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Based on observation and staff interview during the survey walk-through, components of the building structural system did not comply with required fire resistance ratings in accordance with 19.1.6.2. These deficiencies could affect all patients within the building, as well as any staff and visitors present, by allowing bulding collapse during a fire condition.

Findings include:

A. At 1:20pm on 1/7/13 it was observed in the Attic of the original building that the top flanges and a portion of the web of two beams supporting the Attic concrete floor deck were exposed without protection to qualify to meet the designated and required minimum construction type of Type II (111).

B. At 1:25pm on 1/7/13 it was observed that the requirements of the Exception to 19.1.6.1, part (b) were not met because the framing of the roof system was not minimum 1-hour fire resistance rated or the barrier between the unprotected roof framing at the Attic level was not separated from the stair at the Level Two floor because the wall and soffit between the stair run to the Attic and the remainder of the Stair was not constructed in accordance with 2-hour rated construction.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1 or otherwise protected in accordance with the exceptions. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of separation from the corridor could result in smoke compromising the use of the facility's exit access corridors.

Findings include:

A. At 8:40am on 1/8/13 it was observed that the reception window at the ER waiting room was provided with a shutter to separate the office area from the corridor/waiting area, but clipboards, decorations, and kleenex boxes were placed within the shutters travel path which could prevent the shutter from closing effectively.

Based on observation during the survey walk-through, not all vertical openings are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

A. At 2:55pm on 1/7/13 it was observed that a duct in the "West, A wing" House Supervisor's room on the Level Two floor was not confirmed to be provided with a fire damper to comply with 19.3.1.1 and NFPA 90A-1999, 3-3.2.

B. At 3:15pm on 1/7/13 it was observed that 2 ducts in the "East, B wing" old Gift Shop Storage room on the Level Two floor were not provided with fire dampers installed within the thickness of the fire rated floor system to comply with 19.3.1.1 and NFPA 90A-1999, 3-3.2.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire in the event of a fire condition to escape from hazardous rooms into the exit access .

Findings include:

A. Doors required to be self-closing were observed to be held open by wedges and/or materials not in compliance with 7.2.1.8. Locations observed include:

1. At 2:00pm on 1/7/13 the Level Two Bistro Storage room door was observed to be held open by a wedge.

2. At 2:00pm on 1/7/13 the Level Two Gift Shop Storage room door was observed to be held open by 2 wedges and a waste receptacle.

3. At 2:00pm on 1/7/13 the Level Two Gift Shop corridor door was identified on the Life Safety Reference Plan as an opening in a "non-rated smoke barrier/partition" and the door was being held open with a wedge in non-compliance with 8.3.4.3.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire in the event of a fire condition to escape from hazardous rooms into the exit access .

Findings include:

A. At 1:45pm on 1/7/13 at the Level Three Plant Operations Shop it was observed that the pair of double egress corridor doors closed with a gap between the doors of approximately 3/8" in non-compliance with 8.2.3.2.1 and NFPA 80-1999, 2-3.1.7 which limites the gap to 1/8" +/- 1/16" for steel doors.

B. At 2:40pm on 1/7/13 it was observed that the old whirlpool bath room located in the "West, A wing" was utilized as a storage room. The room was not provided with sprinkler protection and was not confirmed to be separated by 1-hour rated construction including a 3/4-hour self-closing door assembly.

C. At 8:30am on 1/8/13 it was observed that the door to the ER Soiled Utility room was not self-closing to a latched condition.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 9:15am on 1/8/13 it was observed that the corridor on the Level One floor noted on the Life Safety Reference Plans to be enclosed with minimum 2-hour rated construction and indicated by staff to form an exit passageway from the west stair of the original building. The indicated exit passageway does not comply with the requirements of 7.2.6 and 7.1.3.2.1(e) based upon the following:

1. The exit passageway contained medical gas zone valves.

2. The exit passageway contained ventilation grilles.

3. The exit passageway contained conduits/data cables which did not serve the exit passageway enclosure.

4. The exit passageway was the only access to a normally unoccupied medical gas manifold room in non-compliance with 7.1.3.2.1(d).

