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Based on observation during the survey walk-through, staff interview and review of facility provided information; the construction type of the building does not comply with requirements. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

A. On 4/12/16 at 10:50 AM, while accompanied by ADF and MO, in the South Basement, of the Material Management, the structural steel beam for the floor deck above was not protected or spray -on fire proofing was not provided to maintain the identified Type II (222) construction type in accordance with NFPA 101-2000, 19.1.6.2 and NFPA 220.

B. On 04/19/2016 at 2:26 PM, accompanied by DFM and PM, compressed wood decking was observed to be a part of the floor ceiling assembly in Machine Room 10. This is not in compliance with 19.1.6.2.

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A. During the survey walk-through it was observed that exit signs did not identify a continuous path of egress in all cases. This deficiency could affect any patients, staff, or visitors in the cited area by preventing them from safely exiting the building under fire conditions.

Findings include:

1. On 04/18/16 at 2:15 PM, while accompanied by the ADF and PM, 2 North, Second Floor the IMCU (Step Down Unit), the exit access corridor near the IMCU 23N lacks exit signage to identify a 2nd path of exit.

2. On 04/19/2016, accompanied by DFM and PM, it was observed that the following locations lacked exit signage that identifies a second means of egress as required by 19.2.10.1:

Locations include:

a. At 9:27 AM, in the north basement at the cross corridor doors in the MRI corridor near Pulmonary Rehab.
b. At 2:15 PM, in the basement at the cross corridor doors located near the phone switch.

3. On 04/19/16 at 10:30 AM, while accompanied by the ADF and MO, 1 Northwest, First Floor Recovery Suite located across the OR#22 and OR#24, exit signage(s) is not provided to define the available path of egress to exit. This does not comply with 19.2.10.1.
4. On 04/19/16 at 11:05 AM, while accompanied by the ADF and MO, 1 Northeast, First Floor the exit access corridor outside the Microbiology Lab lacks exit signage to identify access to two available exits. This does not comply with 19.2.5.9.
5. On 04/19/16 at 10:45 AM, while accompanied by the ADF and MO, 1 Northeast, First Floor Medical Records lacks exit signage, which the path of egress to an exit is not identifiable.

B. On 04/19/2016 at 10:15 AM, accompanied by DFM and PM, it was observed that on the first floor Stair 13 is signed as an exit, but within the stair signage directs the path of egress to the first floor, not to the basement, which is the level of exit discharge for this stair. This does not comply with 19.2.10.1.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and building ' s exit access corridors.

Findings include:

A. On 04/18/16 at 12:40 PM, while accompanied by the ADF and the PM, 4 South, 4th Floor Med/Surg Unit, the Visitor ' s Lounge (401S) which is greater than 100 square feet, non sprinklered room is being used as storage for beds, etc., which is not provided with one hour fire enclosure and the door is not fire rated. This does not comply with 19.3.2.1 and 8.4.1.

B. On 04/18/16 at 1:25 PM, while accompanied by the ADF and the PM, 3 South, Third Floor Med/Surg Unit, the Patient Room 310 is being used for storage, which the area was not provided with sprinkler protection or was not otherwise enclosed with one hour fire rated construction and the door to this room is not fire rated. This does not comply with 19.3.2.1 and 8.4.1.

C. On 04/19/16 at 9:15 AM, while accompanied by the ADF and the MO, I Northwest on the First Floor, the door to the Equipment Storage Room near the OR #23 did not self close.

During the survey walk through, it was observed that the facility failed to provide exit enclosures with a minimum one hour fire rated construction. This deficiency would affect all building occupants by permitting fire and smoke to enter the exit enclosure, thus rendering it unusable.

Findings include:

A. On 04/18/2016 at 2:25 PM, accompanied by DFM and MO, at the first floor exit passageway serving Stair 9, it was observed that ducts penetrating the fire rated walls above the south pair of cross corridor doors west of the Employee Lounge are not provided with fire dampers as required by 7.1.3.2.1 Exception No. 1 and 8.2.3.2.4.

B. At the dates and times indicated, accompanied by DFM, MO, and PM, doors in the exit enclosures noted were observed to be fitted with metal plates where the hardware has been removed or have unsealed penetrations. During staff interview it could not be determined whether the required fire rating of the doors has been maintained.

1. On 04/18/2016 at 2:38 PM, the abandoned door between the first floor exit passageway serving Stair 12 and Vascular Testing C.
2. On 04/19/2016 at 10:15 AM, the first floor door into Stair 13.
3. On 04/19/2016 at 10:24 AM, the door between the basement exit passageway serving Stair 13 and Diabetes Education.

