HospitalInspections.org

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. Room # A468, there were penetrations in rated walls that were not properly sealed to maintain the required fire rating of the walls.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 8th Floor, North Tower,- Hemo, Corridor door with self closing device held open with Electro-Magnetic device , did not close upon activation of Fire Alarm as required.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. The corridor door to Reception Room @ Clerical Room was held open with wooden wedge.

2. Adult ED/ Fast Track - Corridor door to clean utility room held open with rubber glove.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. The fire door to the eight floor diverter shaft 125 is not self-closing and latching.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The access door to the vertical chase is not a listed self-closing and latching fire door - located in room 4D085.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. There is a hole in the smoke barrier wall above doors 904A.

Based on observation, on April 28, 2011 at approximately 8:00am onward:

1. The combination fire and smoke curtain did not close with activation of ceiling smoke detectors adjacent to the required smoke barrier.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 4 th Floor - Cross Corridor smoke doors ( # 077B) and (# A457) did not close for smoke tight seal when tested.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 8th floor, Cross Corridor smoke doors (#8 B 116) and at ICU-4C, 4th floor did not close on activation of Fire Alarm.

Based on observation, on April 26, 2011 at approximately 7:30 am onward,

1. There are holes in the door to housekeeping room M055 - the door equipped with a hasp that prevents exiting from inside the room.

2. Electrical rooms R-701 & 702 - 2-hr rated walls - There was no fire damper in Exhaust duct thru walls.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The special locking arrangements for selected doors are noncompliant based upon the following:

a. lack of complete installation in accordance with required building codes - locks at doors 40075C and CCU (7th floor) are not provided with a master release on/off switch at a supervised nurse's station.

2. 6th Floor , Stairwell #61, Exit door equipped with Mag- locks did not release with activation of Fire Alarm, the door did release with over ride switch at door. This must be corrected immediately.

Based on observation from Monday 4/25/2011 at approx 1:00 PM onward:

K32 - special locking arrangements are incomplete in the following areas:
1. exit near second floor elevators - no on/off switches adjacent to doors, no wiring diagram posted at fire alarm control panel, and no master release switch at a supervised station.
2. access controlled locks at cross corridor doors near stair #2 - no sensor is provided in accordance with Life Safety Code.
3. no master release switch for first floor electromagnetic locks near stair #2.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 2nd Floor - Exit door next to #214 equipped with magnetic locking device did not release with emergency over ride switch, it did release with FA.

2. Exit door equipped with Mag- locks did not release with activation of Fire Alarm, the door did release with over ride switch at door. This must be corrected immediately.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 9th Floor - 400 A Wing - Panic Hardware would not release door under normal operation. This door is equipped with NC Special (Mag) Locking.

2. Ground Level , Exit door to Cancer Center is equipped with NC Special (Mag) locking - There is no master release switch at manned Nursing Station.

3. 7th Floor, Stair #2 , Exit door is equipped with NC Special (Mag) locking - There is no master release switch at manned Nursing Station.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. Exit discharges from Rehab Center had no hard surface path to public way nor Emergency lighting to safe public way.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. There is approximately a half inch gap between the meeting edge of fire doors RT01 - the astragal provided is not sufficient to maintain required fire rating.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The exit access doors require greater than a thirty pound force to set the doors in motion - doors from Chinese garden.

Based on observation, on April 27, 2011 at approximately 5:30am onward,

1. There is no forty-two inch guardrail between access door and shaftway floor penetration - third floor operating room suite.

Based on observation, on April 27, 2011 at approximately 5:30am onward,

1. There is no guardrail provided between exit access door from shaftway room A-874 and floor penetration.

2. 10 Floor - Greater than thirty foot plus dead -end corridor at South Corridor, Main Entrance

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The horizontal sliding door to room R419 is used as an exit access door - the doors to similar rooms are not located within a suite of rooms.

Based on observation Monday , 4/25/2011 at approximately 1:00 PM onward :

1. 9th Floor : There was no lighting on Emergency Circuit ( LS Branch) for family waiting room # 90064

2. There was not exit discharge lighting in the exit discharge path from the first floor Reynolds to West & Watlington. (1st floor Reynolds)

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. There is no lighting identified on the Life Safety Branch of the essential electrical system in the following areas:

a. central corridor near the dialysis coordinator office - eight floor

b. corridor near bio-med office - eight floor

c. corridor near eight floor nurse's station

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The emergency lighting serving the exit discharge could not be verified as being connected to the Life Safety Branch of the essential electrical system - located at M213B across from morgue pick-up area.

