HospitalInspections.org

A) (New 03/20/14) Exit Stair # 6 has an Exit Passageway at the 1st Floor. This passageway has a door into an electrical closet which complies with the Hospitals written adoption of a CMS categorical Waiver. Inside the closet is a door which provides access to a continuous underground tunnel below, which is under a public sidewalk. This tunnel is located outside of the two hour barrier which separates this space from the Hospital. The door between this space and the 1st Floor closet is not a 90 minute fire rated door assembly in accordance with 19.1.1.4.2.

A) Based upon random observation throughout the Hospital, based on document review and/or the lack of documentation and based on personnel interview of the Regional Director of Facilities and the Manager of Facilities, the surveyor finds that portions of the Hospital are Type II (000) Construction, as defined by NFPA 220. The Hospital is a five story building that does not comply with the minimum construction type requirements of 19.1.6.2:

Finding include but are not limited to:

1) Corrected 03/19/14

a) Deleted 03/19/14

b) Portions of the building have steel structural members. Some of this structure is protected as a fire rated assembly with monolithic ceilings. UL numbers for these systems were not available. Portions of the Main Building have been fire proofed via a project that was not completed. U L Design Numbers for the systems used for this project were not submitted to the Department and were not available on site. Portions of the building have structural steel elements that are unprotected (see below).

c) Deleted 03/19/14

2) While portions of the 4th Floor have fire proofed steel above lay-in ceilings and/or monolithic ceilings protecting structural steel above. The north end of the 4th Floor corridor up to the four hour vestibule was observed, with the Manager of Facilities present to be unprotected steel structural elements above a lay-in ceiling. This observation constitutes Type II (000) Construction. Roughly 40' of the north end of this corridor was not sprinklered in an otherwise sprinklered fire compartment.

a) Deleted 03/19/14

3) Corrected 03/19/14

a) Corrected 03/19/14

4) Corrected 06/06/13.

5) (New 03/20/14): There is an underground interstitial space below the 1st Floor which is accessed via an opening the floor slab north of the 1st Floor Outpatient Lab. The opening in the floor and for an adjacent shaft is supported by unprotected steel columns and unprotected steel beams.

Failure to install and maintain fire rated structural assemblies could result in a failure of the building structure during a fire.



16339


Corrected 03/19/14

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that the doors to exit access corridors do not always have positive latching hardware in accordance with 19.3.6.3.2.

Findings include:

1) Corrected 3/19/14

2) 2nd Floor Surgery Building: Lobby T2112 has a surgical suite boundary identified in the east side of this Lobby. The pair of doors into the surgical suite lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

3) 2nd Floor Surgery Building: The PACU Recovery area is identified as a suite. This suite has two pairs of doors at each end. Both pairs of doors lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

4) Corrected 3/19/14.

5) 3rd Floor Northwest Wing: The pair of auto -open doors to the C-section unit lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 and 03/19/14 that the auto-open function on these doors is not disabled from fire alarm activation.

6) (New 03/19/14): 3rd Floor Northwest Wing: The single corridor door at the west end tf the C-section unit lack functioning positive latching hardware. The door latch was taped so that it would not function.

Failure to maintain corridor doors in accordance with code could allow fire and smoke to spread to corridors in a fire emergency.

A) Based on observation and based upon the lack of documentation, the surveyor finds that vertical openings are not protected in accordance with 8.2. of NFPA 101 - 2000 and/or NFPA 90A - 1999.

Findings include:

1) South Penthouse: Multiple ducts penetrate the fire rated floor assembly without fire dampers installed at the top of each shaft in accordance with NFPA 90A. The room at the top of the shafts referenced has too many many uses including as kitchen exhaust fan, elevator equipment, air compressors etc. all of which conflict with the room as part of the vertical shaft enclosures below

This includes the duct penetration for E64 along with all duct penetrations near E10.