5. One of the double egress doors into the exit passageway from the Radiology area was not labeled as fire rated and the gap between the closed doors exceeded 1/4" in non-compliance with 8.2.3.2.1 and NFPA 80-1999, 2-3.1.7 which limites the gap to 1/8" +/- 1/16" for steel doors.

Surveyor notes that this corridor may not be required to be considered an exit passageway if the requirements of 7.7.2 can be demonstrated to be met and Life Safety Reference Plans clearly identify the intent/requirements for the rated barrier walls.

Based on observation during the survey walk-through, not all exit stairs are separated from other parts of the building to comply with 8.2.5 and 7.2.2. These deficiencies could affect any patients in the facility, as well as any staff and visitors present required to use the exit by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 10:35am on 1/8/13 it was observed that the south stair of the Atrium Addition contained a ventilation supply diffuser at the lowest level ceiling which is in non-compliance with 7.1.3.2.1(e). A review of plan drawings also indicated a separate duct passing thru this stair enclosure which serves other areas and may not be separated from the stair enclosure unless the stair riser/tread and landing construction is protected to form the stair enclosure.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 18.2.1 and Chapter 7. These deficiencies could affect any patients, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets or provided with dead bolt locks operated only by a key from either side or provided with inoperable hardware. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. The key-only dead bolt locks are not operable for exiting without a key in noncompliance with 7.1.10.1. Locations observed include but are not necessarily limited to the following:

1. At 1:50pm on 1/7/13 it was observed that the door to the rooftop mechanical equipment from the Level Three Mecahincal room was equipped with a panic device and a deadbolt lock keyed from both sides. The deadbolt lock in combination with the panic device does not comply with the requirements of 7.2.1.5.6 when accessing the roof and the provisions of 7.2.1.5.4 when exiting the roof if the door becomes locked from inside.

2. At 1:55pm on 1/7/13 it was observed that deadbolt locks were installed in addition to locksets at the following locations:

a. At 2 doors of 2 offices on the east side of the Atrium on Level Three.

b. At 2 doors of 1 office on the west side of the Atrium on Level Three.

Based on observation during the survey walk-through, not all exits are arranged so that exiting is readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect any patients, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building and safety.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets or provided with dead bolt locks operated only by a key from either side or provided with inoperable hardware. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. The key-only dead bolt locks are not operable for exiting without a key in noncompliance with 7.1.10.1. Locations observed include but are not necessarily limited to the following:

1. At 3:05pm on 1/7/13 it was observed that the double egress cross corridor doors at the west boundary of the "East, B wing construction area" on the Level Two floor were provided with inoperable hardware. One door was equipped with a panic device and the other door had the panic device removed and replaced with a lever lockset. The lever lockset prevents the operation of the panic device because the lever lockset bolt engages the panic device door to prevent its operation. The use of a panic device on this door implies egress is available through this door, but it is not. Signage to "use other door" is not deemed adequate provisions to over ride the implied panic device operated door. The requirements of 7.2.1.5.6 are not met.

2. At 9:00am on 1/8/13 it was observed that the mobile MRI trailer "corridor" door was equipped with a deadbolt lock keyed from both sides in addition to panic device hardware. The requirements of 7.2.1.5.4 and 7.2.1.5.6 are not met.

3. At 9:00am on 1/8/13 it was observed that the MRI scan room door is equipped with a deadbolt lock keyed from both sides. The requirements of 7.1.10.1 are not met.

B. At 2:35pm on 1/7/13 it was observed that the exit discharge path at the bottom of the exterior stair from the west exit from the "West, 'A' wing" was not complete. A stable path from the stair landing to the paved parking requires traversing a grass bank. The requirements of 7.7.1 are not met.

Based upon observation during the survey walk-thru, fire separation barriers are not maintained in accordance with 19.1.2.3 and 8.2.3. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the different adjacent areas.