Based on observation, on April 26, 2011 at approximately 7:30am onward

1. There is no exit sign near cross corridor doors to fourth floor ICU - door 40075C.

Based on observation Monday , 4/25/2011 at approximately 1:00 PM onward :

1. There was not exit signage at the first floor old emergency room exit. (1st floor Reynolds)

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. Staff in operating room suite was not familiar with unlabeled air handler shutdown switch - located at abandoned room in third floor north tower.

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. There is no smoke detector located within eight floor nurse's station area - near door hold-open device located in required smoke barrier.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. There is no sprinklers provided for closets located adjacent to corridors between rooms B-1119 and B-1120 - there are other similar closets on the same floor without sprinklers.


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2. Adult ED/ Fast Track - Room across from FT3 - Storage on shelves blocking sprinkler head coverage.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. Both IT rooms #s 90067 and 90099 , no sprinkler coverage.

2. The electrical room 1029A, in a building not equipped with a sprinkler system, did not have a smoke head. (1st floor Reynolds)

Note: NFPA 13 5-13.11 Electrical Equipment. Sprinkler protection shall be required in electrical equipment rooms. Hoods or Shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met: (a) The room is dedicated to electrical equipment only. (b) Only dry-type electrical equipment is used. (c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (d) No combustible storage is permitted to be stored in the room.

Based on observation on Monday 4/25/2011 at approximately 1:00 PM onward:

1. AHU #18 mechanical room has sprinkler head that is blocked partially by a duct. (9 North)

2. Electrical room next to pharmacy did not have a sprinkler head (3rd floor North room # 3B0006)

3. Telecommunication room, next to equipment room, did not have a sprinkler head (3rd floor North, room # 3B005)

Based on observation on Monday 4/25/2011 at approx 1:00 PM onward:
1. K61 - potter tamper switches with cords are not approved by NFPA standards for monitoring four sprinkler control valves in main mechanical room.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. Sprinkler system components are incomplete in the following areas:

a. storage room 4B026 - utilizes green bulb sprinklers rated for 90 degrees Celsius.

b. staff lounge hallway sprinkler is cover with lint - near room 4B047.

c. room 4D066 - ceiling furring obstructs pendent sprinkler.

2. Sub-basement pump room - Tamper switch when tested did not send alarm.

Based on observation on Monday 4/25/2011 at approx 1:00 PM onward:
1. K62 - green bulb sprinklers rated for 200 degrees Fahrenheit are used in the following rooms:
A. environmental services 2H10-1
B. main mechanical room - room does not contain equipment that produces ambient temperatures in excess of 100 degrees Fahrenheit.

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. mechanical systems in the following areas are incomplete:

a. mechanical room PH019 - duct penetrations of vertical chase are not equipped with service access openings and breakaway connections for fire dampers - could not verify installation a time of survey.

b. air handlers #3, and #4 are not equipped with emergency shutdown switch(es) - eight floor.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. The corridor is used as a return air plenum at office 4B087. The office is not equipped with a return air inlet.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. The mechanical systems are noncompliant due to the following:

a. no fire damper at duct penetration of two hour rated chase adjacent to eight floor communications room 106A.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. The soiled linen chute door will not self-close and latch - fifth floor soiled utility near A-577.

A. Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. There is unattended storage of impediments in the corridor near eight floor elevators - items were not in immediate and continuous use. Note: This condition existed thru-out the entire campus in several areas.

2. Flat screen monitors, mounted on corridor walls, extend greater than three and one half inches into required corridor headroom clearance - located in area containing room R-408.


3. 7th Floor - Wall mounted charting tables in the corridor that were not self retracting/closing

4. Linen Closets at room R709 - with Corridor doors not self closing or open 180 degrees.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. There are unattended impediments stored in the corridor near room N-801.

2. Horizontal sliding door, interior courtyard exit access 4B082, will not swing one hundred eighty degrees to prevent corridor obstruction.





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Based on observation on Monday 4/25/2011 at approx 1:00 PM onward:

1. Clean linen doors open into corridor without closure. The doors did not open 180 degrees. (9 North)

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 2nd Floor - Corridor Doors to Elec Rooms #283A open into the corridor. These doors do not swing 180 degrees into corridor nor have self closing devices on them.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. Ground Level, Corridor door to Rest Room GAA018 sings into corridor, this door is not self closing nor swings 180 degrees to clear corridor egress path.

