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Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. Smoke door labeled 20 minutes, not 45 minutes, in a one hour rated wall. Birth Center, door to triage.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. Corridor not smoke tight with louver in door to IT room, Birth Center first floor to the right of the security desk, HUB 62.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. Facility at the time of the survey could not verify that the door to the Vertical Chase was a 2-hour rated door. Basement EP Storage

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. There are unsealed penetrations in the 1 hour smoke barrier above the cross corridor doors at the family waiting room. Main-4th floor - cross corridor doors at the family waiting room

B. There are unsealed penetrations in the 1 hour smoke barrier above the cross corridor doors at the entrance of the PICU-S area. Main-4th floor- PICU-S

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. The double doors at the smoke barrier leading into the ICU suite on the visitors entrance has a gap grater than 1/8 of an inch. Main 4th floor- ICU Visitors Entrance

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. Fire doors to hyperbaric unit utilize inactive door leaf without self-closing device and automatic flush bolt assembly. (Wound Center located on third floor)

B. The roof/ceiling assembly of the hyperbaric unit utilizes a non-rated roof suspended ceiling assembly. There is no one hour fire resistive enclosure at the roof/ceiling assembly.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. There is an active dead bolt installed on the patient room door, when the dead bolt is engaged it results in more than a one motion of the hand for egress from the room.
Main - 6th floor- Patient room 6156.

B. Stairway J exits into unprotected glass and steel passageway without an alternate exit from within glass and frame enclosure. The stair door prevents reentry due to access controlled egress lock assembly. The passageway encloses an interior courtyard on the basement level.

C. Stairway J is equipped with an incomplete access controlled egress lock - the exit door from the stair is not equipped with a release switch. The switch must be not greater than five feet from the door.

D. The delayed egress locks are not equipped with a sign on the door that states " Push, alarm will sound " lock will release in fifteen seconds. The locks are located near the maintenance room and triage area on the basement level.

E. Corridor area of imaging center terminates in a room with less than eight feet clear and obstructed path. The room is a waiting room located off the main corridor on the basement level.

F. There are dead-bolt locks on power operated horizontal exit doors - located on basement level near ROC waiting room.

G. The access controlled egress locks did not release during activation of the fire alarm system - Locks are located on the CT, and Imaging area cross corridor doors.

H. Exit egress door with delayed egress did not release with pull station or smoke detector. Corrected during survey. 3rd floor, peds exit stairwell.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. Fire doors to east stairway, adjacent to lobby, would not latch.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. There is a deadbolt lock in addition to other positive latching hardware on doors to CT scan #1, and #2.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. Exit access doors from restroom A is twenty-two inches in clear opening. Restroom is located in basement level imaging center.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. Exit egress lighting was switched and could leave the area in darkness. 7th floor group activities rooms, both North and South front halls.

B. Exit egress lighting was switched and could leave the area in darkness. 7th floor exam rooms, both North and South front halls.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. There is no emergency lighting for ground level exit discharge located on north side of facility.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. Additional exit and directional signs are needed in the exit corridor from the kitchen that will lead to the second mean of egress back to the stairwell. Basement Kitchen Exit Corridor

B. Additional exit and directional signs are needed in the rear exit corridor from the pharmacy. Second means of egress was not marked in the corridor. Basement - Pharmacy rear exit corridor.

C. Exit signage was not provided at exit door to the corridor. Second Floor Scan Center near Locker

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. No sprinkler coverage of shower stalls in ambulatory surgery center located on the ground floor - shower stalls are located in patient rooms similar to room #3.

This item is not a deficiency per regional office and hense removed.

B. Upper and lower most portion of the stairwell landing not sprinklered in the north stairwell MOB.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. The six sprinkler risers in the riser room are equipped with accelerator that are equipped with gate and ball valves that are not electronically supervised. West Building - Basement Sprinkler riser room

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. The sprinkler head is blocked in the electrical room just off the back of the medication.
Main - 4th floor- Medication room near 4126

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. The air handling unit did not shut-down with activation of duct-mounted smoke detector.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. There are portable space heaters located in the following areas:

1. bio-med room - basement level

2. Materials supply office - basement level

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. North corridor is obstructed by surgical lights and other impediments - located on ground floor of surgery center.

B. Corridor is obstructed by computer on wheels charging and stored in exit egress - located on ground floor of surgery center outside peds.

C. Exit egress to the public way is obstructed by cars in parking spaces located directly in the path of the egress. North side near parking deck.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. There is a large bulk soiled lined storage cart greater than 32 gallons that was stored in the changing room. Imaging Center

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. The outside cylinders are not protected from extremes of weather and the cylinders are not protected from rusting while the cylinders are sitting on the concrete pad. GMH-outside- Gas manifold area

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. There are oxygen and vacuum system piping supported from mechanical ducts by pipe hangers - pipe hangers must be secure to the structure - located on basement level.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. The zone control valves serving anesthetizing rooms in ENDO are not arranged to control individual rooms without shutting-off supply in other rooms. Valve box is located on the basement level.

B. The relative humidity is 32.6% and 25% respectively as measured by sensors located in operating room #7 of the main hospital tower.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. The storage room was being used for oxygen storage and there was not a No Smoking signage posted on the storage room door. Basement - Advanced Home Health Care Storage

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. The emergency system supplying load indicator is not functioning on the generator annunciator panel. During loss of normal power to the Life Safety Branch transfer switch there was no visual indicator response.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. Nurse Call system and key-pad system are wired to the Life Safety Branch of the essential electrical system - located on ground floor of ambulatory surgery center.

Based on observation, on February 7, 2012 at approximately 3:00pm onward, the following items were non-compliant, specific findings include;

A. The Alcohol Based Hand Rub dispenser is within seven inches of the electrical light switch. Basement - chemical treatment area across from the nurses station.