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Based on observations and discussions with the facility staff during the facility walk through on 07/13/2011 and 07/14/2011 it was noted that the fire alarm system components were not in compliance with NFPA 72 and NFPA 99, as follows;
1). The face plate of a fire alarm booster panel on the ground floor/south was labeled to indicate that power was supplied from "BGLCB" electrical panel. Panel "BGLCB" is a panel powered fromthe Critical Branch of the EES. A review of that panel indicated that the Fire Alarm system was powered from circuit #35. Fire alarm system components shall be powered from the Life Safety Branch of the EES.
2). The face plate of a fire alarm booster panel on the 5th floor/south was labeled to indicate power coming from Critical Branch panel "CSE-LS, circuit #24". A review of that panel directory indicated that circuit #24 was "blank" (no power).
3). The fire alarm panel located in the emergency department indicated "trouble" on two zones, during the facility walk through on the morning of 07/13/2011 and again on the morning of 07/14/2011. The fire alarm system functioned correctly when tested by facility staff during the walk through on 07/14/2011. However the reason for the "trouble" signal had not been discovered.

Based on observation and discussions with facility staff, during the walk through on 07/13/2011, it was noted that fire sprinkler heads were obstructed, from normal discharge of water during an emergency, by surface mounted light fixtures located too close to the fire sprinkler heads in several pateint bedrooms with monolithic ceiling finishes, located in the west wing, 9th floor/south.

Based on the facility walk through on 07/13/2011 and 07/14/2011 with members of the facility staff, it was observed that not all janitor closets or soiled workrooms were negatively pressured relative to adjoiing spaces, as required.
1). A janitor closet in the surgical suite, near respriatory therapy, was observed to lack a negative pressure with the door open.
2). A soiled workroom located on the 9th floor/south was positively pressured, instead of negative.

Based on observation and discussion during the facility walk through on 07/13/2011, with facility staff members, it was noted that medical gas cylinders at the manifold location, were not secured by chains, racks, or other fastening devices to individually secure each cylinder from falling.

Based on observation and discussions with the facility staff, during the facility walk through on 07/13/2011, it was noted that There was no magnahelic or manometer gauge monitoring the 99% effiency filter bank for the HVAC system serving the ante room of the IV preparation area of the pharmacy on the basement floor/south. All filter beds of 75% or greater shall have draft gauges installed across filters (NFPA 99 5.1.3.3.2).

based on observations and discussion with the facility staff during a walk through of the facility on 07/13/2011 and 07/14/2011 it was noted that certain requirements of NFPA 70 (National Electrical Code)were not met.
1). During the facility walk through it was observed that at Panel "ELBX" (a Life Safety Branch panel)circuits #9 and #18 were providing power to duplex receptacles not approved to be powered from the Life Safety Branch of the EEs.
2). During the walk through survey, a number of panel directories were noted to be outdated with numerous alterations and marginally legible. Panel "DBE-1" had no directory at all.
3). During the walk through survey it was observed that the automatic egress doors for the emergency department ambulance entrance were powered from the normal electrical system panel "BGLHB". All powered egress doors shall be powered from the Life Safety branch of the EES.

Based on observations and discussions with the facility staff during the facility walk through on 07/13/2011 and 07/14/2011 it was noted that the fire alarm system components were not in compliance with NFPA 72 and NFPA 99, as follows;
1). The face plate of a fire alarm booster panel on the ground floor/south was labeled to indicate that power was supplied from "BGLCB" electrical panel. Panel "BGLCB" is a panel powered fromthe Critical Branch of the EES. A review of that panel indicated that the Fire Alarm system was powered from circuit #35. Fire alarm system components shall be powered from the Life Safety Branch of the EES.
2). The face plate of a fire alarm booster panel on the 5th floor/south was labeled to indicate power coming from Critical Branch panel "CSE-LS, circuit #24". A review of that panel directory indicated that circuit #24 was "blank" (no power).
3). The fire alarm panel located in the emergency department indicated "trouble" on two zones, during the facility walk through on the morning of 07/13/2011 and again on the morning of 07/14/2011. The fire alarm system functioned correctly when tested by facility staff during the walk through on 07/14/2011. However the reason for the "trouble" signal had not been discovered.

Based on observation and discussions with facility staff, during the walk through on 07/13/2011, it was noted that fire sprinkler heads were obstructed, from normal discharge of water during an emergency, by surface mounted light fixtures located too close to the fire sprinkler heads in several pateint bedrooms with monolithic ceiling finishes, located in the west wing, 9th floor/south.

Based on the facility walk through on 07/13/2011 and 07/14/2011 with members of the facility staff, it was observed that not all janitor closets or soiled workrooms were negatively pressured relative to adjoiing spaces, as required.
1). A janitor closet in the surgical suite, near respriatory therapy, was observed to lack a negative pressure with the door open.
2). A soiled workroom located on the 9th floor/south was positively pressured, instead of negative.

Based on observation and discussion during the facility walk through on 07/13/2011, with facility staff members, it was noted that medical gas cylinders at the manifold location, were not secured by chains, racks, or other fastening devices to individually secure each cylinder from falling.

Based on observation and discussions with the facility staff, during the facility walk through on 07/13/2011, it was noted that There was no magnahelic or manometer gauge monitoring the 99% effiency filter bank for the HVAC system serving the ante room of the IV preparation area of the pharmacy on the basement floor/south. All filter beds of 75% or greater shall have draft gauges installed across filters (NFPA 99 5.1.3.3.2).

based on observations and discussion with the facility staff during a walk through of the facility on 07/13/2011 and 07/14/2011 it was noted that certain requirements of NFPA 70 (National Electrical Code)were not met.
1). During the facility walk through it was observed that at Panel "ELBX" (a Life Safety Branch panel)circuits #9 and #18 were providing power to duplex receptacles not approved to be powered from the Life Safety Branch of the EEs.
2). During the walk through survey, a number of panel directories were noted to be outdated with numerous alterations and marginally legible. Panel "DBE-1" had no directory at all.
3). During the walk through survey it was observed that the automatic egress doors for the emergency department ambulance entrance were powered from the normal electrical system panel "BGLHB". All powered egress doors shall be powered from the Life Safety branch of the EES.