2) 4th Floor Elevator Foyer east of Elevators # 4 and # 5 - there is a closet with a vertical duct shaft in this foyer:

a) Corrected 06/06/13.

b) Corrected 03/19/14

c) Corrected 05/23/14 - Surveyor 07113 from project inspection IDPH # 9986

d) Corrected 05/23/14 - Surveyor 07113 from project inspection IDPH # 9986

e) Corrected 05/23/14 - Surveyor 07113 from project inspection IDPH # 9986

3) Corrected 06/06/13.

4) 4th Floor Northwest Wing - there is a two hour shaft enclosure shown on drawings south of the Linen Chute at the corner of the corridors. Almost no access was provided to this shaft; however the surveyor observed, with the Director of Facilities and the Safety Manager present, the walls to this shaft do not extend to the deck above in accordance with 8.2 of NFPA 101.

5) The Patient Rooms on the 4th Floor of the Southwest Wing are typical of many rooms on many floors (but not all rooms) for the southern portion of the building.

a) The patient room window walls have induction units that are not installed in accordance with NFPA 90A - 1975.

i) The vertical risers for the induction units are not enclosed as fire rated shafts from deck to deck. Fire ratings for the shaft enclosures were not available and the shaft terminate above the ceilings.

i) The duct feeds from the vertical risers into the induction units are 3" to 4" in diameter. The provider was not able to demonstrate that this duct feeds at sealed at the shaft enclosure in accordance with the original design requirements from NFPA 90A. Almost every room if not all rooms were patient occupied - access for inspection was extremely limited.

b) Although some of the patient rooms have bathroom exhaust duct runs that extend to shafts with fire dampers, a number of rooms typically at the end of the Southeast and Southwest wings have vertically exhaust ducts that extend to the room, that are not enclosure in fire rate shaft enclosures and that also lack fire dampers where the ducts penetrate required shaft enclosures.

c) Similar conditions to those cited above were observed in the 2nd Floor South Wing patient rooms.

d) Based on observation on two patient floors. Based upon the limited information available from the provider and based upon very limited access to patient rooms for inspection, the surveyors find that the patient rooms on the 3rd and 5th Floor as similar or the same as those observed on the 4th and 2nd Floors and the same deficiencies are expected as those cited under "a" and "b" above.

6) There is an elevator foyer at the west end of 4 Southwest. This elevator has an interstitial space that wraps around the east and north side of the elevator shaft. A large duct extends from the elevator shaft without a fire damper, through the north exterior wall. With this arrangement the interstitial space is part of the elevator shaft enclosure.

a) This interstitial space is not sprinklered

b) Corrected 06/06/13.

7) 4th Floor Environmental Services closet opposite Room 409 provides access to a vertical shaft enclosure with multiple systems, ducts, conduit and a kitchen exhaust duct. The provider did not know what was in this shaft and was not able to identify how the kitchen exhaust duct is permitted in this shaft in accordance with NFPA 96.

a) This shaft when viewed from the 4th Floor appears to be open (and not enclosed in a fire rated enclosure) to a portion of the the Floor.

b) One insulted ducts runs horizontally through the shaft and has a fire damper. The west side of the shaft has a duct penetration for which a fire damper was not found.

8) 2nd Floor - Clean Supply Room opposite Room 209: There is a vertical shaft enclosure with a kitchen exhaust duct inside.

a) Corrected 06/06/13.

b) A duct penetrates this shaft horizontally with a fire damper. The provider is not able to demonstrate how this kitchen duct is permitted in the same shaft with other ductwork in accordance with NFPA 90A and NFPA 96.

9) The plans identify a 1st Floor Mechanical Room T1246 near the Main Lobby with a two hour fire rated enclosure.

a) The surveyor finds that this mechanical space is open basement level tunnel spaces below and vertical chases above. This mechanical room is not separated from the tunnels and crawl spaces.

b) The mechanical room and shaft above are open to adjacent ceiling spaces. Duct penetrate the Mechanical Room and shaft above; fire dampers were not found. Access is very limited.

10) (New 03/20/14): Main Building - First Floor, Old Radiology Department - the floor above at or near the Radiology Supervisor Office (second door from the exit) was observed with a duct penetration through the floor above. A fire damper was not found.