Findings include:

A. At 9:35am on 1/8/13 it was observed that the half-light cross corridor doors located on the Level One floor near Room 1904 and the Dining room were not minimum 1 1/2-hour rated to provide continuity of the 2-hour barrier between the Type II (111) and Type II (222) construction types.

B. At 10:10 on 1/8/13 it was observed that the astragal equipped cross corridor doors in the 2-hour fire barrier at the west end of the "East, B wing" at the Level One floor lacked coordinator hardware to allow the doors to always close to a latched condition.

Based on observation during the survey walk-through on 1/7-8/13, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. Exit discharge locations were observed to lack more than one fixture or a fixture with more than one lamp equipped with instantaneous type lighting connected to the emergency power system to comply with 7.8.1.4. Lighting appeared to be HID type which requires restrike and/or warm-up period to provided illumination or only a single incandescent or fluorescent type fixture/lamp was provided. Connection to the emergency power system was not confirmed for all locations. Observed examples include but are not limited to the following:

1. The two fixtures at the west exit discharge of Level Two could not be confirmed due to the lens on the fixtures. Staff could not confirm lamp type at the time of the survey.

2. The two fixtures at the east exit discharge of Level Two could not be confirmed due to the lens on the fixtures. Staff could not confirm lamp type at the time of the survey.

3. The fixtures operating at the ER ambulance entry/exit discharge were observed to be of HID type only.

4. The fixtures operating at the ER entrance/exit discharge canopy were observed to be HID type with the exception of one fixture with an incandecent lamp which was not lit. Switching arrangement was not determined.


17659

Based on observation during the survey walk through while accompanied by the director of building operations, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 18.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

B. Exit discharge from the doctors lounge area had a single fixture and a single lamp which does not meet the requirements of NFPA 101-2000, Section 7.8.1.4, which states that the failure of any single lighting unit does not result in an illumination level of less than .2 ft-candles in any designated area.

Based on observation during the survey walk-through, exit signs were not provided or were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 10:15am on 1/8/13 it was observed that the corridor leading to the PT area on the Level One floor lacked exit signage at the intersecting corridor to identify the second exit path from the corridor to comply with 18.2.5.9 and 18.2.10.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible or properly located to clearly designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 3:05pm on 1/7/13 it was observed that the corridor of the "East, 'B' wing" on the Level Two floor lacked exit signage to identify the second exit path from the corridor to comply with 18.2.5.9 and 18.2.10.

B. At 8:30am on 1/8/13 it was observed that the exit signage at the west end of the corridor outside surgery area was not located closest to the intended cross corridor double egress door.

C. At 9:50am on 1/8/13 it was observed that the directional exit sign located south of the cross corridor doors outside the Boiler room identified a path to the exterior door on the other side of the cross corridor doors. The directional signage is inappropriate on this side of the door and no signage at the exterior door is provided. The corridor leading to the materials management storage room/loading dock exterior door is not marked with exit signage and otherwise exceeds the dead end limitations of 19.2.5.10.

Based on observation during the survey walk through, not all areas of the building fire alarm system components are installed in accordance with 18/19.3.4 and NFPA 72-1999. This could effect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Findings include:

A. At 9:05am on 1/8/13 it was observed that a fire alarm manual pull station was not installed within 5'-0" from the exterior exit door of the MRI access vestibule area to comply with NFPA 72-1999, 2-8.2.2.


17659

Based on observation during the survey walk through while accompanied by the director of building operations , the surveyor found that not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect anybody sleeping in the on-call room during a fire emergency.

Findings include:

B. The doctors sleeping room was not equipped with a fire alarm visual alarm to meet the requirements of NFPA 72-1999, Section 4-4.4.3.

By direct observation the morning of 1/8/13 while in the company of the facility's Construction Project Manager the surveyor finds the ambulance entrance glass vestibule is not provided with fire sprinkler protection. The Emergency Department is considered to be fully protected by a fire protection system.