C. On 04/19/2016 at 10:22 AM, accompanied by DFM and PM, in the basement exit passageway that serves Stair 13 it was observed that the top of the fire rated wall over the cross corridor doors is not properly sealed as required by 8.2.2.2.

During the survey walk-through it was observed that not all exit stairs are constructed in a way that promotes safe usage. These deficiencies could affect any patients, staff, or visitors in the building by creating a tripping or falling hazard during evacuation of the building under emergency conditions.

Findings include:

On 04/19/2016 at 12:33 PM, accompanied by DFM and MO, it was observed that Stair 5, which serves floors 2, 1, and the basement of the south Main Building, has been constructed so that the stair flights are greater than 1 foot apart and has guard rails that have a top and intermediate rail only, not the multiple rails spaced as required by 7.2.2.4.6(3).

Based on observation, document review and staff interview, travel distances required within suites of rooms to the exit access corridors have exceeded the 100 feet permitted for one intervening room and the 50 feet allowed for two intervening rooms. This deficiency could affect any patients and the staff in the suites of rooms by preventing them from reaching an exit or exit access corridors under fire conditions.

Findings include:

A. On 04/19/16 at 8:45 AM, while accompanied by the ADF and MO, 1 Northeast First Floor OR Suite, the identified 127 feet travel distance as shown on the Life Safety Plan from the Operating Room #6, exceeds the 100 feet limit for one intervening to reach the designated exit access. This does not comply with 19.2.5.8.

B. On 04/18/16 at 2:00 PM, while accompanied by the ADF and PM, 2 North Second Floor ICU Suite, the identified travel distance shown on the Life Safety Plan from the ICU Head Nurse Room exceeds the 50 feet permitted, the egress has to pass through 3 intervening spaces to reach the exit access corridor. This does not comply with 19.2.5.8.

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On 04/18/16, on the Second Floor of the ICU Suite, while accompanied by the ADF and PM, in the 2 North, egress doors were observed that are equipped with magnetic locking devices. Magnetic locking devices are not in compliance with the general requirements of 19.2.2.2.4. Example:

1. At 2:40 PM, at the Room ICU 6N egress double doors
2. At 2:45 PM, at the ICU Wait Lounge door near the ICU Supply Room.

B. On 04/18/2016, accompanied by DFM and MO, it was observed that delayed egress locks have been installed at the locations listed below. Delayed egress locks are only permitted by 7.2.1.6.1 to be installed in buildings that are fully protected by a sprinkler system or by smoke detection. The Main Building is only partially sprinklered and detected.

1. At 1:55 PM, at the Labor and Delivery exit doors.
2. At 3:00 PM, at the Emergency Room corridor near the waiting area.

C. On 04/19/2016 at 10:06 AM, accompanied by DFM and PM, it was observed that the exit access door at the basement MRI Suite has both a thumb turn dead bolt and an electric lockset, thus requiring two operations to open the door when locked. This does not comply with 7.2.1.5.4.

D. On 04/19/2016 at 11:20 AM, accompanied by DFM and PM, it was observed that the vestibule that serves as the only path of egress from the OR Men ' s Locker Room is furnished with two exit access doors, one of which has no operating hardware, and the other, which is marked with an exit sign, is blocked when the adjacent stair door is open, which does not comply with 7.1.10.1.

E. On 04/19/16 at 11:00 AM, while accompanied by the ADF and MO, 1 Northeast, First Floor - Blood Bank Suite, the designated egress path from the Blood Draw Rooms and the Janitor ' s Closet aisle is leading into a hazardous Laboratory Unit. This does not comply with 19.2.5.5.

F. On 04/19/16 at 10:25 AM, while accompanied be the ADF and MO, 1 Northeast, First Floor - Laboratory Unit lacks exit access door to the corridor, egress to exit is gained through the intervening aisle of the Blood Bank Suite. This does not comply with 19.2.5.1.



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During the survey walk-through it was observed that not all exit access doors are the required width. This deficiency could impede the ability of patients, staff, and visitors to exit the room quickly in the event of a fire.

Findings include:

On 04/19/2016 at 12:35, accompanied by DFM and PM, it was observed that the exit access door from the Chapel is provided with a pair of approximately 18 inch leafs. One of the leafs is required by 7.2.1.2.3 Exception No. 3 to be 28 inches in width.