Based on observation, on April 27, 2011 at approximately 8:00am onward,

1.There are full and empty oxygen cylinders are intermingled in the same storage racks - north tower, third floor operating room suite, 5th Floor Respitory Therapy.

Based on observation on Monday 4/25/2011 at approximately 1:00 PM onward:

1. Oxygen/ Med Gas gauges not registering correctly - could not test alarms.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. There is no lighting identified on the Critical Branch of the essential electrical system in the following area:

a. eight floor nurse's station

2. Fire alarm power supply, circuit #27, is wired to critical branch panelboard CL-4-C - panelboard is located in room 4D068.

Based on observation, on April 27, 2011 at approximately 5:30am onward, the essential electrical system is noncompliant due to the following:

a. during loss of normal power to the life safety branch automatic transfer switch, the system required approximately nineteen seconds to restore power to the emergency systems.

b. audible signaling device cannot be tested using generator annunciator test switch.

c. low fuel level, when there is approximately a three hour capacity remaining in the main tank, audible and visual indicator is not monitored on the generator annunciator panel(s).

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1 The life safety branch panelboard contains auto doors east and west - located on panelboard LSL8.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. The essential electrical system is noncompliant due to the following:

a. during loss of normal power to the life safety branch transfer switch, the essential electrical system required approximately nineteen seconds to restore power to required systems.

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. electrical systems are incomplete in the following areas:

a. exposed bulb fluorescent light fixture is used above storage shelf - penthouse floor storage room near cafeteria.

b. medication refrigerator in medication preparation room is connected to normal power receptacle - eight floor.

c. light in medication preparation room is not connected to the critical branch of the essential electrical system - eight floor.

Based on observation, on April 27, 2011 at approximately 5:30am onward,

1. There are unlisted relocatable power taps used in patient care areas of the third floor operating room suite. Standard relocatable power taps are not listed for use in patient care areas of health care facilities.

2.The medical refrigerator was plugged into normal power. Corrected during the survey. (9 North)



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Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. Room # A468, there were penetrations in rated walls that were not properly sealed to maintain the required fire rating of the walls.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 8th Floor, North Tower,- Hemo, Corridor door with self closing device held open with Electro-Magnetic device , did not close upon activation of Fire Alarm as required.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. The corridor door to Reception Room @ Clerical Room was held open with wooden wedge.

2. Adult ED/ Fast Track - Corridor door to clean utility room held open with rubber glove.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. The fire door to the eight floor diverter shaft 125 is not self-closing and latching.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The access door to the vertical chase is not a listed self-closing and latching fire door - located in room 4D085.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. There is a hole in the smoke barrier wall above doors 904A.

Based on observation, on April 28, 2011 at approximately 8:00am onward:

1. The combination fire and smoke curtain did not close with activation of ceiling smoke detectors adjacent to the required smoke barrier.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 4 th Floor - Cross Corridor smoke doors ( # 077B) and (# A457) did not close for smoke tight seal when tested.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 8th floor, Cross Corridor smoke doors (#8 B 116) and at ICU-4C, 4th floor did not close on activation of Fire Alarm.

Based on observation, on April 26, 2011 at approximately 7:30 am onward,

1. There are holes in the door to housekeeping room M055 - the door equipped with a hasp that prevents exiting from inside the room.

2. Electrical rooms R-701 & 702 - 2-hr rated walls - There was no fire damper in Exhaust duct thru walls.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The special locking arrangements for selected doors are noncompliant based upon the following:

a. lack of complete installation in accordance with required building codes - locks at doors 40075C and CCU (7th floor) are not provided with a master release on/off switch at a supervised nurse's station.

2. 6th Floor , Stairwell #61, Exit door equipped with Mag- locks did not release with activation of Fire Alarm, the door did release with over ride switch at door. This must be corrected immediately.

Based on observation from Monday 4/25/2011 at approx 1:00 PM onward:

K32 - special locking arrangements are incomplete in the following areas:
1. exit near second floor elevators - no on/off switches adjacent to doors, no wiring diagram posted at fire alarm control panel, and no master release switch at a supervised station.
2. access controlled locks at cross corridor doors near stair #2 - no sensor is provided in accordance with Life Safety Code.
3. no master release switch for first floor electromagnetic locks near stair #2.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 2nd Floor - Exit door next to #214 equipped with magnetic locking device did not release with emergency over ride switch, it did release with FA.