11) (New 03/20/14) There is an underground interstitial space below the 1st Floor which is accessed via an opening the floor slab north of the 1st Floor Outpatient Lab. This interstitial space is also open to a five story pipe shaft. A two hour fire barrier separating the pipe shaft from the interstitial space is not provided in accordance with NFPA 90A.

Failure to provide and maintain fire rated shaft enclosures and fire dampers at shaft penetrations will allow fire to spread from floor to floor in a fire emergency.



16339

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients in the facility, as well as any staff and visitors present, because the lack of proper installation of shaft could result in smoke or fire to migrate from one floor to another.

Findings include:

A. Corrected 06/06/13.

B. Corrected 03/19/14

C. Main Building - Third Floor/Med Surge Unit: The Life Safety drawings indicated two hour shaft walls near the Stair #1 by Patient Room 322 and based upon observation the shaft walls are not two hour fire rated to comply with 19.3.1.1. in accordance with 8.2.5. Also, the shaft above the ceiling contain a hole that is not fire sealed to comply with 8.2.3.2.3.

D. (New 03/19/14): Northeast Wing - 5th Floor Level - Stair #7: The designated two hour fire rated exit stair wall has been penetrated and pipes behind have been exposed on the west side of the stair wall. The exposed pipes which were observed are open to the stair do not comply with 7.1.3.2.1 e).

A) Based on observation with the Director of Facilities and the Safety Manager present, the surveyor finds that required exit enclosures are not installed and maintained in accordance with 7.1 and 8.2 of NFPA 101.

Findings include but are not limited to

1) Corrected 03/19/14

2) The south side of the Hospital has a two story foyer east of the Main Lobby. This foyer has a two story stair that connects the Hospital via a bridge across the street to a medical office building to the south. This two story foyer is identified on plans with a two hour fire rated separation between the foyer and the Hospital.

a) Corrected 03/19/14

b) A duct penetrates the 2 hour wall above
the fire doors at the 1st Floor without a
fire damper in accordance with 7.1 and
8.2 of NFPA 101.

5) Stair # 4 has a side-lite type panel in a steel frame next to the fire door on each floor. The provider is not able to identify how this thin panel at the stair enclosure is part of a two hour fire separation.

6) Stair # 4 serves as a required means of egress for four floors above the 1st Floor. The stair lacks an exit discharge in accordance with 7.7.1 or 7.7.2.

7) (Modified 03/19/14): Stair # 2 discharges into the 1st Floor exit passageway. The door to the Woman's Bathroom in this exit passageway is not a 90 minute fire rated door assembly.

8) Deleted 03/19/14

Failure to maintain exits could result in injury or death to staff and patients in a fire emergency.



16339

Based upon random observation the surveyor finds that exits are not enclosed and maintained as protected path to a public way to comply with Chapter 7 of NFPA 101. These deficiencies could affect any patients from this building and
as well as any staff and visitors because designated exit stairs are not protected against fire or smoke conditions to comply with 8.2.5.2.

Findings include:

1. Corrected 03/19/14 - per Cat. Waiver

2. Main Building - Stair #6 discharges at the First floor through a required exit passageway. This exit passageway is not identified on any facility plans as an exit passageway. This exit passageway does not comply with 7.1.3.2.2 due to the following:

a. The passageway lacks a continuous
protected path to an exit discharge in
accordance with 7.7.1. Surveyor
noted that the passageway contains
ductwork penetrations that are not
dampered, piping and other systems
which do not serve the passageway.

b. Corrected 03/19/14 - per Cat.
Waiver

c. (New 03/19/14): With the Director of
Facilities and construction personnel
present on 03/19/14, the surveyor
observed two new fire dampers installed
in the east wall; however the same
ducts penetrate the west wall and lack
fire dampers.

d. (New 03/19/14): With the Director of
Facilities and construction personnel
present on 03/19/14, the surveyor
observed a dumbwaiter shaft
(dumbwaiter abandoned and shaft is now
used as a duct shaft) with a door which
opens into the exit passageway. Two
large ducts penetrated the exit enclosure
and lack fire dampers.