Based on observation and documetn review the surveyor noted designated suites (as shown on the facility life safety plan), which exceed the 10,000 square feet for non patient sleeping rooms and the 5,000 square feet for suites of sleeping rooms. This deficiency could affect any patients, and staff and visitors in the suites of rooms by preventing them from reaching an exit under fire conditions.

Findings include:

A. On 04/19/16 at 2:05 PM, 2 North, Second Floor ICU Suite the identified 6,187 square feet (as shown on the Life Safety Plan), exceeds the 5,000 square footage allowed, which this does not comply with 19.2.5.6. See also K036.

B. On 04/18/16 at 8:35 AM, 1 northeast First Floor OR Suite the identified 11,906 square feet (as shown on the Life safety Plan), exceeds the 10,000 square footage allowed, which this does not comply with 19.2.5.7. See also K036.

During the survey walk-through it was observed that the path of egress in the basement passes from the Main Building into the adjacent MOC1, which is a business occupancy, and that the 2 hour rated separation wall is not constructed and equipped as a horizontal exit. This deficiency could affect patients and staff by compromising the horizontal exit.

Findings include:

A. On 04/19/2017 at 9:17 AM, accompanied by DFM and PM, it was observed that the horizontal exit near Mechanical Room #12 lacks a fire alarm pull at the cross corridor doors, which does not comply with 19.3.4.1 and 9.6.2.3.

B. On 04/19/2016, accompanied by DFM and PM, it was observed that the 2 hour rated wall at the horizontal exit between the Main Building and the MOC1 in the basement is not properly fire sealed as required by 8.2.2.2 at the locations identified below:

1. At 9:20 AM, at the top of the wall and beam penetration above the cross corridor doors.
2. At 9:24 AM, at the beam penetration and perimeter of the west wall of the storage room adjacent to the cross corridor doors.

During the survey walk-through it was observed that not all exit signs are illuminated by the EES. This deficiency could affect patients and staff by permitting the direction of egress to become unclear during a loss of power.

Findings include:

On 04/19/2016, accompanied by DFM and PM, exit lights were observed to not be illuminated as required by 7.10.5.2 at the locations identified below:

1. At 10:31 AM, in the vestibule outside of the OR Men ' s Locker Room.
2. At 10:42 AM, in the Nuclear Med department.

During the document review process it was observed that the Provider ' s Fire Plan does not clearly direct staff in the proper use of the RACE procedure. This deficiency could affect patients and staff in the event of a fire and staff failing to follow the policy correctly.

Findings include:

On 04/19/2016 at 12:47 PM, accompanied by DFM and FMC, it was observed that the Provider ' s Fire Plan, in the description of the RACE acronym, contained the following statement under the " A - Alarm " procedure: " Simulate building ' s fire alarm system activation after visiting hours " . Activation of the fire alarm is required by 19.7.2.1.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with code. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. On 04/18/16, at 12:35 AM, while accompanied by the ADF and PM, 4 South, on the 4th Floor Med/Surge Unit, , the surveyor observed a smoke detector in the Soiled Utility Room , which is located within 3'-0" of a supply air diffuser. This does not comply with NFPA 72 1999 2-3.5.1.

During the survey walk-through it was observed that not all ceilings are maintained as required to permit proper activation of the sprinkler system. This deficiency could affect patients and staff in the event that a fire did not activate the sprinklers.

Findings include:

On 04/19/2016, accompanied by DFM and PM, the listed locations were observed to not be furnished with a complete finished ceiling and the sprinkler heads were observed to be located more than the 12 inches below the floor structure above, which does not comply with NFPA 13 1999 5-6.4.1.1.

1. At 10:02 AM, at the MRI Mechanical Room.
2. At 10:27 AM, at the shell space located in the Cardiac Rehab unit.

Based on observation, the facility failed to provide a proper electrical service to the fire pump. This could effect anyone in the portion of the building served from this fire pump if normal power failed during a fire.


Findings include:

A. On 4/19/16 at 10:30 am, while accompanied by OS, the surveyor observed that two of the fire pumps were not equipped with the four alarm points required by NFPA-20, Section 7-4.7: a) loss of phase, b) pump running, c) phase reversal, and d) connected to emergency source of power.

B. On 4/19/16 at 9:40 am, while accompanied by the OS, the surveyor observed that the fire pump in the expansion was not served by the emergency generator to meet the requirements of NFPA-20.

Based on observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are not installed in accordance with code. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

Findings include:

A. On 04/18/16 at 12:50 PM, while accompanied by the ADF and PM, the Duct penetrations through the walls of 2 hour fire rated ventilation shafts were observed, which lack of fire dampers required by 8.2.3.2.4.1 and NFPA 90A 1999 3-3.4.1. Locations observed include:

1. 4th Floor Med / Surge Unit, the shaft by the Center Stairwell #2.

