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Based on random observation during the survey walk-through and staff interview, 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. At 1:20 PM on June 18, 2013, the following conditions were observed relative to a Cardiac Catheterization Trailer located immediately north of the First Floor Imaging Department, which, according to the provider's Corporate Director of Facilities, is used to serve inpatients:
1. During an interview held at the site, the provider's Facilities Engineering Manager was not able to identify the construction type for the Cardiac Catheterization Trailer.

2. The formerly unsprinklered Vestibule, observed to be of Type II (000) construction (which does not comply with 19.1.6.2.) was observed to have been modified to become unsprinklered Type V (000) construction because a wood enclosure had been constructed between the former Vestibule and the new Trailer, as well as over the Trailer.

3. The Type II (000)/Type V (000) construction was observed to not be separated from the adjacent Type I (332) construction by minimum 2 hour fire rated construction, as required by 19.1.1.4.1. and 19.1.6.2., because the wall between them includes an aluminum storefront assembly with windows and a door.

B. At 3:40 PM on June 18, 2013, the following conditions were observed at the Lower Level Tunnel, which is south and east of Stair 9:

1. The west portion of the Tunnel's floor/ceiling assembly (between Lower Level and First Floor) was observed to be of Type II (000) construction, which is not consistent with the construction type for the remainder of the building as required by 19.1.6.2., because the assembly includes unprotected steel beams.

2. During an interview held at the site, compliance with 19.1.6.2. could not be determined for the floor/ceiling assembly (between Lower Level and First Floor) for the remaining portion of the Tunnel, which was observed to include unprotected metal deck supported by concrete beams or concrete block walls, because the provider's Facilities Engineering Manager was not able to identify its construction type.

C. Unprotected steel structure was observed, as prohibited by 19.1.6.2., because it is not consistent with the building's designated construction type: Locations observed include (all Lower Level, floor/ceiling assembly between Lower Level and First Floor):
1. 8:49 AM June 19, 2013: Social Services Suite Storage Room, unprotected steel angle supporting the metal floor deck above.

2. 8:58 Am June 19, 2013: Old Coal Chute (located inside Mechanical Room), unprotected steel beams.

Based on random observation during the survey walk-through, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. This deficiency could affect any patients, staff, or visitors in the Third Floor Intensive Care Unit by permitting smoke to develop in occupied portions of the building.

Findings include:

A. At 2:08 PM on June 17, 2013, Masonite pegboard, which does not carry a Class A or B flame spread rating as required by 19.3.3.2.(1), was observed in the Third Floor Intensive Care Unit Equipment Room.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the First Floor Surgical Department by allowing smoke or fire to enter the egress corridor.

Findings include:

A. At 11:08 AM on June 18, 2013, the pair of horizontal sliding doors at the First Floor Surgical Department Pre-Op Holding Room (which typically latch upon closure) were observed to not latch, as required by 19.3.6.3.2., when power to the automatic door operating assembly is turned off.

Based on random 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. These deficiencies could affect any patients or staff in the First Floor Surgical Department by allowing smoke or fire to pass into other occupied portions of the Department.

Findings include:

A. At 10:50 AM on June 18, 2013, the following conditions were observed at the First Floor Surgical Department Sterile Core:
1. The doors to 7 Operating Rooms were observed to not be positive latching as required by 19.3.2.1 and 8.2.3.2.3.1(2).

2. The pair of horizontal sliding doors to the adjacent Corridor (which typically latch upon closure) were observed to not be self-closing or positive latching, as required by 19.3.2.1 and 8.2.3.2.3.1(2), when power to the automatic door operating assembly is turned off.

Based on random observation during the survey walk-through, not all exit passageways are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 1:13 PM on June 18, 2013, electrical conduits which do not serve the enclosure were observed above the ceiling in the First Floor Exit Passageway serving Exit Stair 5, as prohibited by 7.1.3.2.1(e).

B. At 2:39 PM on June 18, 2013, doors to the First Floor Exit Passageway serving Exit Stair 3 were observed to not be self-closing as required by 8.2.3.2.3.1(1). Doors observed include:
1. The door to the Hospitalist's Office (north side of Exit Passageway).

