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Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies to comply with 7.1.3.2.1 (e) and 19.3.1.1. These deficiencies could affect all patients within the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection of an exit stair.

Findings include:

A. Afternoon of 12/04/12 a water pipe was observed within an exit stair enclosure which does not serve the stair. This construction does not maintain the 2-hour fire rated enclosure. Location observed:

1. First floor level, Stair # 3 this condition exists on several different floor levels within this stair.

B. 1. Corrected 06/25/13.

2. Corrected 06/25/13.

Based on random observation and staff interview during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all timesto comply with 19.2.1 and Chapter 7. These deficiencies could affect all patients, staff and visitors in the facility, by preventing occupants from reaching an exit from the building.

Findings include:

A. Morning of 12/5/12 numerous controlled access egress doors did not release upon loss of power. Example locations observed:

1. Both Cath Labs
2. Corrected 06/25/13.
3. Corrected 06/25/13.

B. Afternoon of 12/04/12 pair of cross corridor glass doors located at Birth Center Nurses Station contain a remote wall hung activation device with a green button reading "emergency exit lift cover push button". The facility representative was unable to determine the function of this remote egress device.

C. Corrected 06/25/13.

Based on random observation and staff interview during the survey walk-through, not all designated suites are provided with exits to comply with 19.2.5. Intervening rooms within a suite allow for a delay in becoming aware of a fire and to reach an exit access corridor. This condition could affect patients, visitors and staff within the O.R. and PACU areas.

Findings include:

A. Morning of 12/05/12 PACU deemed a suite by the facility, lacks the required arrangement of a means of egress and does not comply with 19.2.5.3 due to the following:

1. A designated means of egress through a staff dictation/work area (continuous counter, with chairs and storage) does not comply with 19.2.3.3 for obstructions within the means of egress and maintaining a clear minimum egress width.

2. The pair of egress doors from PACU lack access to a corridor to comply with 19.2.5.1. The PACU connects to a deadend elevator/stair lobby without direct access to a corridor.

3. Due to the conditions in A.1 and A.2. the PACU suite which is over 2,500 square feet does not comply with 19.2.5.3 for a minimum of two remote exits.

Based on direct observation 12/3/12, the surveyor finds the facility failed to provide automatic sprinkler protection for the following areas. These deficiencies compromise the safety of all occupants and does not allow for fire suppression and alarm to the facility:

A. Corrected 06/25/13.

B. The facility failed to provide automatic sprinkler protection for the patient room wardrobes on 3 South nursing unit.

Based on random observation during the survey walk through Medical gas systems are not maintained in accordance with NFPA 99 and NFPA 50.

Findings include:

A. Corrected 06/25/13.


B. Afternoon of 12/5/12 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. First floor PACU
2. Corrected 06/25/13.

Based on random observation during the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

A. The 400, 600, and 1000 KW emergency generators did not have a remote annunciators or a derangement signal at a 24 hour staffed location to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

A. Interim Life Safety Measures: 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. Life safety panels 5LS2, B2LS1and other life safety panels throughout the older portion of the main building are serving loads other than those specifically allowed by NFPA70, Section 517-32.

B. Critical panels F5CR5, 4CR7-A1, F3CR5, BB2CR1, B2CR1, and B2CR2 were serving loads other than those allowed on the critical power system. Critical panel F5CR5 had a circuit feeding the fire alarm system, 4CR7 and F3CR5 were serving med gas alarms (which should be on the life safety panel). This does not meet the requirements of NFPA70, Section 517-33.

C. The fire alarm circuit breaker in the panel F2LS1 as well as any othe breakers serving fire alarm panels or NAC are required to be marked red and have a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.

D. Panels PPENPH, EMBR1, EMBR2, CLP1, CLP2, EAG, EMBW1, E1, ESB2 and other emergency panels are not separated into life safety, critical and equipments branches in accordance with the 1999 Edition of NFPA-70, Section 30 through 35.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. Normal power receptacles were not provided in operating rooms, and rooms 1, 2, 17, and 19 in the ER 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 which could endanger any patient being treated at the time.

B. Electrical room A414A housed 4160 Volt, 2000 Amp switchgear and did not have access and exiting meeting the requirements of NFPA-70, Section 110-33, and Table 110-34(a). This sutuation could endanger the life of anyone working in the electrical room if a fault occured on the equipment.

C. The car lighting disconnects for the oaks elevators, and elevators 3, 4, and 5 did not meet the requirements of NFPA-70, Section 620-53.

D. Corrected 06/25/13.

E. Several panel schedules in the older part of the hospital were hand written and not current and did not meet the requirements of NFPA-70, Section 110-22.