The door to this shaft was propped open
with construction personnel working in
the exit and in the shaft. The exit path
was partially obstructed; there were
multiple tripping hazards and the shaft
was open to the exit. The surveyor
found not apparent interim life safety
measures for these conditions.


3. Main Building - Stair #3 discharges at the First Floor. The surveyor finds that the building is not fully sprinklered. The stair discharge does not comply with 7.7.1 or 7.7.2.

4. Corrected 06/06/13..

5. Main Building - First Floor, Stair #1: Based on observation the surveyor finds that an exit discharge enclosure (that serve a 5 story exit stair) does not provide a continuous protected path of escape to comply with 19.3.2. An exit stair enclosure was observed that does not comply with 7.1.3.2.1.(e) except #1. The designated 2-hour fire rated exit passageway lacked separation and protection due to the following:

a. The Exit Discharge of Stair #1 appears
to utilizes an exit passageway. The exit
passageway is not identified on any
plans.

The enclosure contains an elevator
which is open to an exit passageway and
does not meet NFPA 101 2000 -
7.1.3.2.1(d).

b. A duct was observed penetrating
the fire rated walls above the double
doors to E.D. suite which is part of the
exit passageway, and it was observed
to lack a fire damper .

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that required means of egress are not maintained as a continuously protected path to the outside in accordance with Chapter 7 and 8.2 of NFPA 101.

Findings include:

3) 2nd Floor Surgery Building addition: Elevator Lobby T2112 is part of a required exit access corridor. This corridor space lacks two remote paths of egress in accordance 19.2.5.9. Exit signs direct portions of the means of egress into the suites to the south and east which does not comply with 19.2.5.9. The only complying exit paths from this space (a horizontal exit and a exit stair) are next to each other and are not remote.

4) 2nd Floor Southeast Wing: There is an existing pair of cross corridor doors in the corridor with exit signs on both sides of the doors. These doors are not identified as smoke doors or doors in fire barriers. The exit path in both directions are required, however the doors only swing in one direction and do not comply with 7.2.1.4.2.

5) Corrected 03/19/14

7) Corrected 03/19/14

8) (New 03/20/14): 1st Floor Corridor T1091 is identified on plans as an exit access corridor although is does not comply with NFPA 101 - 2000:

a) It is a dead-end corridor greater than 30'-0". This item is not included in the FSES.

b. The corridor is directed into the ED Suite and does not comply with 19.2.5.9.

c. The pair of doors at the ED Suite have magnetic locking devices. Although the locking functions comply with 7.2.1.6.1 the doors lacks the signage required by 7.2.1.6.1.

d. This corridor was continuously lined on both sides of the corridor by supply carts, equipment and beds. The corridor was reduced in width from 8'-0" to 36".

Failure to provide and maintain adequate means of egress could result in injury or death to staff and patients in a fire emergency.



16339


Corrected 03/19/14

A. Based on observation, the surveyors finds that designated outpatient suites do not appear to have two remote exit access doors to comply with 19.2.5.2. Example location observed:

1. Main Building - First Floor, Cardiac Cath Lab Suite (identified 3,301 square feet in the Life Safety Plan): The suite is in excess of 2,500 square feet and lacks two remote exit paths to comply with 19.2.5.3.

2. Corrected 03/19/14

A) Based on document review and random observation with the Regional VP, Director of Facilities and the Safety Manager present, the surveyors observed two, three and four hour fire barriers are provided throughout the building and multiple four hour Chicago Vestibules are installed on each floor but no always at the same location on each floor. While these Chicago Vestibules could comply as horizontal exit, there is not information available that clearly indicates that they are used as such, that they are required by NFPA 101 and/or how they comply with 19.2.2.5. The surveyor notes that these fire barriers and Chicago Vestibule also defined required smoke compartments; however this information is missing - see K048.

Based on random observation, the surveyor finds that some of these fire barriers are deficient as fire barriers and/or smoke barriers and do not comply with Chapter 8 of NFPA 101.