2. The door to the Omnicell Room (formerly Physical Therapy) (east side of Exit Passageway).

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 1:05 PM on June 17, 2013, the rooftop egress path for the Elevator Lobby serving the Helipad was observed to not be in compliance with Chapter 7, based on the following observed conditions:

1. The egress path was observed to cross from a steel ramp to a steel platform, and then down to the roof.
a. A steel channel between the ramp and the platform was observed which protrudes above both the ramp and the platform by more than 1/2", which results in a change in elevation prohibited by 7.1.6.2.

b. The steel platform was observed to not be at the same level as the ramp, which also results in a change in elevation prohibited by 7.1.6.2.

c. The step down from the platform:

1) Was observed to be in excess of 8", as prohibited by 7.2.2.2.1(b).
2) Was observed to lack a handrail required by 7.2.2.4.2.

2. The egress path was observed to pass in close proximity to a plumbing vent and an abandoned roof curb, which constitute tripping hazards prohibited by 7.1.10.2.1.

3. The egress path was observed to pass from the roof into Exit Stair 5. The step from the door sill into Exit Stair 5:
a. Was observed to be in excess of 8", as prohibited by 7.2.2.2.1(b).
b. Was observed to lack a handrail required by 7.2.2.4.2.

B. At 1:20 PM on June 18, 2013, the following conditions were observed at the exit stair serving the Cardiac Catheterization Trailer:

1. No solid risers were observed to be present, resulting in a lip at the underside of each tread as prohibited by 7.2.2.3.3.

2. The stairs were observed to lack handrails on both sides as required by 7.2.2.4.2.

C. At 2:39 PM on June 18, 2013, the door from the First Floor Omnicell Room (formerly Physical Therapy) to the adjacent Exit Passageway serving Exit Stair 3 was observed to be obstructed by large pieces of equipment as prohibited by 7.1.10.2.1.

Based on random observation during the survey walk-through, not all designated suites are provided with exits in accordance with 19.2.5.2. This deficiency could affect any patients, staff, or visitors in the Lower Level Cardiac Catheterization Suite by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 3:30 PM on June 18, 2013, due to the presence of temporary construction barriers, the Lower Level Cardiac Catheterization Suite was observed to lack a second, remote means of egress required by 19.2.5.3.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. At 9:49 AM on June 18, 2013, several holes, approximately 1/4" in diameter and as prohibited by 8.2.3.2.3.1(1) and NFPA 80 1999 15.2.5.1., were observed in each leaf of a pair of 90 minute fire rated cross-corridor doors located immediately east of the Second Floor Elevators near Exit Stair 4.

B. The pair of cross-corridor doors in the designated 2 hour fire rated wall immediately east of Stair 9 were observed to not comply with 8.2.3.2.3.1(1) because:
1. The doors do not carry a minimum 90 minute fire resistance rating.

2. The doors are not positive latching.

During an interview held in the Facilities Engineering Conference Room at 8:30 AM on June 18, 2013, provider staff members including the Corporate Director of Facilities, the Facilities Engineering Director, and a Maintenance Technician explained that patient safety would be compromised if a comprehensive test of the building fire alarm system were conducted as part of the building survey. They stated that this was due to the inability of the system to bypass the shutdown of air handling systems and the high outside temperature and humidity. It will therefore be necessary for surveyors on a future Federal Monitoring Survey to conduct a test of the building fire alarm system, after the facility has re-programmed the system to permit the bypass of air handling unit shutdown.


14416


A. By direct observation the afternoon of 6/17/13, the surveyor finds while in the company of the Lead Maintenance Technician, the facility failed to connect / maintain the installed duct smoke detector on the Same Day Surgery air handler. This deficiency could affect any patients, staff, or visitors in the area supplied by the air handling unit by permitting smoke to pass through the air handling unit and related ductwork.



17659


Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could affect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

B. Smoke detectors in the staff elevator lobby, (elevator 82015), and ER exam room #7 are not separated from air supply diffusers by at least 3' as required by NFPA-72, Section 2-3.5.1.

C. The fire alarm circuit breakers in Life Safety Panels ESC-1, and ELS5 are required to be marked with red and have a lock-on device on the circuit breakers to comply with NFPA-72, Section 1-5.2.5.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. At 1:20 PM on June 18, 2013, the First Floor Emergency Department exterior canopy, under which the Cardiac Catheterization Trailer and related combustible construction have been placed, was observed to not be covered by the building's automatic sprinkler system as required by NFPA 13 1999 5-13.8.2.

B. At 8:49 on June 19, 2013, the Lower Level Social Services Suite Storage Room was observed to be open to the interstitial space above the ceilings of the adjacent room to the north, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the First Floor Surgical Department because smoke and fire could pass into it from the Mechanical Room above.