Based upon observations during the Survey walk-through, it was determined that the facility failed to maintain the corridors free of obstructions in accordance with 7.1.10. This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors.

Findings include:

A. At 9:45am on 1/8/13 it was observed that carts and materials were stationed in the corridor outside the Kitchen and Dining room.

B. At 9:50am on 1/8/13 it was observed that materials were stored on pallets in the ramped corridor outside the Materials Management room.

C. At 10:10am on 1/8/13 it was observed that chair seating was stationed in the corridor outside Cardiopulminary which obstructed the 8'-0" width.

Based on observation, the surveyor finds the facility failed to provide piped medical gas systems in accordance with NFPA 99, 1999, Chapter 4.

Findings include:

A. At 9:10am on 1/8/13 it was observed that the medical gas manifold room on the Level One floor near the original building west stair discharge contained electrical receptacle(s) and a light switch located below the 5'-0" height required to comply with NFPA 99-1999, 4-3.1.1.2(a)11.d.


14416

B. By direct observation the afternoon of 1/7/13 while in the company of the facility's Project Manager and Director of Plant Operations the surveyor find the installation of the medical gas zone valves are in non-compliance with NFPA 99, 1999, 4-3.1.2.3 (d). Separation of the zone control valves from supplied outlets and inlets they serve is not provided at the following locations.

1. The Emergency Department

2. The Prep/Recovery for Same Day Surgery

Based on observations during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other Code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute 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 random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other Code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute 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 during the survey walk-through while accompanied by the project manager and the director of building operations, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA 99-1999 and NFPA 70-1999, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

A. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panel CB2 had circuits feeding a fire alarm panel, med gas alarm panel, (these items should be served from the life safety panel), and critical distribution panel NECB was labeled with circuits feeding life safety panels. This does not meet the requirements of NFPA 70-1999, Section 517-32 and 33.

B. Life safety panel LSB in the patient wing serves room receptacles and other non-life safety loads, (should be served by the critical branch). Life safety panels ALSB-1 and E2 are serving nurse call, lab receptacles and other non-life safety loads, and the life safety distribution panel NELSB has two circuits labeled as serving two critical panels which does not meet the requirements of NFPA 70-1999, Section 517-30 through 35.

C. Equipment panel AEMEQ serves the beam smoke detector and the PA system that should be served by the life safety system, and the fire alarm panel in the IT room in the generator building is served from the equipment panel rather than the life safety panel. This does not meet the requirements of NFPA 70-1999, Section 517-32.

Based on random observation during the survey walk-through not all portions of the building electrical system are installed in accordance with NFPA 70 (1999).

Findings include:

A. Not all Emergency receptacles in the ER treatment area and the Endo room were all labeled to indentify the panel and circuit from which they are fed to comply with NFPA 99-1999, Section 3-4.2.2.4(a)2 and NFPA 70-1999, Section 517-19(a).

1. Receptacles in the Endo room were inconsistantly identified. Both red outlets with red coverplates and red outlets with ivory coverplates were observed. Not all of these outlets were labeled with panel and circuit identifiers.

2. Red receptacles in the ER treatment stations were inconsistantly identified. Not all of these outlets were labeled with panel and circuit identifiers.


17659

Based on observation during the survey walk-through while accompanied by the project manager and the director of building operations, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70-1999 and NFPA 99-1999.

Findings include:

B. Normal power receptacles were not provided in operating rooms as required by NFPA 70-1999, Section 517-19, and NFPA 99-1999, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power these rooms could be left with no power.

C. Three sinks in the operating room suite had counter top receptacles within six feet of the sink that were not GFCI protected in accordance with NFPA 70-1999, Section 517-20.

D. The major treatment room in the emergency department needs a normal receptacle to meet the requirements of NFPA 70-1999, Section 517-19.

Based on observation during the survey walk-through while accompanied by the project manager and the director of building operations, the surveyor found that portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor did not find a single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation in elevator equipment room-3903 as required by NFPA 70-1999, Section 620-53.