Findings include

1) Ice Machine Alcove T4037 is defined on some plans with a four hour fire barrier on the west side of the space and with fire barriers on all sides on other plans.

a) There is an existing fire shutter on the east side of the space with a fusible link. The shutter is not designed to close in accordance with 7.2.1.8 and the space has not exit path is the shutter closes.

b) The designed four hour fire barrier at the west side of this space is four inches of pyrobar with voids in the barrier above the ceiling. This condition does not constitute a two hour or a four hour fire barrier.

2) Similar conditions were observed at the same location on the 2nd Floor except that a duct penetration through the designed fire barrier on the 2nd Floor lacks a fire damper.

3) Similar of the same conditions are expected at the 3rd Floor.

Failure to maintain fire barriers will allow smoke and fire to spread to other compartments.





16339


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 as required by NFPA 101, 8.2.3.2.4.1&2. Findings include:

1. Main Building, Fifth Floor: Designated 4 hour Chicago Vestibule near the Nurse Education Room is a required smoke barrier in addition to a fire barrier. The surveyor observed a duct penetration that is not fire and smoke dampered.

2. Corrected 06/06/13.

3. Main Building - First Floor, Emergency Department Suite: In the morning of 12/19/12, the designated two hour fire wall was observed with a duct penetration that is not fire dampered. Location observed above the SE pair of doors to the ED Suite.

4. Main Building - First Floor near the NE Emergency Department Suite: In the morning of 12/19/2012, the designated four (4) hour Chicago Vestibule / fire separation wall near the Nurse Station I and by the Decontamination Room was observed with duct penetrations (2) that are not dampered.

5. Corrected 06/06/13.

A) Corrected 06/06/13.

B) Corrected 03/19/14

C) Underground spaces, crawl spaces and underground tunnels along with the accesses to such spaces are not identified on the Life Safety Plans dated February 2012. The surveyor observes that a portion of this space is used for storage and that the storage use is open to the entire crawl space. The surveyor also observes that a portion of this space may be sprinklered, however there are no barriers that separate the sprinklered area from the unsprinklered area.




16339


A. Corrected 03/19/14

B. Corrected 03/19/14

A) Corrected 03/19/14




16339


A. Based on random observation during the survey walk-through and staff interview, not all portions of the building fire alarm system are installed in accordance with 19.3.4 findings include:

1. Corrected 06/06/13.

2. Main Building, Second Floor (ICU Suite): Pair of double doors (hold-open) to the ICU Suite near the Stairwell #6 did not close to latch during the activation of the fire alarm system.





17659


Based on random observation during the survey walk through while accompanied by the senior electrician and the coordinator 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 all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

1. Corrected 03/19/14

2. Corrected 06/06/13.

3. Corrected 06/06/13.

A) Based on random observation with the Director of Facilities and the Safety Manager present the surveyor finds that the sprinkler system is not installed and maintained in accordance with NFPA 13 -1999:

Findings include but are not limited to:

Note: The surveyors find that the building is not fully sprinklered and therefore does not qualify for any exceptions under NFPA 101 for fully sprinklered buildings. The surveyors further observe that no floor is fully sprinklered and that in some cases some smoke or fire compartments are not fully sprinklered.

1) Corrected 03/19/14

7) Corrected 03/19/14

B) (New 03/20/14) Based on random observation with the Director of Facilities present on 3/19/13 - 3/20/14, the surveyor finds that rooms or spaces lack sprinkler protect in otherwise sprinklered areas or compartments. In some cases the lack sprinkler system does not comply with the exceptions under NFPA 13 -1999.

Locations include:

1. 2 North - the Ice Machine Alcove lacks sprinkler protection.

2. 1st Floor Boiler Room - the door to the ComEd electrical vault is not sprinklered. The room is enclosed in a with a fire barrier that meets or exceeds the exceptions under NFPA 13; however, the door to this space does not close automatically and latch.