2. Exit door equipped with Mag- locks did not release with activation of Fire Alarm, the door did release with over ride switch at door. This must be corrected immediately.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 9th Floor - 400 A Wing - Panic Hardware would not release door under normal operation. This door is equipped with NC Special (Mag) Locking.

2. Ground Level , Exit door to Cancer Center is equipped with NC Special (Mag) locking - There is no master release switch at manned Nursing Station.

3. 7th Floor, Stair #2 , Exit door is equipped with NC Special (Mag) locking - There is no master release switch at manned Nursing Station.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. Exit discharges from Rehab Center had no hard surface path to public way nor Emergency lighting to safe public way.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. There is approximately a half inch gap between the meeting edge of fire doors RT01 - the astragal provided is not sufficient to maintain required fire rating.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The exit access doors require greater than a thirty pound force to set the doors in motion - doors from Chinese garden.

Based on observation, on April 27, 2011 at approximately 5:30am onward,

1. There is no forty-two inch guardrail between access door and shaftway floor penetration - third floor operating room suite.

Based on observation, on April 27, 2011 at approximately 5:30am onward,

1. There is no guardrail provided between exit access door from shaftway room A-874 and floor penetration.

2. 10 Floor - Greater than thirty foot plus dead -end corridor at South Corridor, Main Entrance

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The horizontal sliding door to room R419 is used as an exit access door - the doors to similar rooms are not located within a suite of rooms.

Based on observation Monday , 4/25/2011 at approximately 1:00 PM onward :

1. 9th Floor : There was no lighting on Emergency Circuit ( LS Branch) for family waiting room # 90064

2. There was not exit discharge lighting in the exit discharge path from the first floor Reynolds to West & Watlington. (1st floor Reynolds)

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. There is no lighting identified on the Life Safety Branch of the essential electrical system in the following areas:

a. central corridor near the dialysis coordinator office - eight floor

b. corridor near bio-med office - eight floor

c. corridor near eight floor nurse's station

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The emergency lighting serving the exit discharge could not be verified as being connected to the Life Safety Branch of the essential electrical system - located at M213B across from morgue pick-up area.

Based on observation, on April 26, 2011 at approximately 7:30am onward

1. There is no exit sign near cross corridor doors to fourth floor ICU - door 40075C.

Based on observation Monday , 4/25/2011 at approximately 1:00 PM onward :

1. There was not exit signage at the first floor old emergency room exit. (1st floor Reynolds)

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. Staff in operating room suite was not familiar with unlabeled air handler shutdown switch - located at abandoned room in third floor north tower.

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. There is no smoke detector located within eight floor nurse's station area - near door hold-open device located in required smoke barrier.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. There is no sprinklers provided for closets located adjacent to corridors between rooms B-1119 and B-1120 - there are other similar closets on the same floor without sprinklers.


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2. Adult ED/ Fast Track - Room across from FT3 - Storage on shelves blocking sprinkler head coverage.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. Both IT rooms #s 90067 and 90099 , no sprinkler coverage.

2. The electrical room 1029A, in a building not equipped with a sprinkler system, did not have a smoke head. (1st floor Reynolds)

Note: NFPA 13 5-13.11 Electrical Equipment. Sprinkler protection shall be required in electrical equipment rooms. Hoods or Shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met: (a) The room is dedicated to electrical equipment only. (b) Only dry-type electrical equipment is used. (c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (d) No combustible storage is permitted to be stored in the room.

Based on observation on Monday 4/25/2011 at approximately 1:00 PM onward:

1. AHU #18 mechanical room has sprinkler head that is blocked partially by a duct. (9 North)

2. Electrical room next to pharmacy did not have a sprinkler head (3rd floor North room # 3B0006)

3. Telecommunication room, next to equipment room, did not have a sprinkler head (3rd floor North, room # 3B005)

Based on observation on Monday 4/25/2011 at approx 1:00 PM onward:
1. K61 - potter tamper switches with cords are not approved by NFPA standards for monitoring four sprinkler control valves in main mechanical room.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. Sprinkler system components are incomplete in the following areas:

a. storage room 4B026 - utilizes green bulb sprinklers rated for 90 degrees Celsius.

b. staff lounge hallway sprinkler is cover with lint - near room 4B047.

c. room 4D066 - ceiling furring obstructs pendent sprinkler.

