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A) Based on direct observation on December 11, 2012, with the Hospital Operation Manager and the Executive VP of Quality, also observing and based upon a review of the Construction Documents for the building dated January 2009, the surveyor finds that the Main Lobby of this facility has a three story open stair that connects to the Lower Level, 1st and 2nd Floors. This stair is open to most of the spaces on the 1st and 2nd Floor and it is open to all 1st and 2nd Floor exit access corridors. The stair is shown on drawings with a one hour separation at the Lower Level. This three story open space does not comply with Section 8.2.5 and more specifically it does not comply with with 8.2.5.5, 8.2.5.6, 8.2.5.7 or 8.2.5.8.

Findings include:

1) The stair is open to the 1st Floor, the large lobby space and waiting areas of the 1st Floor and all of the exit access corridors of the 1st Floor which includes at least two means of egress for the 1st Floor PT/OT space.

2) The stair is open to most spaces on the 2nd Floor including all of the exit access corridors. Exit paths to other enclosed exit stairs must travel through spaces exposed to the open stair.

3) No atrium smoke control system was found

4) Although the Lower Level is identified on plans with a one hour fire barrier separation the fire barrier is incomplete and not installed in accordance with 8.2.5 (fire barriers for vertical openings):

a) Corrected 4/11/13.

b) The door to the Teledata Room is a 3/4 hour fire door instead of a one hour B Label door minimum.

c) Corrected 4/11/13.
d) Corrected 4/11/13.
e) Corrected 4/11/13.

f) See also K021

5) Even with 4 "a" through "f" corrected the open stair will still not comply with 8.2.5. Failure to install and maintain vertical opening protection will allow fire to spread throughout multiple floors and multiple spaces in a fire emergency.

A) Based on random observation and the lack of documentation the surveyor finds that emergency means of egress lighting is not maintained in accordance with 7.9.3 of NFPA 101. Findings include:

1) Corrected 04/11/2013.

A) Based on personnel interview, random observation and document review the surveyor finds that the sprinkler system is not tested, serviced and maintained in accordance with NFPA 25:

1) Documentation of quarterly flow testing is incomplete. A quarterly fire alarm report dated October 2012 identifies testing of five or five water flow detection devices. This report lacked specifics. The surveyor was not able to find five water flow detection devices in the building and the Hospital Operations Manager was not able to identify the location of five water flow detection devices. See also K056.

a) A quarterly sprinkler report dated 5/14/12 indicates that some form of flow testing was done; however specific testing with the location of each device and the time from water flow to activation of the fire alarm was not documented.

b) No documentation was available on site that demonstrates flow testing of each flow switch for three of four quarters of 2012 and the last quarter of 2012.

2) No annual documentation of testing, service and maintain was found on site for 2012. The only report available was a report dated 5/14/12 and it was identified as a quarterly report for testing and maintenance.

3) The facility has a dry-pipe sprinkler system at a drive through canopy. The quarterly report dated 5/14/12 references this system but does not clearly indicate that it was tested in accordance with NFPA 13/NFPA 25.

a) The report does not include an annual internal inspection of the dry-pipe valve.

b) An attachment to the report indicates that the required three year full flow test has not been performed as required by NFPA 25, Section 9.4.4.2.2.1.

4) Corrected April 11, 2013.

Failure to maintain the sprinkler system could result in failure during a fire emergency.

A) Based on review of documentation for the previous 11 months, the surveyor finds that the sprinkler systems are not tested, serviced and maintained in accordance with NFPA 13 and NFPA 25-1999.

Findings include;

1) Documentation of quarterly testing of sprinkler flow switches is incomplete. The records are incomplete and do not demonstrate quarterly testing of each flow switch. Documentation with the date or testing, the location of each device, and the time from water flow to activation of the fire alarm was not found.

2) The Documentation for annual testing and service of multiple dry pipe sprinkler systems is incomplete. The documentation available on site for each system does not clearly identify an internal inspection of each dry pipe valve and does not identify the date for the three year full flood test that is required.

The above find includes but is not limited to the system that protects the ambulance bay and the MRI system.

Failure to test and maintain the sprinkler system could result in failure during a fire.