3. The Boiler Room is sprinklered. The Boiler Room is open to a Lower Level (which is more of a tunnel space and crawl space). The area is the Lower Level, near the Boiler Room opening is sprinklered; however all spaces, all tunnels and or crawlspace areas which are also open to the Boiler Room are sprinklered. There are no fire barriers in this Lower Level to limit what must be sprinklered.

4. Electrical Room T1213 is used for storage and therefore does not comply with the exception for non-sprinklered spaces. A penetration through a two hour wall is not sealed for two hour construction. It is not sprinklered in accordance with NFPA 13.

5. The 1st Floor Chapel closet lacks sprinkler protection.

6. There is an underground interstitial space below the 1st Floor which is accessed via an opening the floor slab north of the 1st Floor Outpatient Lab. This interstitial space is used as a storage area for pipe insulation and other materials. If is also open to a pipe shaft. The space is not sprinklered in accordance with NFPA 13 and all of the areas open to it also lack sprinkler protection.

Failure to install and maintain sprinkler protection could result in partial coverage and spread of fire and smoke in a fire emergency.

1. 6th floor Mechanical Room (T6003). By direct observation in the company of the Coordinator of Building Operations the surveyor could not determine that all duct penetrations through floor or shaft enclosures contain fire damper at the following locations.

a. Shaft (T6008) next to the elevator shafts, the supply duct penetrations (2).

b. Floor penetration in the maintenance shop space (T6011) East and South of the elevator shafts.

2. 6th floor Mechanical Room (T6015).

a. Floor penetration for exhaust fan E62.

b. Floor penetration for exhaust fan E63.

c. Floor penetration for what appears to be dishwasher exhaust East of the kitchen exhaust fans. 05/23/14 - Kitchen grease duct has not been removed and capped.

A) Corrected 06/06/13.

B) Corrected 07/25/14 - based on project response letter dated 7/14/14 for Project 9986 Clear this tag on next survey!!!!!!!!


14416

C) Corrected 05/23/14 - Surveyor 07113 from project inspection IDPH # 9986

A) Corrected 06/06/13.




16339

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. This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors because means of egress are not continuously maintained.

Findings include:

B. Main Building - Third Floor, OB Unit: In the morning of 12/17/12 it was observed that the corridor ceiling in the 3rd floor OB department was not at the minimum 7'-6" height required by 7.1.5. Height was approximately 7'-2". This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors.

Based on direct observation, the surveyor finds the facility failed to provide separation by an intervening wall between the medical gas zone valves and the outlets they serve to comply with NFPA 99, 1999, 4-3.1.2.3 (d). These deficiencies could pose a potential hazard to patients if medical gas zone valves are not installed properly in accordance with NFPA 99.

A. In the morning of 12/19/12, by direct observation the surveyor finds that not all medical gas zone valves are separated from the outlets/inlets they serve. This does not comply with NFPA 99, 1999, 4-3.1.2.3. Locations observed:

1. Main Building - First Floor, E. R. Suite, E.R. Examination Bays (A, B, C, D,E, and F):

2. Main Building - First Floor, E. R. Suite serving bays D, E, F, G, and H

3. Main - First Floor, Radiology Suite for Prep/Recovery Bays

4. Main Building - First Floor, Ultrasound Suite

5. Main Building - First Floor, Cardiac Cath Suite

6. Corrected 03/19/14

A) From random observation the surveyor finds that the building is not fully sprinklered and smoke dampers are not installed at designated smoke barriers in accordance with 8.3.6 of NFPA 101.

Findings include but are not limited to:

1) (Revised 03/19/14): 2nd Floor Southeast Wing: The four hour vestibule between 2 SE and the Surgery Building addition to the east is a required smoke barrier. It is not identified as a smoke barrier on plans. Both smoke compartments lack sprinkler protection; one duct penetration lacks a smoke damper in accordance with 8.3.6 of NFPA 101 and in accordance with NFPA 90.