2. 3rd Floor Med / Surge Unit (Oncology), the shaft by the Center Stairwell #2.

Based on observation and document review, the surveyor finds the facility failed to protect cooking facilities in accordance with code. This deficiency could affect all occupants of the building in case of a fire emergency.

A. On 04/19/16At 9:45am while accompanied by the Lead Mechanic/Operator, the surveyor observed, the manual means for activating the fire suppression system is not in a readily identifiable and accessible location for the cafeteria grill. The manual pull station is located in the adjacent kitchen hidden from view of the cafeteria grill. NFPA 96, 1998, 7-5.1

B. On 04/19/16 at 9:50am while accompanied by the Lead Mechanic/Operator, the surveyor observed, the portable Class K fire extinguisher for use as the secondary backup to the cooking exhaust hood suppression system is not readily identifiable and accessible. The only Class K fire extinguisher located in the kitchen is hidden from view of the hood location and is used to service both the kitchen and cafeteria. The fire extinguisher accessible and adjacent to the manual pull station for the kitchen hood suppression system is of the wrong class for use on combustible cooking media. NFPA 10, 1998, 2-3.2

C. On 4/19/16 at 9:55am while accompanied by the Lead Mechanic/Operator, the surveyor reviewed, for the Kitchen & Cafeteria, the monthly inspection of the cooking hood fire suppression system are not conducted/documented per NFPA 1998, 17 9.2 / 17A 5.2.

Based on observation during the survey walk through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

Locations observed include:

A. On 04/19/16 at 8:45 AM, 1 Northwest, First Floor while accompanied by the ADF and MO, the GI back corridor contain equipment, patient bed and supplies, which access to Stair # 25 from the corridor was observed to be partially blocked and is not maintained for the convenient removal of patients. This does not comply with 19.2.3.3 and 7.1.10.2.1.

B. On 04/19/16 at 9:00 AM, 1 Northwest, First Floor, while accompanied by the ADF and MO, the exit access leading to the Exit Stair #21 near the Surgical Supplies Room was observed with stored carts and linen supplies, which blocked the required path of egress. This does not comply with 19.2.3.3 and 7.1.10.2.1.

Based on observations it was determined that the facility did not maintain the medical gas systems. This deficient practice could affect patients, staff and visitors if a delay in staff response during an emergency with the medical gas system occured.

Findings include:


A. On 04/18/16 at 1:30pm, in the company of the facility ' s Lead Mechanic/Operator, the surveyor observed in the GI lab, that the separation of medical gas zone control valves from supplied outlets and inlets is not done per NFPA 99, 1999, 4-3.1.2.3 (d).

B. On 04/19/2016 at 11:04 AM, accompanied by DFM and PM, medical gas valves serving the Clinical Engineering Department were observed to not be labeled as to the location they serve as required by NFPA 99 1999 4-3.1.2.14(b)(3)

Based on observation, the facility failed to maintain a proper emergency power system. If the generator fails to operate upon the loss of normal power, this could affect all occupants of the building.

Findings Include:

A. On 4/18/16 at 2:15 pm, while accompanied by the OS, the surveyor observed the emergency generator annunciator is not located at a 24 hour staffed location in accordance with the 1999 addition of NFPA-110, Section 3-5.6.1.

This STANDARD is not met as evidenced by:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute the 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 observation, the facility failed to provide a proper electrical system. This could effect any patient if a transfer switch failed.

Findings include:

1. On 4/18/16 at 1:10 pm, while accompanied by the OS, the surveyor observed the following areas were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 1999 Edition of NFPA-99, Section 3-3.2.1.2(a)1.

a. The operating rooms
b. ICU and IMCU rooms
c. GI procedure rooms
c. Nursery headwalls

2. On 4/18/16 at 1:30 pm, while accompanied by the OS, the surveyor observed that the elevator equipment rooms were not equipped with a lighting disconnect served from the life safety branch of emergency power in accordance with the 1999 Edition of NFPA-70, Section 620-22, and Section 517-32.

Based on observation the facility failed to provide an elevator recall system. This could effect anybody using the elevator during a fire.

Findings include:

On 4/18/16 at 2:30 pm, while accompanied by the OS, the surveyor observed that Elevators J and K were not equipped with smoke detectors in the elevator equipment room tied to a recall system to meet the requirements of ANSI/ASME A 17.1.