Findings include:

A. At 8:57 AM on June 18, 2013, 13 ducts which penetrate the floor/ceiling assembly of the Second Floor Surgical Mechanical Room were observed to lack fire dampers required by NFPA 90A 1999 3-3.2.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. At 10:45 AM on June 18, 2013, equipment was observed being stored in Surgical Department Corridors prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. South East-West Corridor: Three gurneys; signs were observed above each location which identified it as the location at which the gurney for a specific Operating Room was to be stored. Similar signs were observed in the north East-West Corridor.

2. North-South Corridor: Metal rack with products on it.

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 the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, 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. The surveyor observed that life safety panel ESC-1 next to the surgical director's office, (109), serves loads other than those specifically allowed by NFPA70, Section 517-32.

B. The surveyor observed that the following critical panels were serving items other than those allowed by NFPA-70, Section 517-33:

1. Critical panels EC1A, serving the ER, was serving loads such as med gas and emergency and exit lights, which are required to be served from the life safety panel.
2. Critical panels ELA and ELB which are supplied from a critical transfer switch, had circuits feeding exit lights that are required to be served from the life safety branch panel.
3. Critical panels ECID and ECID1 were serving several fire alarm circuits, all of which are required to be served from the life safety panels.
4. Critical panel EC12 is serving all kitchen equipment and is required to be served from an equipment panel to comply with NFPA-70, Section 517-34.

Based on random observation during the survey walk through, 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 elevator machine room for elevator 82008 for Same Day Surgery was observed to be equipped with sprinklers, but there was not a heat detector within 2' of the sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. Elevators 1, 2, 82011 (Cath Lab), and 82003 (Family Practice) were observed to lack single, lockable disconnects for emergency cab lighting, receptacles, and ventilation, located in the elevator machine rooms, required by NFPA-70, Section 620-53.

C. The disconnect for the emergency cab lighting and controls for the hydraulic elevator for Same Day Surgery was observed to not be properly labeled as to source panel and circuit in accordance with NFPA-70, Section 620-53.

D. The Family Practice (elevator 82008), and the Same Day Surgery (elevator 82003), elevator machine rooms were observed to not be equipped with smoke detectors for the elevator recall system as required by ASME A17.1-211.3.

Based on random observation during the survey walk-through and staff interview, 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. At 1:20 PM on June 18, 2013, the following conditions were observed relative to a Cardiac Catheterization Trailer located immediately north of the First Floor Imaging Department, which, according to the provider's Corporate Director of Facilities, is used to serve inpatients:
1. During an interview held at the site, the provider's Facilities Engineering Manager was not able to identify the construction type for the Cardiac Catheterization Trailer.

2. The formerly unsprinklered Vestibule, observed to be of Type II (000) construction (which does not comply with 19.1.6.2.) was observed to have been modified to become unsprinklered Type V (000) construction because a wood enclosure had been constructed between the former Vestibule and the new Trailer, as well as over the Trailer.

3. The Type II (000)/Type V (000) construction was observed to not be separated from the adjacent Type I (332) construction by minimum 2 hour fire rated construction, as required by 19.1.1.4.1. and 19.1.6.2., because the wall between them includes an aluminum storefront assembly with windows and a door.

B. At 3:40 PM on June 18, 2013, the following conditions were observed at the Lower Level Tunnel, which is south and east of Stair 9:

1. The west portion of the Tunnel's floor/ceiling assembly (between Lower Level and First Floor) was observed to be of Type II (000) construction, which is not consistent with the construction type for the remainder of the building as required by 19.1.6.2., because the assembly includes unprotected steel beams.

2. During an interview held at the site, compliance with 19.1.6.2. could not be determined for the floor/ceiling assembly (between Lower Level and First Floor) for the remaining portion of the Tunnel, which was observed to include unprotected metal deck supported by concrete beams or concrete block walls, because the provider's Facilities Engineering Manager was not able to identify its construction type.

C. Unprotected steel structure was observed, as prohibited by 19.1.6.2., because it is not consistent with the building's designated construction type: Locations observed include (all Lower Level, floor/ceiling assembly between Lower Level and First Floor):
1. 8:49 AM June 19, 2013: Social Services Suite Storage Room, unprotected steel angle supporting the metal floor deck above.

2. 8:58 Am June 19, 2013: Old Coal Chute (located inside Mechanical Room), unprotected steel beams.