B. The surveyor did not find a disconnect for the emergency lighting and controls in equipment room-3903 fed from the life safety panel in accordance with NFPA 70-1999, Section 517-32(f).

Based on observation and staff interview during the survey walk-through, components of the building structural system did not comply with required fire resistance ratings in accordance with 19.1.6.2. These deficiencies could affect all patients within the building, as well as any staff and visitors present, by allowing bulding collapse during a fire condition.

Findings include:

A. At 1:20pm on 1/7/13 it was observed in the Attic of the original building that the top flanges and a portion of the web of two beams supporting the Attic concrete floor deck were exposed without protection to qualify to meet the designated and required minimum construction type of Type II (111).

B. At 1:25pm on 1/7/13 it was observed that the requirements of the Exception to 19.1.6.1, part (b) were not met because the framing of the roof system was not minimum 1-hour fire resistance rated or the barrier between the unprotected roof framing at the Attic level was not separated from the stair at the Level Two floor because the wall and soffit between the stair run to the Attic and the remainder of the Stair was not constructed in accordance with 2-hour rated construction.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1 or otherwise protected in accordance with the exceptions. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of separation from the corridor could result in smoke compromising the use of the facility's exit access corridors.

Findings include:

A. At 8:40am on 1/8/13 it was observed that the reception window at the ER waiting room was provided with a shutter to separate the office area from the corridor/waiting area, but clipboards, decorations, and kleenex boxes were placed within the shutters travel path which could prevent the shutter from closing effectively.

Based on observation during the survey walk-through, not all vertical openings are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

A. At 2:55pm on 1/7/13 it was observed that a duct in the "West, A wing" House Supervisor's room on the Level Two floor was not confirmed to be provided with a fire damper to comply with 19.3.1.1 and NFPA 90A-1999, 3-3.2.

B. At 3:15pm on 1/7/13 it was observed that 2 ducts in the "East, B wing" old Gift Shop Storage room on the Level Two floor were not provided with fire dampers installed within the thickness of the fire rated floor system to comply with 19.3.1.1 and NFPA 90A-1999, 3-3.2.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire in the event of a fire condition to escape from hazardous rooms into the exit access .

Findings include:

A. Doors required to be self-closing were observed to be held open by wedges and/or materials not in compliance with 7.2.1.8. Locations observed include:

1. At 2:00pm on 1/7/13 the Level Two Bistro Storage room door was observed to be held open by a wedge.

2. At 2:00pm on 1/7/13 the Level Two Gift Shop Storage room door was observed to be held open by 2 wedges and a waste receptacle.

3. At 2:00pm on 1/7/13 the Level Two Gift Shop corridor door was identified on the Life Safety Reference Plan as an opening in a "non-rated smoke barrier/partition" and the door was being held open with a wedge in non-compliance with 8.3.4.3.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire in the event of a fire condition to escape from hazardous rooms into the exit access .

Findings include:

A. At 1:45pm on 1/7/13 at the Level Three Plant Operations Shop it was observed that the pair of double egress corridor doors closed with a gap between the doors of approximately 3/8" in non-compliance with 8.2.3.2.1 and NFPA 80-1999, 2-3.1.7 which limites the gap to 1/8" +/- 1/16" for steel doors.

B. At 2:40pm on 1/7/13 it was observed that the old whirlpool bath room located in the "West, A wing" was utilized as a storage room. The room was not provided with sprinkler protection and was not confirmed to be separated by 1-hour rated construction including a 3/4-hour self-closing door assembly.

C. At 8:30am on 1/8/13 it was observed that the door to the ER Soiled Utility room was not self-closing to a latched condition.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 9:15am on 1/8/13 it was observed that the corridor on the Level One floor noted on the Life Safety Reference Plans to be enclosed with minimum 2-hour rated construction and indicated by staff to form an exit passageway from the west stair of the original building. The indicated exit passageway does not comply with the requirements of 7.2.6 and 7.1.3.2.1(e) based upon the following:

1. The exit passageway contained medical gas zone valves.

2. The exit passageway contained ventilation grilles.

3. The exit passageway contained conduits/data cables which did not serve the exit passageway enclosure.

4. The exit passageway was the only access to a normally unoccupied medical gas manifold room in non-compliance with 7.1.3.2.1(d).

