the provider at 1:15 PM on May 31, 2012, when it was demonstrated that the conditions had been corrected.

Findings include:

A. During a test of the building fire alarm system conducted at 1:45 PM on May 30, 2012, and again at 11:45 AM on May 31, 2012, delayed egress locks were observed that did not release upon activation of the building fire alarm system as required by 7.2.1.6.1. Locations observed include (all Second Floor):
1. Pair of cross-corridor doors at the southeast egress path from the NICU.

2. Pair of cross-corridor doors between the NICU and the Labor and Delivery Unit.

3. Pair of cross-corridor doors immediately east of On Call Room A222.

B. During a test of the building's infant abduction system conducted at 11:40 AM on May 31, 2012, delayed egress locks were observed that did not release within 30 seconds after the application of force to the release device as required by Subpart (c) of 7.2.1.6.1. The surveyor notes that, since there is more than 1 delayed egress locking mechanism in the tested egress path (see Exception 2. to 19.2.2.2.4.), the doors listed below were confirmed by the provider's Manager of Architectural Services (at the time of the test) to be interlocked so that all delayed egress locking mechanisms in a path will release together. Doors at which this condition was observed include (all Second Floor):

1. Pair of cross-corridor doors between the NICU and the Labor and Delivery Unit.

2. Door to Exit Stair at the northeast corner of the Mother/Baby Unit (adjacent to Patient Sleeping Room B-211).

C. The signage and activating devices for a series of delayed egress locking assemblies were observed to not be located on the doors themselves as required by 7.2.1.6.1. The surveyor notes that this condition was observed at numerous doors on the Second and Third Floors of the building; the following are examples of this condition:
1. 3:10 PM May 29, 2012: Third Floor pair of cross-corridor doors at the south end of the B Wing.

2. 1:10 PM May 30, 2012: Second Floor pair of cross-corridor doors at the south end of the B Wing.

3. 1:25 PM May 30, 2012: Second Floor pair of cross-corridor doors between the NICU and the Labor and Delivery Unit.
C. At 10:43 AM on May 31, 2012, the Corridor from the First Floor Cardiac Rehab Suite, as well as from the south door from the Pediatric Outpatient/Cardiac Function Suite, was observed a dead end corridor of excessive length (as measured to the corridor intersection at the northeast corner of the Pain Center waiting Room) as prohibited by 19.2.5.9.

D. At 8:51 AM on May 31, 2012, the pair of cross-corridor doors at the northeast corner of the First Floor Emergency Department were observed to be equipped with a magnetic locking device, which can prevent egress toward the south, as prohibited by 19.2.2.2.4.

.



16339


Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. 9:45AM, 05/30/2012 - C Building, Third Floor: Doors were observed to be equipped with slide bolts and capable to be locked against egress which do not comply with 7.2.1.5.1.
Locations inclde:

1. Toilet Room for C-301 and C-302.

2. Toilet Room for C-323 and C-322.

3. Toilet Room for C-305 and C-304.

4. Toilet Room for C-319 and C-320.


B. Doors were observed that are equipped with a keyed deadbolt hardware from outside the room, and do not comply with 7.2.5.1. These deficiencies could affect patients receiving treatment, as well as any staff and visitors present, by preventing them from exiting the building under emergency conditions. Locations observed include:

1. 10:30 AM 05/30/2012, E-Building, 2nd Floor: The Patient / Office Room doors #227-230 are equipped with keyed deadbolt.
C. Exit stair that continue beyond the level of exit discharge was observed that is not equipped with interrupter gates which does not comply with 7.7.3. . Location(s) observed:

1. First floor Stair adjacent to the Gift Shop.

.

Based on random observation during the survey walk-through and document review, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 39.2.1.

Findings include:

A. At 8:30 AM on May 31, 2012, it was determined that the (undated) Rated Wall Master Plan for the First Floor of the building indicates that at least 1 exit stair (equaling 50 per cent of the total number of exit stairs serving other building stories) does not discharge exterior to the building as required by 7.7.2. This determination was confirmed during the survey walk-through at 9:30AM on that date.

.

Based on random observation during the survey walk-through and document review, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 39.2.1.

Findings include:

A. At 8:30 AM on May 31, 2012, it was determined that the (undated) Rated Wall Master Plan for the First Floor of the building indicates that the West Exit Stair discharges interior to the building as prohibited by 7.7.1. because the building is not fully covered by an automatic sprinkler system. This determination was confirmed during the survey walk-through at 10:45AM on that date.

.

Based on random observation during the survey walk-through and document review, not all designated suites are provided with exits in accordance with 19.2.5.2. This deficiency could affect any patients, visitors, or staff in the suite because access to a corridor will require a longer travel distance than in a suite of complaint size.

Findings include:

A. At 10:57 AM on May 30, 2012, the Second Floor NICU Suite was observed to be in excess of 5,000 square feet in area as prohibited by 19.2.5.6. The Rated Wall Master Plan for the facility, dated April 20, 2012, identifies the area of the suite as 8,878 square feet.