Based on random observation during the survey walk-through, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. This deficiency could affect any patients, staff, or visitors in the Third Floor Intensive Care Unit by permitting smoke to develop in occupied portions of the building.

Findings include:

A. At 2:08 PM on June 17, 2013, Masonite pegboard, which does not carry a Class A or B flame spread rating as required by 19.3.3.2.(1), was observed in the Third Floor Intensive Care Unit Equipment Room.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the First Floor Surgical Department by allowing smoke or fire to enter the egress corridor.

Findings include:

A. At 11:08 AM on June 18, 2013, the pair of horizontal sliding doors at the First Floor Surgical Department Pre-Op Holding Room (which typically latch upon closure) were observed to not latch, as required by 19.3.6.3.2., when power to the automatic door operating assembly is turned off.

Based on random 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. These deficiencies could affect any patients or staff in the First Floor Surgical Department by allowing smoke or fire to pass into other occupied portions of the Department.

Findings include:

A. At 10:50 AM on June 18, 2013, the following conditions were observed at the First Floor Surgical Department Sterile Core:
1. The doors to 7 Operating Rooms were observed to not be positive latching as required by 19.3.2.1 and 8.2.3.2.3.1(2).

2. The pair of horizontal sliding doors to the adjacent Corridor (which typically latch upon closure) were observed to not be self-closing or positive latching, as required by 19.3.2.1 and 8.2.3.2.3.1(2), when power to the automatic door operating assembly is turned off.

Based on random observation during the survey walk-through, not all exit passageways are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 1:13 PM on June 18, 2013, electrical conduits which do not serve the enclosure were observed above the ceiling in the First Floor Exit Passageway serving Exit Stair 5, as prohibited by 7.1.3.2.1(e).

B. At 2:39 PM on June 18, 2013, doors to the First Floor Exit Passageway serving Exit Stair 3 were observed to not be self-closing as required by 8.2.3.2.3.1(1). Doors observed include:
1. The door to the Hospitalist's Office (north side of Exit Passageway).

2. The door to the Omnicell Room (formerly Physical Therapy) (east side of Exit Passageway).

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 1:05 PM on June 17, 2013, the rooftop egress path for the Elevator Lobby serving the Helipad was observed to not be in compliance with Chapter 7, based on the following observed conditions:

1. The egress path was observed to cross from a steel ramp to a steel platform, and then down to the roof.
a. A steel channel between the ramp and the platform was observed which protrudes above both the ramp and the platform by more than 1/2", which results in a change in elevation prohibited by 7.1.6.2.

b. The steel platform was observed to not be at the same level as the ramp, which also results in a change in elevation prohibited by 7.1.6.2.

c. The step down from the platform:

1) Was observed to be in excess of 8", as prohibited by 7.2.2.2.1(b).
2) Was observed to lack a handrail required by 7.2.2.4.2.

2. The egress path was observed to pass in close proximity to a plumbing vent and an abandoned roof curb, which constitute tripping hazards prohibited by 7.1.10.2.1.

3. The egress path was observed to pass from the roof into Exit Stair 5. The step from the door sill into Exit Stair 5:
a. Was observed to be in excess of 8", as prohibited by 7.2.2.2.1(b).
b. Was observed to lack a handrail required by 7.2.2.4.2.

B. At 1:20 PM on June 18, 2013, the following conditions were observed at the exit stair serving the Cardiac Catheterization Trailer:

1. No solid risers were observed to be present, resulting in a lip at the underside of each tread as prohibited by 7.2.2.3.3.

2. The stairs were observed to lack handrails on both sides as required by 7.2.2.4.2.

C. At 2:39 PM on June 18, 2013, the door from the First Floor Omnicell Room (formerly Physical Therapy) to the adjacent Exit Passageway serving Exit Stair 3 was observed to be obstructed by large pieces of equipment as prohibited by 7.1.10.2.1.

Based on random observation during the survey walk-through, not all designated suites are provided with exits in accordance with 19.2.5.2. This deficiency could affect any patients, staff, or visitors in the Lower Level Cardiac Catheterization Suite by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 3:30 PM on June 18, 2013, due to the presence of temporary construction barriers, the Lower Level Cardiac Catheterization Suite was observed to lack a second, remote means of egress required by 19.2.5.3.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. At 9:49 AM on June 18, 2013, several holes, approximately 1/4" in diameter and as prohibited by 8.2.3.2.3.1(1) and NFPA 80 1999 15.2.5.1., were observed in each leaf of a pair of 90 minute fire rated cross-corridor doors located immediately east of the Second Floor Elevators near Exit Stair 4.