5. One of the double egress doors into the exit passageway from the Radiology area was not labeled as fire rated and the gap between the closed doors exceeded 1/4" in non-compliance with 8.2.3.2.1 and NFPA 80-1999, 2-3.1.7 which limites the gap to 1/8" +/- 1/16" for steel doors.

Surveyor notes that this corridor may not be required to be considered an exit passageway if the requirements of 7.7.2 can be demonstrated to be met and Life Safety Reference Plans clearly identify the intent/requirements for the rated barrier walls.

Based on observation during the survey walk-through, not all exit stairs are separated from other parts of the building to comply with 8.2.5 and 7.2.2. These deficiencies could affect any patients in the facility, as well as any staff and visitors present required to use the exit by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 10:35am on 1/8/13 it was observed that the south stair of the Atrium Addition contained a ventilation supply diffuser at the lowest level ceiling which is in non-compliance with 7.1.3.2.1(e). A review of plan drawings also indicated a separate duct passing thru this stair enclosure which serves other areas and may not be separated from the stair enclosure unless the stair riser/tread and landing construction is protected to form the stair enclosure.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 18.2.1 and Chapter 7. These deficiencies could affect any patients, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets or provided with dead bolt locks operated only by a key from either side or provided with inoperable hardware. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. The key-only dead bolt locks are not operable for exiting without a key in noncompliance with 7.1.10.1. Locations observed include but are not necessarily limited to the following:

1. At 1:50pm on 1/7/13 it was observed that the door to the rooftop mechanical equipment from the Level Three Mecahincal room was equipped with a panic device and a deadbolt lock keyed from both sides. The deadbolt lock in combination with the panic device does not comply with the requirements of 7.2.1.5.6 when accessing the roof and the provisions of 7.2.1.5.4 when exiting the roof if the door becomes locked from inside.

2. At 1:55pm on 1/7/13 it was observed that deadbolt locks were installed in addition to locksets at the following locations:

a. At 2 doors of 2 offices on the east side of the Atrium on Level Three.

b. At 2 doors of 1 office on the west side of the Atrium on Level Three.

Based on observation during the survey walk-through, not all exits are arranged so that exiting is readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect any patients, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building and safety.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets or provided with dead bolt locks operated only by a key from either side or provided with inoperable hardware. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. The key-only dead bolt locks are not operable for exiting without a key in noncompliance with 7.1.10.1. Locations observed include but are not necessarily limited to the following:

1. At 3:05pm on 1/7/13 it was observed that the double egress cross corridor doors at the west boundary of the "East, B wing construction area" on the Level Two floor were provided with inoperable hardware. One door was equipped with a panic device and the other door had the panic device removed and replaced with a lever lockset. The lever lockset prevents the operation of the panic device because the lever lockset bolt engages the panic device door to prevent its operation. The use of a panic device on this door implies egress is available through this door, but it is not. Signage to "use other door" is not deemed adequate provisions to over ride the implied panic device operated door. The requirements of 7.2.1.5.6 are not met.

2. At 9:00am on 1/8/13 it was observed that the mobile MRI trailer "corridor" door was equipped with a deadbolt lock keyed from both sides in addition to panic device hardware. The requirements of 7.2.1.5.4 and 7.2.1.5.6 are not met.

3. At 9:00am on 1/8/13 it was observed that the MRI scan room door is equipped with a deadbolt lock keyed from both sides. The requirements of 7.1.10.1 are not met.

B. At 2:35pm on 1/7/13 it was observed that the exit discharge path at the bottom of the exterior stair from the west exit from the "West, 'A' wing" was not complete. A stable path from the stair landing to the paved parking requires traversing a grass bank. The requirements of 7.7.1 are not met.