Based on observation during the survey walk-through, staff interview and review of facility provided information; the construction type of the building does not comply with requirements. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

A. On 4/12/16 at 10:50 AM, while accompanied by ADF and MO, in the South Basement, of the Material Management, the structural steel beam for the floor deck above was not protected or spray -on fire proofing was not provided to maintain the identified Type II (222) construction type in accordance with NFPA 101-2000, 19.1.6.2 and NFPA 220.

B. On 04/19/2016 at 2:26 PM, accompanied by DFM and PM, compressed wood decking was observed to be a part of the floor ceiling assembly in Machine Room 10. This is not in compliance with 19.1.6.2.

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A. During the survey walk-through it was observed that exit signs did not identify a continuous path of egress in all cases. This deficiency could affect any patients, staff, or visitors in the cited area by preventing them from safely exiting the building under fire conditions.

Findings include:

1. On 04/18/16 at 2:15 PM, while accompanied by the ADF and PM, 2 North, Second Floor the IMCU (Step Down Unit), the exit access corridor near the IMCU 23N lacks exit signage to identify a 2nd path of exit.

2. On 04/19/2016, accompanied by DFM and PM, it was observed that the following locations lacked exit signage that identifies a second means of egress as required by 19.2.10.1:

Locations include:

a. At 9:27 AM, in the north basement at the cross corridor doors in the MRI corridor near Pulmonary Rehab.
b. At 2:15 PM, in the basement at the cross corridor doors located near the phone switch.

3. On 04/19/16 at 10:30 AM, while accompanied by the ADF and MO, 1 Northwest, First Floor Recovery Suite located across the OR#22 and OR#24, exit signage(s) is not provided to define the available path of egress to exit. This does not comply with 19.2.10.1.
4. On 04/19/16 at 11:05 AM, while accompanied by the ADF and MO, 1 Northeast, First Floor the exit access corridor outside the Microbiology Lab lacks exit signage to identify access to two available exits. This does not comply with 19.2.5.9.
5. On 04/19/16 at 10:45 AM, while accompanied by the ADF and MO, 1 Northeast, First Floor Medical Records lacks exit signage, which the path of egress to an exit is not identifiable.

B. On 04/19/2016 at 10:15 AM, accompanied by DFM and PM, it was observed that on the first floor Stair 13 is signed as an exit, but within the stair signage directs the path of egress to the first floor, not to the basement, which is the level of exit discharge for this stair. This does not comply with 19.2.10.1.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and building ' s exit access corridors.

Findings include:

A. On 04/18/16 at 12:40 PM, while accompanied by the ADF and the PM, 4 South, 4th Floor Med/Surg Unit, the Visitor ' s Lounge (401S) which is greater than 100 square feet, non sprinklered room is being used as storage for beds, etc., which is not provided with one hour fire enclosure and the door is not fire rated. This does not comply with 19.3.2.1 and 8.4.1.

B. On 04/18/16 at 1:25 PM, while accompanied by the ADF and the PM, 3 South, Third Floor Med/Surg Unit, the Patient Room 310 is being used for storage, which the area was not provided with sprinkler protection or was not otherwise enclosed with one hour fire rated construction and the door to this room is not fire rated. This does not comply with 19.3.2.1 and 8.4.1.

C. On 04/19/16 at 9:15 AM, while accompanied by the ADF and the MO, I Northwest on the First Floor, the door to the Equipment Storage Room near the OR #23 did not self close.

During the survey walk through, it was observed that the facility failed to provide exit enclosures with a minimum one hour fire rated construction. This deficiency would affect all building occupants by permitting fire and smoke to enter the exit enclosure, thus rendering it unusable.

Findings include:

A. On 04/18/2016 at 2:25 PM, accompanied by DFM and MO, at the first floor exit passageway serving Stair 9, it was observed that ducts penetrating the fire rated walls above the south pair of cross corridor doors west of the Employee Lounge are not provided with fire dampers as required by 7.1.3.2.1 Exception No. 1 and 8.2.3.2.4.

B. At the dates and times indicated, accompanied by DFM, MO, and PM, doors in the exit enclosures noted were observed to be fitted with metal plates where the hardware has been removed or have unsealed penetrations. During staff interview it could not be determined whether the required fire rating of the doors has been maintained.

1. On 04/18/2016 at 2:38 PM, the abandoned door between the first floor exit passageway serving Stair 12 and Vascular Testing C.
2. On 04/19/2016 at 10:15 AM, the first floor door into Stair 13.
3. On 04/19/2016 at 10:24 AM, the door between the basement exit passageway serving Stair 13 and Diabetes Education.