2. Sub-basement pump room - Tamper switch when tested did not send alarm.

Based on observation on Monday 4/25/2011 at approx 1:00 PM onward:
1. K62 - green bulb sprinklers rated for 200 degrees Fahrenheit are used in the following rooms:
A. environmental services 2H10-1
B. main mechanical room - room does not contain equipment that produces ambient temperatures in excess of 100 degrees Fahrenheit.

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. mechanical systems in the following areas are incomplete:

a. mechanical room PH019 - duct penetrations of vertical chase are not equipped with service access openings and breakaway connections for fire dampers - could not verify installation a time of survey.

b. air handlers #3, and #4 are not equipped with emergency shutdown switch(es) - eight floor.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. The corridor is used as a return air plenum at office 4B087. The office is not equipped with a return air inlet.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. The mechanical systems are noncompliant due to the following:

a. no fire damper at duct penetration of two hour rated chase adjacent to eight floor communications room 106A.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. The soiled linen chute door will not self-close and latch - fifth floor soiled utility near A-577.

A. Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. There is unattended storage of impediments in the corridor near eight floor elevators - items were not in immediate and continuous use. Note: This condition existed thru-out the entire campus in several areas.

2. Flat screen monitors, mounted on corridor walls, extend greater than three and one half inches into required corridor headroom clearance - located in area containing room R-408.


3. 7th Floor - Wall mounted charting tables in the corridor that were not self retracting/closing

4. Linen Closets at room R709 - with Corridor doors not self closing or open 180 degrees.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. There are unattended impediments stored in the corridor near room N-801.

2. Horizontal sliding door, interior courtyard exit access 4B082, will not swing one hundred eighty degrees to prevent corridor obstruction.





21960

Based on observation on Monday 4/25/2011 at approx 1:00 PM onward:

1. Clean linen doors open into corridor without closure. The doors did not open 180 degrees. (9 North)

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 2nd Floor - Corridor Doors to Elec Rooms #283A open into the corridor. These doors do not swing 180 degrees into corridor nor have self closing devices on them.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. Ground Level, Corridor door to Rest Room GAA018 sings into corridor, this door is not self closing nor swings 180 degrees to clear corridor egress path.

Based on observation, on April 27, 2011 at approximately 8:00am onward,

1.There are full and empty oxygen cylinders are intermingled in the same storage racks - north tower, third floor operating room suite, 5th Floor Respitory Therapy.

Based on observation on Monday 4/25/2011 at approximately 1:00 PM onward:

1. Oxygen/ Med Gas gauges not registering correctly - could not test alarms.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. There is no lighting identified on the Critical Branch of the essential electrical system in the following area:

a. eight floor nurse's station

2. Fire alarm power supply, circuit #27, is wired to critical branch panelboard CL-4-C - panelboard is located in room 4D068.

Based on observation, on April 27, 2011 at approximately 5:30am onward, the essential electrical system is noncompliant due to the following:

a. during loss of normal power to the life safety branch automatic transfer switch, the system required approximately nineteen seconds to restore power to the emergency systems.

b. audible signaling device cannot be tested using generator annunciator test switch.

c. low fuel level, when there is approximately a three hour capacity remaining in the main tank, audible and visual indicator is not monitored on the generator annunciator panel(s).

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1 The life safety branch panelboard contains auto doors east and west - located on panelboard LSL8.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. The essential electrical system is noncompliant due to the following:

a. during loss of normal power to the life safety branch transfer switch, the essential electrical system required approximately nineteen seconds to restore power to required systems.

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. electrical systems are incomplete in the following areas:

a. exposed bulb fluorescent light fixture is used above storage shelf - penthouse floor storage room near cafeteria.

b. medication refrigerator in medication preparation room is connected to normal power receptacle - eight floor.

c. light in medication preparation room is not connected to the critical branch of the essential electrical system - eight floor.

Based on observation, on April 27, 2011 at approximately 5:30am onward,

1. There are unlisted relocatable power taps used in patient care areas of the third floor operating room suite. Standard relocatable power taps are not listed for use in patient care areas of health care facilities.

2.The medical refrigerator was plugged into normal power. Corrected during the survey. (9 North)



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