.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any staff or visitors in the area because smoke and fire could be permitted to cross the fire barrier.

Findings include:

A. At 11:30 AM on May 29, 2012, 2 duct penetrations through the required 2 hour rated fire barrier at the west wall of Ground Floor Classroom 5/6 (at the corridor wall to the Ingersoll Building) were observed to not be equipped with fire dampers as required by 8.2.3.2.4.1.

.

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 18.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

1 Exit discharge from some exits use HID type light fixtures that require a warmup period before the lights operate which does not meet the requirements of NFPA-101, Section 7.9.1.2, for lighting to be of instantaneous operation so as not to leave the exit path in darkness.

.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because staff may not be properly prepared for a fire event.

Findings include:

A. Based on document review conducted at 9:35 AM on May 30, 2012, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2011 and 2012, fire drill records for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. February 22, 2011: 3:30 PM.

b. June 29, 2011: 3:30 PM.

c. September 13, 2011: 3:10 PM.

d. December 30, 2011: 3:10 PM.

e. February 22, 2012: 3:30 PM.

2. Third Shift:
a. March 10, 2011: 6:10 AM.

b. May 12, 2011: 5:00 AM.

c. September 20, 2011: 6:00 AM.

d. October 11, 2011: 6:30 AM.

e. March 21, 2012: 6:00 AM.

.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 39.3.4.

Findings include:

A. At 9:23 AM on May 31, 2012, the exterior exit door from the shared vestibule between the First Floor Education Wing and the North Office Building was observed to lack a fire alarm pull manual stations within 5'-0" of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2. The surveyor notes that this condition exists within an existing business occupancy which serves as an egress path for the existing health care occupancy.

.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

A. 10:35AM, 05/29/2012 - E-Building, Second Floor -The wardrobe top shelf obstructs sprinkler protection was observed located in the Alcove across the Nurse Station.

.


17659


Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

1. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

2. The fire pump room does not have a battery operated emergency light as required by NFPA 20-2-7.4.

3. The transfer switch for the fire pump is not located at the pump location as required by NFPA 20-6-6.4.

.



26665


A. Fifth floor stairwell 4 " stand pipe was observed without a pressure gauge at the top in accordance with NFPA 14 2000.

.

Based upon random observation, the surveyor finds that sprinkler systems are not installed and maintained in accordance with NFPA 13:

1. First Floor - Fire Sprinkler/Mechanical Room, it was observed that the sprinkler head in this room which has an open cavity and exposed ceiling is not properly installed to comply with NFPA 13.

2. Second Floor (Sleep Lab Cardiac Floor)- Shell Space (Unassigned Room 263) The spacing for sprinkler heads in this room do not meet the spacing requirements of NFPA 13.

.

A. During the survey walk- through on the morning of May 30, 2912, the Dietary department " K " fire extinguishers were observed without a placard identifying their use only after the hood suppression had discharged in accordance with NFPA 96. Areas observed:

1. Dining room

2. Kitchen food prep area

This deficiency could cause injury to patients or staff due to a depleted secondary means after re-ignition of the grease fire,

.

Based on random observation during the survey walk-through, staff interview, and document review, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the immediate area because fire could be permitted to pass between building stories.

Findings include:

A. The Rated Wall Master Plans for the building, dated April 20, 2012, indicate that a ventilating shaft serving at least 4 building stories is located at the southeast corner of the A Wing, immediately west of a pair of elevators. At 1:57 PM on May 29, 2012, the ceiling of the adjacent Hopper Room (next to Patient Sleeping Room A401) was observed to form a portion of the shaft enclosure but was observed to not carry a minimum 2 hour fire rating, as required by NFPA 90A 1999 3-3.4.1., because the ceiling assembly consists of metal studs with drywall or plaster on the bottom side only. During an interview held at that time and location, the provider's Project Coordinator was not able to identify the limits of the shaft or to confirm that the shaft enclosure is complete.

B. At 3:02 PM on May 29, 2012, a series of pipe penetrations were observed, in the south wall of a ventilating shaft on the north side of the Third Floor corridor adjacent to the pair of doors leading to the C Wing, which are not sealed against the passage of fire as required by 8.2.3.2.4.2.

C. At 10:41 AM on May 30, 2012, a gap was observed between the side of a duct and the adjacent fire rated wall assembly, at the shaft described in Item A. above (within a Second Floor Janitor's Closet). The duct penetration is thus not sealed against the passage of fire as required by 8.2.3.2.4.2.

.


26665


A. During document review process, fire, smoke and combination dampers inspection were identified with deficiencies and no corrective repairs since April and May 2012. Items identified were;

1. Not fully closing

2. No access panel

3. Could not reach access panels

4. Pipes obstructing opening of access panels

.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the immediate area because the gases could contribute to a fire condition.

Findings include:

A. Medical gas tanks were observed being stored, in sprinklered portions of the building, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). Locations observed include:

1. 2:46 PM May 29, 2012: 9 medical gas tanks in the Third Floor D Wing Storage Room adjacent to Patient Sleeping Room D327.

