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Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. CORRECTED 11/1/13

B. At 9:39 AM on April 17, 2013, an unprotected steel column was observed in the Ground Floor Contaminated Linen Room.

Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients in the cited area because the medical gas system could become compromised.

A. At 1:51 PM on April 17, 2013, the medical gas area alarm panel serving the Ground Floor of the 1977 Building was observed to be located in the Biomedical Engineering Office (which can be secured against entry), and not in an accessible location as required by by NFPA 99 1999 4-3.1.2.2(c)(2).

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 random observation during the survey walk-through and document review, the facility's Type 1 Emergency Electrical System (EES) is not divided into the Life Safety Branch, the Critical Branch, and the Equipment Branch as required by NFPA 99 and NFPA 70. These deficiencies could affect any patients, staff, or visitors in the building because the EES could become compromised.

Findings include:

A. The facility's Type 1 EES was observed to not be divided into a Life Safety, Critical, and Equipment Branch as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-30. All Electrical Panels listed below were observed to serve electrical loads which are required to be served by different branches of the EES. Based on a review of the facilities Electrical Panel Circuit Directories conducted at 9:03 AM on April 18, 2013, Electrical Panels at which this condition exists include, but are not limited to:

1. 1977 Building:
a. Third Floor Electrical Panel 3C, at which Circuit 8 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], Circuit 12 is identified as serving the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits are identified as serving other normal electrical loads.
b. Second Floor Electrical Panel 2C, at which Circuit 8 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], and other circuits are identified as serving other normal electrical loads.

c. First Floor Electrical Panel 1C, at which Circuit 32 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], Circuit 34 is identified as serving the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits are identified as serving other normal electrical loads.

d. Electrical Panel EL, at which Circuit 5 is identified as serving Nurse Exit Lights [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(2) and NFPA 70 1999 517-32(b)], Circuits 4 and 7 are identified as serving Emergency Lights [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(1) and NFPA 70 1999 517-32(a)], Circuit 6 is shown as serving a Medical Gas Alarm Panel [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(b) and NFPA 70 1999 517-32(c)(2)] and other circuits are identified as serving other normal electrical loads.

e. Ground Floor Electrical Panel 1-EM, identified as being an Emergency Panel, was identified as serving normal electrical loads including:

1) Corridor receptacles (Circuits 1 and 2).

2) Normal Kitchen lighting (Circuits 6, 7, 9, 10, 11, and 12.

2. 2001 Addition/2011 Vertical Expansion:

a. At 9:03 AM on April 18, 2013, Fourth Floor Electrical Panel LS2A, identified as a Life Safety Panel, which was observed to serve the Nurse call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], and the Infant Abduction System [which is not permitted to be served by the Life Safety Branch by NFPA 99 1999 3-4.2.2.2(b) and NFPA 70 1999 517-32].

b. At 9:55 Am on April 18, 2013, First Floor Electrical Panel ES1A was observed to serve the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits identified as serving other normal electrical loads.