C. On 04/19/2016 at 10:22 AM, accompanied by DFM and PM, in the basement exit passageway that serves Stair 13 it was observed that the top of the fire rated wall over the cross corridor doors is not properly sealed as required by 8.2.2.2.

During the survey walk-through it was observed that not all exit stairs are constructed in a way that promotes safe usage. These deficiencies could affect any patients, staff, or visitors in the building by creating a tripping or falling hazard during evacuation of the building under emergency conditions.

Findings include:

On 04/19/2016 at 12:33 PM, accompanied by DFM and MO, it was observed that Stair 5, which serves floors 2, 1, and the basement of the south Main Building, has been constructed so that the stair flights are greater than 1 foot apart and has guard rails that have a top and intermediate rail only, not the multiple rails spaced as required by 7.2.2.4.6(3).

Based on observation, document review and staff interview, travel distances required within suites of rooms to the exit access corridors have exceeded the 100 feet permitted for one intervening room and the 50 feet allowed for two intervening rooms. This deficiency could affect any patients and the staff in the suites of rooms by preventing them from reaching an exit or exit access corridors under fire conditions.

Findings include:

A. On 04/19/16 at 8:45 AM, while accompanied by the ADF and MO, 1 Northeast First Floor OR Suite, the identified 127 feet travel distance as shown on the Life Safety Plan from the Operating Room #6, exceeds the 100 feet limit for one intervening to reach the designated exit access. This does not comply with 19.2.5.8.

B. On 04/18/16 at 2:00 PM, while accompanied by the ADF and PM, 2 North Second Floor ICU Suite, the identified travel distance shown on the Life Safety Plan from the ICU Head Nurse Room exceeds the 50 feet permitted, the egress has to pass through 3 intervening spaces to reach the exit access corridor. This does not comply with 19.2.5.8.

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On 04/18/16, on the Second Floor of the ICU Suite, while accompanied by the ADF and PM, in the 2 North, egress doors were observed that are equipped with magnetic locking devices. Magnetic locking devices are not in compliance with the general requirements of 19.2.2.2.4. Example:

1. At 2:40 PM, at the Room ICU 6N egress double doors
2. At 2:45 PM, at the ICU Wait Lounge door near the ICU Supply Room.

B. On 04/18/2016, accompanied by DFM and MO, it was observed that delayed egress locks have been installed at the locations listed below. Delayed egress locks are only permitted by 7.2.1.6.1 to be installed in buildings that are fully protected by a sprinkler system or by smoke detection. The Main Building is only partially sprinklered and detected.

1. At 1:55 PM, at the Labor and Delivery exit doors.
2. At 3:00 PM, at the Emergency Room corridor near the waiting area.

C. On 04/19/2016 at 10:06 AM, accompanied by DFM and PM, it was observed that the exit access door at the basement MRI Suite has both a thumb turn dead bolt and an electric lockset, thus requiring two operations to open the door when locked. This does not comply with 7.2.1.5.4.

D. On 04/19/2016 at 11:20 AM, accompanied by DFM and PM, it was observed that the vestibule that serves as the only path of egress from the OR Men ' s Locker Room is furnished with two exit access doors, one of which has no operating hardware, and the other, which is marked with an exit sign, is blocked when the adjacent stair door is open, which does not comply with 7.1.10.1.

E. On 04/19/16 at 11:00 AM, while accompanied by the ADF and MO, 1 Northeast, First Floor - Blood Bank Suite, the designated egress path from the Blood Draw Rooms and the Janitor ' s Closet aisle is leading into a hazardous Laboratory Unit. This does not comply with 19.2.5.5.

F. On 04/19/16 at 10:25 AM, while accompanied be the ADF and MO, 1 Northeast, First Floor - Laboratory Unit lacks exit access door to the corridor, egress to exit is gained through the intervening aisle of the Blood Bank Suite. This does not comply with 19.2.5.1.



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During the survey walk-through it was observed that not all exit access doors are the required width. This deficiency could impede the ability of patients, staff, and visitors to exit the room quickly in the event of a fire.

Findings include:

On 04/19/2016 at 12:35, accompanied by DFM and PM, it was observed that the exit access door from the Chapel is provided with a pair of approximately 18 inch leafs. One of the leafs is required by 7.2.1.2.3 Exception No. 3 to be 28 inches in width.

