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Based upon observation during the survey walk-thru, Exit Stair enclosures are not maintained in conformance with Code requirements. Failure to provide the required separation of the Exit from other areas of the building to provide a protected path of egress can compromise the ability for occupants to exit the building during a fire/smoke emergency.

Findings include:

On 7/12/21 at 2:55pm while in the company of the CE it was observed that the door at the 6th floor level which accesses the stair extending to the 7th floor elevator penthouse did not self-close in the frame and latch to comply with NFPA 80 and NFPA 101-2012, 7.1.3.2.1(9).

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the lighting provided. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. On 7/13/21 while in the company of the DPS it was observed that exit discharge lighting was not confirmed to be of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Not all Exit discharge locations are provided with multiple fixtures or lamps or the lamp type was HID without quartz restrike which does not comply with 7.8.1.4. Locations observed:

1. At 10:40am at the 1st floor exterior exit door discharge east of the Emergency Dept. Waiting room suite leading to an exterior stair and ramp.

2. At 10:50am at the 1st floor exterior exit door discharge adjacent the loading dock.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. On 7/12/21 at 3:00pm while in the company of the CE it was observed that the two 6th floor exit stairs were identified only with signage reading "stairway" in lieu of the signage required by 7.10.3.1 to read "EXIT".

B. On 7/13/21 at 10:00am while in the company of the DPS it was observed that the 2nd floor corridor east of the ICU east entry door lacked access to a second exit to comply with 19.2.5.4. The entry door to the ICU suite was marked as "Not an Exit" and the length of the dead end corridor exceeded the 30' permitted by 19.2.5.2. The area containing this corridor was not otherwise identified as a compliant suite in accordance with 19.2.5.7 on the available Life Safety Reference Plans .

C. On 7/13/21 at 10:35am while in the company of the DPS it was observed that the exit sign at the OR corridor south of the cross corridor doors near OR #5 was a directional sign where a directional sign is not appropriate to comply with 7.10.2. Exiting is expected to be thru the door and not be directed east and west before passing through the door.

D. On 7/13/21 at 10:45am while in the company of the DPS it was observed that exit signage directed exiting thru the identified Emergency Dept. Waiting room suite in non-compliance with NFPA 101-2012, 19.2.5.4. The DPS indicated that after-hours traffic was being directed into the defined Waiting suite to pass by the security desk. It was not clear why the ED Waiting & corridor was being defined as a suite.

Based upon observation during the survey walk-thru, enclosure of vertical openings is not maintained in conformance with Code requirements. Failure to provide the required separation of vertical openiong from other areas of the building can result in fire and smoke conditions moving to other floors and compromizing occupants.

Findings include:

A. On 7/13/21 while in the company of the DF and MS it was observed that the access door installed in the two hour fire rated HVAC shaft was not confirmed to be fire rated due to lack of a tag confirming the rating, at the following locations. This condition does not comply with NFPA 101-2012, Sections 19.3.1.1 - 19.3.1.6:

1. At 10:05 am on Second floor
2. At 10:50 am on Third Floor
3. At 11:45 am on Fourth Floor

Based upon observation, hazardous areas are not properly 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 compromise the use of the adjacent corridor for exiting.

Findings include:

On 7/13/21 at 10:30am while in the company of the DPS it was observed that the sprinklered small storage room containing the red bio-hazard bin, deemed to be a Hazardous Area containing combustibles in size and density exceeding that normal to the general occupancy of the suite, was not provided with a self-closing positive latching door to comply with 19.3.2.1.3, 19.3.6.3.5 and 19.7.5.7.1.

Based on observation the facility failed to document inspection of the kitchen / cafeteria hood fire suppression system. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 7/13/21 at 11:10am in the company of the CE observation of the inspection tags for the grease hood fire protection system, it was observed the record of the date and initials of the person completing the monthly inspection is not provide on the tag. NFPA, 17, 2009, 11.2.4 / NFPA 17A, 2009, 7.2.5.

Based upon observation during the survey walk-thru, sprinkler systems are not maintained in accordance with Code requirements. Failure to maintain the sprinkler system can compromise occupant safety and building protection when the sprinkler system does not perform as intended to control a fire condition.

Findings include:

A. On 7/12/21 at 3:00pm while in the company of the CE it was observed at the 6th floor of the 1981 building that a construction project was on-going which removed ceiling tile. The sprinkler heads were oriented in the pendant position at the level of the anticipated ceiling and not in compliance with NFPA 13-2011, 8.6.4.1 regarding the maximum distance from the deck above. The CE indicated that a Fire Watch had not been implemented to compensate for the impairment of the sprinkler system to comply with NFPA 25-2011, 15.5.2.

B. On 7/13/21 at 11:00am while in the company of the DPS it was observed that the sprinkler protection in the exterior canopy of the Emergency Dept. walk-in entry was compromised by ceiling cut-outs at the sprinkler piping and head creating a condition not in compliance with NFPA 13-2011, 8.6.4.1. It was indicated that repairs to the sprinkler piping above the soffit system were required to drain the dry pipe system to prevent freezing. Completion of the soffit work was still pending.

Based on observation the facility lacks correct signage for the use of fire extinguishers in the cafeteria. This deficient practice could affect patients, staff and visitors during a kitchen cooking grease fire event.

The finding is:

On 7/13/21 at 11:10am accompanied by the CE, it was observed that the installed K fire extinguisher lack signage for the correct sequence and use of the K fire extinguisher located by the grease hood in the cafeteria. NFPA 96, 2011, 10.2.2

Based on observation and staff interview during the survey walk through the facility lacks complete bonding of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:

On 7/13/21 at 10:45am accompanied by the CE, it could not be confirmed through observation and staff interview that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B)