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Based on observation, Hazardous areas were not separated from other areas in accordance with 38.3.2.1 and 8.4. Thsi deficiency could affect all occupants required to utilize the means of egress that these spaces open onto.

Findings include:

A. The Clean Supply/Storage room in the Outpatient Rehabilitation Unit in Pavilion A was not provided with a self-closing door to comply with 8.4.1.2 and 8.2.4.3.5.

B. The Soiled Holding room in the Outpatient Rehabilitation Unit in Pavilion A was not provided with a self-closing door to comply with 8.4.1.2 and 8.2.4.3.5.
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Based on random observation during the survey walk-through, not all exit or exit access 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 all patients in the facility required to utilize the exit path, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Corridors are obstructed by door swings which do not comply with 7.2.1.4.4.

1. On the morning of 3/6/12, the interior discharge of Stair 0 located at the 1st floor level was observed to be equipped with an auto opener which does not allow the door to swing so as not to obstruct the corridor more than 7" in the full open position. Movement thru the adjacent cross corridor double egress pair of doors and the corridor is obstructed.
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Exit signage is not provided to identify available exit routes to comply with 18.2.5.9, 18.2.10, and 7.10.1.4.

Findings include:

A. On the afternoon of 3/5/12, it was observed that exiting is directed into the center core Patient elevator lobbies which provided access to the core area stair. The corridor/lobby beyond the stair entry door is greater than 30' in length and is not provided with visible exit signage to identify the second exit route from these corridor/lobby spaces. This deficiency could affect all occupants required to utilize the Patient elevator corridor to access the required exit stair or the required second exit path in the event the center core stair becomes compromised or entry into the stair is by-passed in an emergency.

1. The 1st floor is the level of exit discharge for the core area stair which discharges to the interior of the building in accordance with 7.7.2. The 5th floor is a designated building re-entry level to comply with 7.2.1.5.2. Two exit paths to the exterior or to other exit stairs are not marked at these locations.

2. This condition was observed on most if not all floors.

B. On the morning of 3/6/12, Exit Access Corridors were observed not to be provided with exit signage to identify two available exit routes to comply with 7.5.1.2. Signage is either not provided or is obstructed by other building information signage. This deficiency could affect all accupants required to utilize the subject corridors as their means of egress from the areas. Locations observed include but are not necessarily limited to:

1. 2nd floor corridor near Stair 5 toward Stair 4.
2. 2nd floor corridor from Patient elevator lobby.
3. 2nd floor corridor outside Endoscopy Procedure rooms.
4. 2nd floor corridors in the Pre-Post Op areas.
5. 2nd floor corridor serving the Physicians' Lounge/Lockers
6. 2nd floor corridor serving the Ultrasound rooms.
7. Lower level corridor serving the Pharmacy.
8. Lower level corridor serving the North Mechanical room.
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Exit signage is not provided to identify available exit routes to comply with 38.2.10, and 7.10.1.4. This deficiency could affect all occupants required to utilize the stair and main corridor exit path.

Findings include:

A. The corridor exit path from the Outpatient Rehabilitation Unit located in Pavilion A adjacent the hospital is directed thru a 'service' corridor which also serves as the interior exit discharge for a stair. The door between the main corridor and the 'service' corridor is equipped with a lockset with the handle kept in the locked postion but an electric strike provided which is in the unlatched/unlocked position. It was not determined at the time of the survey, under what conditions the locking system was activated. Exit signage in the main corridor directing occupants to the main lobby betwen the 'A' and 'B' Pavilions was not otherwise provided. Exit signage within the 'service' corridor which serves as the discharge for the stair only identifies a single path of exit to the exterior. The corridor is not constructed as an exit passageway to allow a single exit and the second exit to comply with 7.5.1.2 is not marked.
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Based on observation, Hazardous areas were not separated from other areas in accordance with 38.3.2.1 and 8.4. Thsi deficiency could affect all occupants required to utilize the means of egress that these spaces open onto.

Findings include:

A. The Clean Supply/Storage room in the Outpatient Rehabilitation Unit in Pavilion A was not provided with a self-closing door to comply with 8.4.1.2 and 8.2.4.3.5.

B. The Soiled Holding room in the Outpatient Rehabilitation Unit in Pavilion A was not provided with a self-closing door to comply with 8.4.1.2 and 8.2.4.3.5.
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Based on random observation during the survey walk-through, not all exit or exit access 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 all patients in the facility required to utilize the exit path, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Corridors are obstructed by door swings which do not comply with 7.2.1.4.4.

1. On the morning of 3/6/12, the interior discharge of Stair 0 located at the 1st floor level was observed to be equipped with an auto opener which does not allow the door to swing so as not to obstruct the corridor more than 7" in the full open position. Movement thru the adjacent cross corridor double egress pair of doors and the corridor is obstructed.
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Exit signage is not provided to identify available exit routes to comply with 18.2.5.9, 18.2.10, and 7.10.1.4.

Findings include:

A. On the afternoon of 3/5/12, it was observed that exiting is directed into the center core Patient elevator lobbies which provided access to the core area stair. The corridor/lobby beyond the stair entry door is greater than 30' in length and is not provided with visible exit signage to identify the second exit route from these corridor/lobby spaces. This deficiency could affect all occupants required to utilize the Patient elevator corridor to access the required exit stair or the required second exit path in the event the center core stair becomes compromised or entry into the stair is by-passed in an emergency.

1. The 1st floor is the level of exit discharge for the core area stair which discharges to the interior of the building in accordance with 7.7.2. The 5th floor is a designated building re-entry level to comply with 7.2.1.5.2. Two exit paths to the exterior or to other exit stairs are not marked at these locations.

2. This condition was observed on most if not all floors.

B. On the morning of 3/6/12, Exit Access Corridors were observed not to be provided with exit signage to identify two available exit routes to comply with 7.5.1.2. Signage is either not provided or is obstructed by other building information signage. This deficiency could affect all accupants required to utilize the subject corridors as their means of egress from the areas. Locations observed include but are not necessarily limited to:

1. 2nd floor corridor near Stair 5 toward Stair 4.
2. 2nd floor corridor from Patient elevator lobby.
3. 2nd floor corridor outside Endoscopy Procedure rooms.
4. 2nd floor corridors in the Pre-Post Op areas.
5. 2nd floor corridor serving the Physicians' Lounge/Lockers
6. 2nd floor corridor serving the Ultrasound rooms.
7. Lower level corridor serving the Pharmacy.
8. Lower level corridor serving the North Mechanical room.
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Exit signage is not provided to identify available exit routes to comply with 38.2.10, and 7.10.1.4. This deficiency could affect all occupants required to utilize the stair and main corridor exit path.

Findings include:

A. The corridor exit path from the Outpatient Rehabilitation Unit located in Pavilion A adjacent the hospital is directed thru a 'service' corridor which also serves as the interior exit discharge for a stair. The door between the main corridor and the 'service' corridor is equipped with a lockset with the handle kept in the locked postion but an electric strike provided which is in the unlatched/unlocked position. It was not determined at the time of the survey, under what conditions the locking system was activated. Exit signage in the main corridor directing occupants to the main lobby betwen the 'A' and 'B' Pavilions was not otherwise provided. Exit signage within the 'service' corridor which serves as the discharge for the stair only identifies a single path of exit to the exterior. The corridor is not constructed as an exit passageway to allow a single exit and the second exit to comply with 7.5.1.2 is not marked.
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