Based on observation and documetn review the surveyor noted designated suites (as shown on the facility life safety plan), which exceed the 10,000 square feet for non patient sleeping rooms and the 5,000 square feet for suites of sleeping rooms. This deficiency could affect any patients, and staff and visitors in the suites of rooms by preventing them from reaching an exit under fire conditions.

Findings include:

A. On 04/19/16 at 2:05 PM, 2 North, Second Floor ICU Suite the identified 6,187 square feet (as shown on the Life Safety Plan), exceeds the 5,000 square footage allowed, which this does not comply with 19.2.5.6. See also K036.

B. On 04/18/16 at 8:35 AM, 1 northeast First Floor OR Suite the identified 11,906 square feet (as shown on the Life safety Plan), exceeds the 10,000 square footage allowed, which this does not comply with 19.2.5.7. See also K036.

During the survey walk-through it was observed that the path of egress in the basement passes from the Main Building into the adjacent MOC1, which is a business occupancy, and that the 2 hour rated separation wall is not constructed and equipped as a horizontal exit. This deficiency could affect patients and staff by compromising the horizontal exit.

Findings include:

A. On 04/19/2017 at 9:17 AM, accompanied by DFM and PM, it was observed that the horizontal exit near Mechanical Room #12 lacks a fire alarm pull at the cross corridor doors, which does not comply with 19.3.4.1 and 9.6.2.3.

B. On 04/19/2016, accompanied by DFM and PM, it was observed that the 2 hour rated wall at the horizontal exit between the Main Building and the MOC1 in the basement is not properly fire sealed as required by 8.2.2.2 at the locations identified below:

1. At 9:20 AM, at the top of the wall and beam penetration above the cross corridor doors.
2. At 9:24 AM, at the beam penetration and perimeter of the west wall of the storage room adjacent to the cross corridor doors.

During the survey walk-through it was observed that not all exit signs are illuminated by the EES. This deficiency could affect patients and staff by permitting the direction of egress to become unclear during a loss of power.

Findings include:

On 04/19/2016, accompanied by DFM and PM, exit lights were observed to not be illuminated as required by 7.10.5.2 at the locations identified below:

1. At 10:31 AM, in the vestibule outside of the OR Men ' s Locker Room.
2. At 10:42 AM, in the Nuclear Med department.

During the document review process it was observed that the Provider ' s Fire Plan does not clearly direct staff in the proper use of the RACE procedure. This deficiency could affect patients and staff in the event of a fire and staff failing to follow the policy correctly.

Findings include:

On 04/19/2016 at 12:47 PM, accompanied by DFM and FMC, it was observed that the Provider ' s Fire Plan, in the description of the RACE acronym, contained the following statement under the " A - Alarm " procedure: " Simulate building ' s fire alarm system activation after visiting hours " . Activation of the fire alarm is required by 19.7.2.1.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with code. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. On 04/18/16, at 12:35 AM, while accompanied by the ADF and PM, 4 South, on the 4th Floor Med/Surge Unit, , the surveyor observed a smoke detector in the Soiled Utility Room , which is located within 3'-0" of a supply air diffuser. This does not comply with NFPA 72 1999 2-3.5.1.

During the survey walk-through it was observed that not all ceilings are maintained as required to permit proper activation of the sprinkler system. This deficiency could affect patients and staff in the event that a fire did not activate the sprinklers.

Findings include:

On 04/19/2016, accompanied by DFM and PM, the listed locations were observed to not be furnished with a complete finished ceiling and the sprinkler heads were observed to be located more than the 12 inches below the floor structure above, which does not comply with NFPA 13 1999 5-6.4.1.1.

1. At 10:02 AM, at the MRI Mechanical Room.
2. At 10:27 AM, at the shell space located in the Cardiac Rehab unit.

Based on observation, the facility failed to provide a proper electrical service to the fire pump. This could effect anyone in the portion of the building served from this fire pump if normal power failed during a fire.


Findings include:

A. On 4/19/16 at 10:30 am, while accompanied by OS, the surveyor observed that two of the fire pumps were not equipped with the four alarm points required by NFPA-20, Section 7-4.7: a) loss of phase, b) pump running, c) phase reversal, and d) connected to emergency source of power.

B. On 4/19/16 at 9:40 am, while accompanied by the OS, the surveyor observed that the fire pump in the expansion was not served by the emergency generator to meet the requirements of NFPA-20.

Based on observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are not installed in accordance with code. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

Findings include:

A. On 04/18/16 at 12:50 PM, while accompanied by the ADF and PM, the Duct penetrations through the walls of 2 hour fire rated ventilation shafts were observed, which lack of fire dampers required by 8.2.3.2.4.1 and NFPA 90A 1999 3-3.4.1. Locations observed include:

1. 4th Floor Med / Surge Unit, the shaft by the Center Stairwell #2.

