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Based on observation components of the buildings designated construction type do not comply with, 19.1.6.2, and NFPA 220, 2012 Edition. This condition could affect individuals on the floor of fire incident from safely traveling the means of egress to the nearest exit.

Finding include:

A. On 10/14/2020 at 10:00am while accompanied by the MPO portions of the Hospital do not comply with the minimum construction type requirements of 19.1.6.2, 82.1.3 and NFPA 220, 2012, 4.3.1 which defines the requirements for elements to comply with the construction classification of a building. There is no fire rated separation between the limited combustible classification of the first floor Cardio Rehabilitation area (type II (000)) and the noncombustible classification of the remaining health care building (I (332)). This condition does not comply with 8.2.1.3 for a 2-hour separation for connected structures of different construction types.
Location observed: First floor Cardio Rehabilitation (Solarium).

B. On 10/13/2020 at 1:10pm while accompanied by the MPO portions of the Hospital contain unprotected steel which does not comply with the minimum construction type requirements of 19.1.6.2. Location observed: Second floor Cardiac Med/Surg corridor adjacent to Center Stair, above ceiling exposed steel angle at expansion joint lacks fire protection.

Based on observation, means of egress corridors are not kept cleared from obstructions. This deficiency could affect all residents, staff and visitors if the emergency evacuation is obstructed.

The finding is:

On 10/14/2020 at 10:00am, while accompanied by the MS the following Storage Closets doors remaioopen onto means of egress corridors and do not maintain access to unobstructed corridor widths to comply with 19.2.3.4. These doors are not installed with self-closing devices.

Locations observed:
Storage closets 111, 123, 137A, 137B and 157.

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.

The finding is:

On 10/14/2020 at 10:45am while in the company of the MS it was observed that the four exit discharge doors were installed with 15 Seconds Delayed Egress Locking devices. These devices lack the proper signage " PUSH UNTIL ALARM SOUNDS, DOORS WILL BE OPENED IN 15 SECONDS" which does not comply with 19.2.2.2.4(2) and 7.2.1.6.2(4).

Based on observation not all doors are available at all times for egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising the direction of egress within a room or exit access corridor.

The finding is:

On 10/13/2020 at 1:26pm accompanied by the MPO the Second floor South Stair entry door contains a magnetic lock. The lock did appear to be disengaged, however, not permanently therefore, this condition does not comply with 19.2.2.2.5.2. During discussion with the facility representatives the floor/wing does not contain any patients with particular clinical needs requiring the locking of the stair door against egress.

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.

The finding is:

On 10/14/2020 at 10:20am while accompanied by the MPO, it was observed that exit discharge lighting could not be confirmed to be of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8 7.8 & 7.9.1.3. Due to the clouded condition of the fixture cover it could not be confirmed to be provided with multiple lamps to comply with 7.8.1.4. Location observed: First floor exterior discharge from exit passageway adjacent to Office Building and across from Xray/Diagnostic area.

Based on observation, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The finding is:

On 10/13/2020 at 2:05pm while accompanied by the MPO observation determined that not all critical care areas, where anesthesia is administered, contain battery-powered emergency lights to comply with NFPA 99 2012 6.3.2.2.11.1 and NFPA 70 2011 517-63A.
Example location observed: Second floor Eye Surgery O.R. #4.

Based upon observation, vertical openings beteen floor levels are not protected to maintain separation of floor levels. Failure to maintain separation of floor levels can result in fire/smoke conditions migrating to other floors of the building.

The finding is:

On 10/14/2020 at 9:50am while in the company of the MS two copper pipes were observed penetrating the floor above from the Basement Mechanical Room. These are installed with combustible insulation and fire caulked at the insulation but not on the inside around the copper pipes. This does not resist the passage of smoke/fire to the floor above to comply with 8.6 and 8.3.4.2.

Based on document review and on site observations of hazardous areas, the facility failed to provide separation between hazardous rooms from surrounding areas. This deficient practice could affect patients, staff and visitors if a fire spread without proper fire separation.

Findings include:

A. On 10/14/2020 at 10:05am while accompanied by the MPO doors lack positive latching hardware. Location observed: Pair of corridor doors located across from the first floor Out Patient Surgery suite nurse station leading into the former procedure room (currently used as storage). This room is not indicated as being part of the suite and is a hazardous area, therefore the doors are to be self closing and latching to comply with 19.3.6.3.5 and 19.3.2.1.3.

B. On 10/14/2020 while accompanied by the MPO required means of egress corridors are being used as storage. The large amount of shelving and combustible items compromises the use of the corridors and does not comply with 19.2.5.7.1.3(D) or 8.7.1.1(3) requiring a 1-hour enclosure or sprinkler protection and a smoke proof enclosure. Locations observed:

1. At 10:35am numerous gurneys with mattresses were observed within the First floor Xray/Diagnostic area. The location on the Life Safety drawings indicates enclosing walls, which are not currently in place.

2. At 10:45am numerous shelving, cabinets and equipment were observed within the First floor Xray/Diagnostic area. The location is the south corridor adjacent to the Xray rooms.

3. At 2:10pm numerous shelving, cabinets, cribs and equipment were observed within the Second floor Endoscopy corridors, adjacent to O.R's #1 and #2.