Based upon observation during the survey walk-thru, fire separation barriers are not maintained in accordance with 19.1.2.3 and 8.2.3. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the different adjacent areas.

Findings include:

A. At 9:35am on 1/8/13 it was observed that the half-light cross corridor doors located on the Level One floor near Room 1904 and the Dining room were not minimum 1 1/2-hour rated to provide continuity of the 2-hour barrier between the Type II (111) and Type II (222) construction types.

B. At 10:10 on 1/8/13 it was observed that the astragal equipped cross corridor doors in the 2-hour fire barrier at the west end of the "East, B wing" at the Level One floor lacked coordinator hardware to allow the doors to always close to a latched condition.

Based on observation during the survey walk-through on 1/7-8/13, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. Exit discharge locations were observed to lack more than one fixture or a fixture with more than one lamp equipped with instantaneous type lighting connected to the emergency power system to comply with 7.8.1.4. Lighting appeared to be HID type which requires restrike and/or warm-up period to provided illumination or only a single incandescent or fluorescent type fixture/lamp was provided. Connection to the emergency power system was not confirmed for all locations. Observed examples include but are not limited to the following:

1. The two fixtures at the west exit discharge of Level Two could not be confirmed due to the lens on the fixtures. Staff could not confirm lamp type at the time of the survey.

2. The two fixtures at the east exit discharge of Level Two could not be confirmed due to the lens on the fixtures. Staff could not confirm lamp type at the time of the survey.

3. The fixtures operating at the ER ambulance entry/exit discharge were observed to be of HID type only.

4. The fixtures operating at the ER entrance/exit discharge canopy were observed to be HID type with the exception of one fixture with an incandecent lamp which was not lit. Switching arrangement was not determined.


17659

Based on observation during the survey walk through while accompanied by the director of building operations, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 18.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

B. Exit discharge from the doctors lounge area had a single fixture and a single lamp which does not meet the requirements of NFPA 101-2000, Section 7.8.1.4, which states that the failure of any single lighting unit does not result in an illumination level of less than .2 ft-candles in any designated area.

Based on observation during the survey walk-through, exit signs were not provided or were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 10:15am on 1/8/13 it was observed that the corridor leading to the PT area on the Level One floor lacked exit signage at the intersecting corridor to identify the second exit path from the corridor to comply with 18.2.5.9 and 18.2.10.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible or properly located to clearly designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 3:05pm on 1/7/13 it was observed that the corridor of the "East, 'B' wing" on the Level Two floor lacked exit signage to identify the second exit path from the corridor to comply with 18.2.5.9 and 18.2.10.

B. At 8:30am on 1/8/13 it was observed that the exit signage at the west end of the corridor outside surgery area was not located closest to the intended cross corridor double egress door.

C. At 9:50am on 1/8/13 it was observed that the directional exit sign located south of the cross corridor doors outside the Boiler room identified a path to the exterior door on the other side of the cross corridor doors. The directional signage is inappropriate on this side of the door and no signage at the exterior door is provided. The corridor leading to the materials management storage room/loading dock exterior door is not marked with exit signage and otherwise exceeds the dead end limitations of 19.2.5.10.

Based on observation during the survey walk through, not all areas of the building fire alarm system components are installed in accordance with 18/19.3.4 and NFPA 72-1999. This could effect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Findings include:

A. At 9:05am on 1/8/13 it was observed that a fire alarm manual pull station was not installed within 5'-0" from the exterior exit door of the MRI access vestibule area to comply with NFPA 72-1999, 2-8.2.2.


17659

Based on observation during the survey walk through while accompanied by the director of building operations , the surveyor found that not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect anybody sleeping in the on-call room during a fire emergency.

Findings include:

B. The doctors sleeping room was not equipped with a fire alarm visual alarm to meet the requirements of NFPA 72-1999, Section 4-4.4.3.