2. 3rd Floor Med / Surge Unit (Oncology), the shaft by the Center Stairwell #2.

Based on observation and document review, the surveyor finds the facility failed to protect cooking facilities in accordance with code. This deficiency could affect all occupants of the building in case of a fire emergency.

A. On 04/19/16At 9:45am while accompanied by the Lead Mechanic/Operator, the surveyor observed, the manual means for activating the fire suppression system is not in a readily identifiable and accessible location for the cafeteria grill. The manual pull station is located in the adjacent kitchen hidden from view of the cafeteria grill. NFPA 96, 1998, 7-5.1

B. On 04/19/16 at 9:50am while accompanied by the Lead Mechanic/Operator, the surveyor observed, the portable Class K fire extinguisher for use as the secondary backup to the cooking exhaust hood suppression system is not readily identifiable and accessible. The only Class K fire extinguisher located in the kitchen is hidden from view of the hood location and is used to service both the kitchen and cafeteria. The fire extinguisher accessible and adjacent to the manual pull station for the kitchen hood suppression system is of the wrong class for use on combustible cooking media. NFPA 10, 1998, 2-3.2

C. On 4/19/16 at 9:55am while accompanied by the Lead Mechanic/Operator, the surveyor reviewed, for the Kitchen & Cafeteria, the monthly inspection of the cooking hood fire suppression system are not conducted/documented per NFPA 1998, 17 9.2 / 17A 5.2.

Based on observation during the survey walk through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

Locations observed include:

A. On 04/19/16 at 8:45 AM, 1 Northwest, First Floor while accompanied by the ADF and MO, the GI back corridor contain equipment, patient bed and supplies, which access to Stair # 25 from the corridor was observed to be partially blocked and is not maintained for the convenient removal of patients. This does not comply with 19.2.3.3 and 7.1.10.2.1.

B. On 04/19/16 at 9:00 AM, 1 Northwest, First Floor, while accompanied by the ADF and MO, the exit access leading to the Exit Stair #21 near the Surgical Supplies Room was observed with stored carts and linen supplies, which blocked the required path of egress. This does not comply with 19.2.3.3 and 7.1.10.2.1.

Based on observations it was determined that the facility did not maintain the medical gas systems. This deficient practice could affect patients, staff and visitors if a delay in staff response during an emergency with the medical gas system occured.

Findings include:


A. On 04/18/16 at 1:30pm, in the company of the facility ' s Lead Mechanic/Operator, the surveyor observed in the GI lab, that the separation of medical gas zone control valves from supplied outlets and inlets is not done per NFPA 99, 1999, 4-3.1.2.3 (d).

B. On 04/19/2016 at 11:04 AM, accompanied by DFM and PM, medical gas valves serving the Clinical Engineering Department were observed to not be labeled as to the location they serve as required by NFPA 99 1999 4-3.1.2.14(b)(3)

Based on observation, the facility failed to maintain a proper emergency power system. If the generator fails to operate upon the loss of normal power, this could affect all occupants of the building.

Findings Include:

A. On 4/18/16 at 2:15 pm, while accompanied by the OS, the surveyor observed the emergency generator annunciator is not located at a 24 hour staffed location in accordance with the 1999 addition of NFPA-110, Section 3-5.6.1.

This STANDARD is not met as evidenced by:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute the 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 observation, the facility failed to provide a proper electrical system. This could effect any patient if a transfer switch failed.

Findings include:

1. On 4/18/16 at 1:10 pm, while accompanied by the OS, the surveyor observed the following areas were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 1999 Edition of NFPA-99, Section 3-3.2.1.2(a)1.

a. The operating rooms
b. ICU and IMCU rooms
c. GI procedure rooms
c. Nursery headwalls

2. On 4/18/16 at 1:30 pm, while accompanied by the OS, the surveyor observed that the elevator equipment rooms were not equipped with a lighting disconnect served from the life safety branch of emergency power in accordance with the 1999 Edition of NFPA-70, Section 620-22, and Section 517-32.

Based on observation the facility failed to provide an elevator recall system. This could effect anybody using the elevator during a fire.

Findings include:

On 4/18/16 at 2:30 pm, while accompanied by the OS, the surveyor observed that Elevators J and K were not equipped with smoke detectors in the elevator equipment room tied to a recall system to meet the requirements of ANSI/ASME A 17.1.