2. 9:12 AM May 31, 2012: 12 medical gas tanks in First Floor PACU Soiled Utility Room.

.

Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients served by the associated medical gas outlets because it may be difficult to close the medical gas valves under emergency conditions.


A. At 2:51 PM on May 30, 2012, the medical gas zone (shut-off) valves serving the Second Floor Caesarian Section Recovery Room were observed to be located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d).

B. At 2:06 PM on May 29, 2012, a set of medical gas zone (shut-off) valves was observed behind a door, on the Fourth Floor, which leads from the ABC Elevators to the C Wing. These valves are thus not visible and accessible at all times as required by NFPA 99 1999 4-3.1.2.3(i).

.


26665


A. During the survey tour of the nitrous oxide manifold room on the morning of May 30, 2012, the ground floor in the mechanical room the low wall exhaust appeared to be connected to a general area exhaust/return air duct and not a dedicated exhaust to the outside in accordance NFPA 99 1999 Chapter 4.

This deficiency could cause injury to patients and staff by allowing nitrous oxide to other areas.

B. During the survey tour of the ground floor mechanical room, three vacuum pumps were observed to be supplying the patient vacuum system. Two pumps were piped to the receiver with a common source isolation valve for the system and the third pump was piped into the system after the source valve with a valve connecting it to the main line without a durable tag identifying what areas were served in accordance with NFPA 99 1999 Chapter 4.

This deficiency could cause injury to patients requiring medical vacuum.

C. During the survey tour of the medical air location on ground floor mechanical room the three medical air systems was observed without a CO monitor in accordance with NFPA 99 1999 Chapter 4.

This deficiency could cause injury to patients due to high level of carbon monoxide it the air.

.

Based on random observationduring the survey walk-through the generator equipment does not meet all requirements of NFPA-110.

Findings include:

1. The generators were located in the same room as the 12470 Volt primary power service equipment which does not comply with NFPA-110, Section 5-2.1. This deficiencies could affect all building occupants because a failure of the generators could also effect the normal power service.

2. The generator annunciator panels were not monitored at a constantly attended location and were not arranged with a derangement alarm which did not meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

3. Each generator did not have an individual remote shut down switch to comply with NFPA-110, Section 3-5.5.6.

.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Life Safety, Critical and Equipments branches of power were not separated throughout the building. The E-wing of the building had no separation at all, all branches were served by a single transfer switch. Areas of the building where modernization projects had been performed had some separation , but there were still emergency panels throughout that had mixtures of critical and equipment such as panel LPEMA4 and EMB4 which served patient rooms but also served room heating and cooling equipment, and panels such as LPEM4, EMB3, LPEMA3, EC3, ELS, LPEMA2, and 2CLR2 which were serving critical and life safety loads. The loads served by the emergency power system should be separated into three branches to comply with NFPA-70, Sections 517-32 through 34, and NFPA-99, Section 3-4.2.2.2 and 3-4.2.2.3.

.

Based on random observation during the survey walk-through, not all portions of the facility's electrical system are installed in accordance with NFPA 70. These deficiencies could affect any patients being treated in the Operating Rooms because power and light may not always be available to provide treatment.

Findings include:

A. A series of First Floor Operating Rooms were observed to lack electrical receptacles served by the building's normal power system as required by NFPA 70 1999 517-19(a). Locations observed include:
1. 10:50 AM May 31, 2012: Operating Room 1.

2. 10:55 AM May 31, 2012: Operating Room 3.

B. Critical care patient beds were observed at which electrical receptacles served by the building emergency electrical system are not labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a). Locations observed include:

1. 10:50 AM May 31, 2012: Operating Room 1.

2. 10:55 AM May 31, 2012: Operating Room 3.

C. At 11:27 AM on May 30, 2012, 1 of 2 Second Floor Caesarian Section Rooms was observed to lack a battery-powered emergency light required by NFPA 99 1999 3-3.2.1.2(a)(5)(e) and NFPA 70 1999 517-63(a). The other Caesarian Section Room was not accessible to the surveyor due to an ongoing procedure

.


16339


Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. 2:30PM, 05/29/2012 Building C and E Link Fourth Floor: Electrical panels were observed at which a clear working space of 3'-0" in front of the panel is not maintained as required by NFPA 70 1999 110-26(a). Locations observed include:

1. Janitor's Closet. ( Note: This appears to be a typical situation in other floors Example: Third, Second and First Floors ).

B. 9:15AM, 05/29/2012 C- Building, 3rd Floor Corridor near C-318: Data cables above the ceiling area supported by the ceiling panel and other conduits are not adequately supported from deck above to comply with NFPA 70 1999 800-52(e).

.


17659


Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Improper grounding could create a shock hazard for all occupants of the building.

Findings include:

1. Staff was not able to locate were the med gas piping was bonded as required by NFPA-70, Section 250.104(c).

.