By direct observation the morning of 1/8/13 while in the company of the facility's Construction Project Manager the surveyor finds the ambulance entrance glass vestibule is not provided with fire sprinkler protection. The Emergency Department is considered to be fully protected by a fire protection system.

Based upon observations during the Survey walk-through, it was determined that the facility failed to maintain the corridors free of obstructions in accordance with 7.1.10. This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors.

Findings include:

A. At 9:45am on 1/8/13 it was observed that carts and materials were stationed in the corridor outside the Kitchen and Dining room.

B. At 9:50am on 1/8/13 it was observed that materials were stored on pallets in the ramped corridor outside the Materials Management room.

C. At 10:10am on 1/8/13 it was observed that chair seating was stationed in the corridor outside Cardiopulminary which obstructed the 8'-0" width.

Based on observation, the surveyor finds the facility failed to provide piped medical gas systems in accordance with NFPA 99, 1999, Chapter 4.

Findings include:

A. At 9:10am on 1/8/13 it was observed that the medical gas manifold room on the Level One floor near the original building west stair discharge contained electrical receptacle(s) and a light switch located below the 5'-0" height required to comply with NFPA 99-1999, 4-3.1.1.2(a)11.d.


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B. By direct observation the afternoon of 1/7/13 while in the company of the facility's Project Manager and Director of Plant Operations the surveyor find the installation of the medical gas zone valves are in non-compliance with NFPA 99, 1999, 4-3.1.2.3 (d). Separation of the zone control valves from supplied outlets and inlets they serve is not provided at the following locations.

1. The Emergency Department

2. The Prep/Recovery for Same Day Surgery

Based on observations during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other Code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute 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 random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other Code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute 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 during the survey walk-through while accompanied by the project manager and the director of building operations, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA 99-1999 and NFPA 70-1999, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

A. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panel CB2 had circuits feeding a fire alarm panel, med gas alarm panel, (these items should be served from the life safety panel), and critical distribution panel NECB was labeled with circuits feeding life safety panels. This does not meet the requirements of NFPA 70-1999, Section 517-32 and 33.

B. Life safety panel LSB in the patient wing serves room receptacles and other non-life safety loads, (should be served by the critical branch). Life safety panels ALSB-1 and E2 are serving nurse call, lab receptacles and other non-life safety loads, and the life safety distribution panel NELSB has two circuits labeled as serving two critical panels which does not meet the requirements of NFPA 70-1999, Section 517-30 through 35.

C. Equipment panel AEMEQ serves the beam smoke detector and the PA system that should be served by the life safety system, and the fire alarm panel in the IT room in the generator building is served from the equipment panel rather than the life safety panel. This does not meet the requirements of NFPA 70-1999, Section 517-32.

Based on random observation during the survey walk-through not all portions of the building electrical system are installed in accordance with NFPA 70 (1999).

Findings include:

A. Not all Emergency receptacles in the ER treatment area and the Endo room were all labeled to indentify the panel and circuit from which they are fed to comply with NFPA 99-1999, Section 3-4.2.2.4(a)2 and NFPA 70-1999, Section 517-19(a).

1. Receptacles in the Endo room were inconsistantly identified. Both red outlets with red coverplates and red outlets with ivory coverplates were observed. Not all of these outlets were labeled with panel and circuit identifiers.

2. Red receptacles in the ER treatment stations were inconsistantly identified. Not all of these outlets were labeled with panel and circuit identifiers.


17659

Based on observation during the survey walk-through while accompanied by the project manager and the director of building operations, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70-1999 and NFPA 99-1999.

Findings include:

B. Normal power receptacles were not provided in operating rooms as required by NFPA 70-1999, Section 517-19, and NFPA 99-1999, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power these rooms could be left with no power.

C. Three sinks in the operating room suite had counter top receptacles within six feet of the sink that were not GFCI protected in accordance with NFPA 70-1999, Section 517-20.

D. The major treatment room in the emergency department needs a normal receptacle to meet the requirements of NFPA 70-1999, Section 517-19.