B. The pair of cross-corridor doors in the designated 2 hour fire rated wall immediately east of Stair 9 were observed to not comply with 8.2.3.2.3.1(1) because:
1. The doors do not carry a minimum 90 minute fire resistance rating.

2. The doors are not positive latching.

During an interview held in the Facilities Engineering Conference Room at 8:30 AM on June 18, 2013, provider staff members including the Corporate Director of Facilities, the Facilities Engineering Director, and a Maintenance Technician explained that patient safety would be compromised if a comprehensive test of the building fire alarm system were conducted as part of the building survey. They stated that this was due to the inability of the system to bypass the shutdown of air handling systems and the high outside temperature and humidity. It will therefore be necessary for surveyors on a future Federal Monitoring Survey to conduct a test of the building fire alarm system, after the facility has re-programmed the system to permit the bypass of air handling unit shutdown.


14416


A. By direct observation the afternoon of 6/17/13, the surveyor finds while in the company of the Lead Maintenance Technician, the facility failed to connect / maintain the installed duct smoke detector on the Same Day Surgery air handler. This deficiency could affect any patients, staff, or visitors in the area supplied by the air handling unit by permitting smoke to pass through the air handling unit and related ductwork.



17659


Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could affect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

B. Smoke detectors in the staff elevator lobby, (elevator 82015), and ER exam room #7 are not separated from air supply diffusers by at least 3' as required by NFPA-72, Section 2-3.5.1.

C. The fire alarm circuit breakers in Life Safety Panels ESC-1, and ELS5 are required to be marked with red and have a lock-on device on the circuit breakers to comply with NFPA-72, Section 1-5.2.5.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. At 1:20 PM on June 18, 2013, the First Floor Emergency Department exterior canopy, under which the Cardiac Catheterization Trailer and related combustible construction have been placed, was observed to not be covered by the building's automatic sprinkler system as required by NFPA 13 1999 5-13.8.2.

B. At 8:49 on June 19, 2013, the Lower Level Social Services Suite Storage Room was observed to be open to the interstitial space above the ceilings of the adjacent room to the north, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the First Floor Surgical Department because smoke and fire could pass into it from the Mechanical Room above.

Findings include:

A. At 8:57 AM on June 18, 2013, 13 ducts which penetrate the floor/ceiling assembly of the Second Floor Surgical Mechanical Room were observed to lack fire dampers required by NFPA 90A 1999 3-3.2.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. At 10:45 AM on June 18, 2013, equipment was observed being stored in Surgical Department Corridors prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. South East-West Corridor: Three gurneys; signs were observed above each location which identified it as the location at which the gurney for a specific Operating Room was to be stored. Similar signs were observed in the north East-West Corridor.

2. North-South Corridor: Metal rack with products on it.

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 the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, 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. The surveyor observed that life safety panel ESC-1 next to the surgical director's office, (109), serves loads other than those specifically allowed by NFPA70, Section 517-32.

B. The surveyor observed that the following critical panels were serving items other than those allowed by NFPA-70, Section 517-33:

1. Critical panels EC1A, serving the ER, was serving loads such as med gas and emergency and exit lights, which are required to be served from the life safety panel.
2. Critical panels ELA and ELB which are supplied from a critical transfer switch, had circuits feeding exit lights that are required to be served from the life safety branch panel.
3. Critical panels ECID and ECID1 were serving several fire alarm circuits, all of which are required to be served from the life safety panels.
4. Critical panel EC12 is serving all kitchen equipment and is required to be served from an equipment panel to comply with NFPA-70, Section 517-34.

Based on random observation during the survey walk through, 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 elevator machine room for elevator 82008 for Same Day Surgery was observed to be equipped with sprinklers, but there was not a heat detector within 2' of the sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.

B. Elevators 1, 2, 82011 (Cath Lab), and 82003 (Family Practice) were observed to lack single, lockable disconnects for emergency cab lighting, receptacles, and ventilation, located in the elevator machine rooms, required by NFPA-70, Section 620-53.

C. The disconnect for the emergency cab lighting and controls for the hydraulic elevator for Same Day Surgery was observed to not be properly labeled as to source panel and circuit in accordance with NFPA-70, Section 620-53.

D. The Family Practice (elevator 82008), and the Same Day Surgery (elevator 82003), elevator machine rooms were observed to not be equipped with smoke detectors for the elevator recall system as required by ASME A17.1-211.3.