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Based on direct observation it was determined that the facility installed exit signage not in accordance with Code requirements. Incorrect installation of exit signs can compromise the ability of occupants to find available exits from the building during a required evacuation due to a fire/smoke event.

The finding is:

On July 19, 2022, at 1:57 pm while in the company of the VP, FD, & FS, it was observed that an illuminated exit sign was installed above a door leading into the Old ICU suite, an unoccupied area now used primarily for storage. The door is also marked as not an exit with a sign at surveyor's eye level. This is not in accordance with 19.2.5.4, 7.10.1.1, & 7.10.8.3.1.

Based on direct observation fire alarm system components are not installed and maintained in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended and delay proper repairs when necessary.

Findings include:

On July 19, 2022, while in the company of the VP, FD, & FS, the following deficiencies were observed:

A. At 2:20 pm a Smoke Detector was observed to be installed in close proximity to an HVAC register located in the second-floor corridor near the central elevators, and is therefore not in compliance with NFPA 72-2010, Section 17.7.4.1.

B. At 2:30 pm a Smoke Detector was observed to be installed in close proximity to an HVAC register located in the MRI Scan room, and is therefore not in compliance with NFPA 72-2010, Section 17.7.4.1.

C. At 2:44 pm two Smoke Detectors were observed to be installed in close proximity to HVAC registers located in first-floor corridor number 174, as shown on Life Safety plans, and is therefore not in compliance with NFPA 72-2010, Section 17.7.4.1.

Based on document review the fire alarm system is not being inspected, tested and maintained in accordance with Code requirements. Failure to properly inspect, test and maintain the fire alarm system can result in failure of the system to operate as intended to warn occupants of a fire/smoke event.

Findings include:

On July 19, 2022, at 12:29 pm while in the company of the VP, FD, & FS, it was observed that the documentation for the Semi-Annual Initiating Device Visual Inspections as required by NFPA 72-2010, Table 14.3.1 (9), was not available for review.

Based on document review the sprinkler system is not being inspected, tested and maintained in accordance with Code requirements. Failure to properly inspect, test and maintain the sprinkler system can result in failure of the system to operate as required when needed to control a fire event.

Findings include:

On July 19, 2022, while in the company of the VP, FD, & FS, it was observed that the following documentation was not available for review:

A. At 12:32 pm, the documentation for the Weekly Sprinkler System Control Valves Inspection as required by NFPA 25-2011, Table 13.1.1.2, was not available for review.

B. At 12:33 pm, the documentation for the Monthly Sprinkler System Pressure Gauges Inspection as required by NFPA 25-2011, Table 5.1.1.2, was not available for review.

C. At 12:33 pm, the documentation for the Five-Year Fire Department Connection/Hydrostatic Piping test as required by NFPA 25-2011, Table 5.1.1.2, was not available for review.

Based on document review, fire and smoke doors are not maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency.

Findings include:

On July 19, 2022, at 12:51 pm while in the company of the VP, FD, & FS, it was observed that the documentation for Annual Fire and Smoke Door Inspections in accordance with Section 21.7.6, 8.3.3.1, 7.2.1.15, and NFPA 80-2010, Section 5.2.4.2, indicated deficiencies which have not been corrected at the time of the survey.

Based on direct observation the facility lacks complete electrical bonding of the medical gas piping system. Failure to install and maintain this installation could potentially result in the piping system becoming electrically energized. This deficient practice could affect patients, staff and visitors.

Findings include:

On July 19, 2022, at 2:55 pm while in the company of the VP, FD, & FS, it could not be confirmed through direct observation that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70-2011 Edition, Section 250.104 (B).

Based on direct observation ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

Findings include:

On July 19, 2022, at 3:30pm while in the company of the VP, FD, & FS a receptacle at the Central Nurse's station was observed near a sink and without GFCI protection to comply with NFPA 70-2011, 210.8(B)(6).

Based on direct observation ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

Findings include:

On July 19, 2022, while in the company of the VP, FD, & FS, the following deficiencies were observed:

A. At 1:35pm a receptacle in Compounding Area 504, as shown on Life Safety Plans, was observed near a sink and without GFCI protection to comply with NFPA 70-2011, 210.8(B)(6).

B. At 1:38pm a receptacle in Picking Area 505, as shown on Life Safety Plans, was observed near a sink and without GFCI protection to comply with NFPA 70-2011, 210.8(B)(6).

C. At 2:15pm a receptacle in Resp. Storage 324, as shown on Life Safety Plans, was observed near a sink and without GFCI protection to comply with NFPA 70-2011, 210.8(B)(6).

D. At 2:31pm a receptacle in Radiology E154, as shown on Life Safety Plans, was observed near a sink and without GFCI protection to comply with NFPA 70-2011, 210.8(B)(6).

Based on document review the facility could not provide evidence of weekly inspections of the Essential Electrical System. Failure to properly inspect the system may affect patient, visitors, and staff during a utility failure.

Findings include:

On July 19, 2022, at 12:40pm while in the company of the VP, FD, & FS, it could not be confirmed that weekly inspection of the facility emergency generator as required by NFPA 110-2010, 8.4.1 is conducted as the documents indicating these inspections are conducted are not available for review.