2) (Revised 03/19/14): 2nd Floor Southeast Wing: The four hour vestibule between 2 SE and the Recovery Room of Surgery Building addition to the east is a required smoke barrier. It is not identified as a smoke barrier on plans. Both smoke compartments lack sprinkler protection; one duct penetration has a fire damper but lacks a smoke damper in accordance with 8.3.6 of NFPA 101 and in accordance with NFPA 90.

Failure to provide and maintain smoke dampers in unsprinklered buildings will allow smoke to spread to multiple areas in a fire emergency.

Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator 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, 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:

1. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panels EP-4W-1, LP-3W-C, LP-3W-C2, LP621, CLP-2W-2, ER-CP1, 1R-LRP-CR-1B, and 1-CLR-3 had circuits feeding the fire alarm panels, med gas alarm panels, and elevator cab lighting (these items should be served from the life safety panel). This does not meet the requirements of NFPA-70, Section 517-32 and 33.

2. Life safety panel EMLP-4 is serving a cardiac monitor and panel EM-L11 is serving the operating rooms on the fifth floor, (should be served by the critical branch), which does not meet the requirements of NFPA-70, Section 517-32.

3. (New 03/20/14): Panel IR-LRP-CR-1B, Panel LP-3W-C2 and/or Panel IR-LRP- IB all have conflicting panels schedules and they have circuits marked as feeding fire alarm system. These panels are identified at Critical Branch Panels of emergency power. The fire alarm panels are not supplied from the Life Safety Branch in accordance with 517-32.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present, the surveyor observed that electrical installations, equipment and materials are not installed and maintained in accordance with NFPA 70 - 1999.

Findings include:

1) Access to electrical panels and switchgear is blocked; 36" of clear space and a clear path are not provided and maintained.

c) 2nd Floor Surgical Suite - Closet with Panel 2-LR-2

i) The room is used for storage but lacks
sprinkler protection in accordance with
NFPA 13.

d) (New 03/20/14): 1st Floor Load Dock Receiving Room. On 03/19/14 with the Director of facilities present the surveyor observed at that access to the Generator Room door and access to an electrical room door was blocked by storage, even with signs in the space indicating that such access was not to be blocked. Adequate provisions to prevent re-occurrence have not been implemented.

Failure to install and maintain electrical systems in accordance with code could cause a fire.



16339

Based on random observation during the survey walk-through, not all portions of the facility's electrical system are installed in accordance with NFPA 70.

Findings include:

A. Corrected 03/19/14

B. Corrected 06/06/13.

C. Corrected 06/06/13.

D. Corrected 06/06/13.




17659


Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. (Modified 03/19/14): Normal power receptacles were not provided in operating rooms on the second floor, and in the patient rooms on the second floor, as required by NFPA-70, Section 517-19, and NFPA-99, 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.

2. Bonding of the piping for the medical gas system could not be located by staff as required by NFPA-70, Section 250-104(c). This could cause a potential difference between med gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

3. Corrected 03/19/14

By direct observation the afternoon of 12/18/12 in the company of the Coordinator of Building Operations, the surveyor finds that sprinkler protection is provided in the penthouse elevator machine room (located at the fifth floor level of Stair Tower No. 1) for the elevator identified in the machine room as Elevator No.1, however heat detectors are not provided or install within 2 feet of each sprinkler head for elevator shut down prior to the discharge of water as required by NFPA 72, 1999 3-9.4 & ANSI/ASME A17.1, 102.2, c, .3).

A) Corrected 03/19/14


17659


Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator 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:

1. The surveyor did not find a single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator as required by NFPA-70, Section 620-53.

2. The surveyor did not find that the disconnect for the emergency lighting and controls for each elevator was fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

A) (New 03/20/14) Exit Stair # 6 has an Exit Passageway at the 1st Floor. This passageway has a door into an electrical closet which complies with the Hospitals written adoption of a CMS categorical Waiver. Inside the closet is a door which provides access to a continuous underground tunnel below, which is under a public sidewalk. This tunnel is located outside of the two hour barrier which separates this space from the Hospital. The door between this space and the 1st Floor closet is not a 90 minute fire rated door assembly in accordance with 19.1.1.4.2.