C. On 10/13/2020 at 1:50pm while accompanied by the MPO two rooms were observed being used as equipment and gurney storage. The gurneys contain mattress and each room has approximately 9 gurneys. The rooms lack doors which comply with 19.3.2.1.2, 8.4 and 19.3.2.1.3. Location observed: Second floor Eye Surgery Prep B and Prep C rooms.

Based on observation, not all fire alarm initiating device are not secured from tampering. This deficiency could jeopardise the life safety of the residents, staff and visitors if the fire alarm fails to activate.


The finding is:

On 10/14/2020 at 10:20 am while accompanied by the MS Fire alarm circuit breaker in the main fire panel located in the basement is not mechanically secured to comply with 2010 edition of NFPA 72, 2010- Sections 10.5.5.2 and 10.5.5.3.

Based on observation, the fire pull stations are not properly located. This could affect patients, staff and visitors of the areas served if the fire alarm system does not operate properly during a fire emergency.

The finding is:

On 10/14/2020 at 9:50am, while accompanied by the MPO manual pull stations are not located within 5 feet of the designated exit door to comply with 9.6.2.3. Location observed: First floor Out Patient Surgery suite hallway adjacent to Staff Lockers contains a pull station approximately 22 feet from the designated 2-hour rated exit located at the opposite end of the hallway.

Based on observation, sprinklers are not provided in all spaces to comply as a fully sprinklered building. Failure to install and maintain a fully sprinklered building could compromise the suppression of a fire affecting all occupants of the building in case of fire event.

Findings include:

A. On 10/13/2020 at 2:25pm while accompanied by the MPO a mechanical space was observed which lacks sprinkler protection to comply with NFPA 13-2010, 4.1. Location observed: Second floor Mechanical room adjacent to Surgery Waiting.

B.. On 10/14/2020 at 10:12am while accompanied by the MPO a ceiling pocket was observed which lacks sprinkler protection to comply with all of NFPA 13-2010, 8.8.7. Location observed: MRI exit stair.

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor doors are not properly installed and maintained.

The finding is:

On 10/13/2020 at 1:20pm while accompanied by the MPO, a means of egress corridor door lacked latching hardware to comply with 19.3.6.3.5 for an acceptable means of keeping the door closed.

1. A thumbturn deadbolt is not compliant with 7.2.1.5.10.1 for the height located above the finished floor. This condition exists on all O.R. corridor access doors. Example location: Second floor Surgery area O.R. #7 contains a deadbolt/thumbturn located in excess of 48 inches above the floor.

2. A a releasing mechanism (latch, lock etc) shall open the door having not more than one releasing operation to comply with 7.2.1.5.10.2. This condition does not exist on any O.R. corridor access door. Example location: Second floor Surgery area O.R. #7 contains a deadbolt/thumbturn located separate from the door's latchset thus requiring two motions to exit.

Based on observation, the facility failed to provide access to fire protection appliances within the ventilation duct system. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 10/14/2020 at 11:20am while accompanied by the MPO through wall ducts penetrations with installed fire dampers lack access panels located at a duct for inspection and maintenance of fire dampers. This condition does not comply with NFPA 80-2010, 19.2.3 and 19.2.3.2.
Location observed: First floor 2-hour designated exit passageway located between Emergency Department(ED) and Respiratory. A round insulated duct approx 12 inch diameter penetrates the wall at an ED exam room. The duct is at a 14 foot distance into the passageway.

Based upon observation, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

The finding is:

On 10/14/2020 at 10:15am while in the company of the MPO, a field evaluated U.L. label for fire rated doors lacked any indication as to the fire resistance rating for the pair of doors to comply with 7.2.1.15.3 and NFPA 80 2010, 5.2.1. Location observed: First floor pair of doors from Cardio Rahabilitation, door ID #154546.

Based on observation the facility failed to install a compliant emergency electrical system. Failure to install and maintain these systems could result in delayed response. This deficient practice could affect patients, staff and visitors during a utility power outage.

The finding is:

On 10/14/20 at 11:15am accompanied by the MPO it was observed that a connection of the battery charger for one of four emergency generators was connected at the battery end of the starting cables and not to the primary side of the starter solenoid (positive) and the EPS frame (negative) to comply with NFPA 110, 2010, 7.12.6.2

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

findings include:

A. On 10/13/2020 while accompanied by the MPO critical care patient beds lack electrical receptacles served by normal power to comply with NFPA 70 2011 517-19(A). During discussion with Facility staff it is determined that this condition occurs in numerous locations.

Example location(s) observed:
1. At 11:15am Second floor Operating Room #7

2. At 1:10pm Second floor Out Patient Eye Surgery #1

3. At 11:25am Second floor P.A.C.U.

4. At 10:20am First floor Out Patient Surgery Operating Rooms

B. On 10/13/2020 while accompanied by the MPO general care areas lack electrical receptacles served by normal power to comply with NFPA 70 2011 517-18(A). During discussion with Facility staff it is determined that this condition occurs in numerous locations.

Example location(s) observed:
1. At 9:45am Third floor Post Surgical overflow

2. At 11:18am Second floor typical Med/Surg room - example room #243

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

On 10/13/2020 while accompanied by the MPO, observation determined that electrical receptacles, served by the emergency power system, in critical care areas are not labeled as to electrical panel and circuit as required by NFPA 70 2011 517-19(A). This condition occurs in numerous locations.

Example location: Out Patient Surgery O.R.'s