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Based on observation during the survey walk through, not all the exit discharge illumination is arranged by either continuous in operation or capable of automatic operation without manual intervention. This could affect all occupants of the building during emergency situations.

Findings include:

On 10/24/18 at 10:30 AM, while accompanied with DE, all exit discharge locations to the exterior excluding the main entry could not be verified that the light fixture has two bulbs to comply with Sections 39.2.8 and 7.8.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all occupants within the areas of the facility, by preventing them from readily identifying the path to an available exit from the building in case of an emergency.

Findings include:

On 10/23/18 at 2:45PM while accompanied with DE, only one path of exit access was observed in the Radiology exit corridor at the smoke barrier pair of doors. Directional Exit sign was not installed at the smoke barrier door in the Radiology exit corridor. This is not in accordance with Sections 19.2.10.1 and 7.10

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire event.

Finding includes:

A. On 10/23/18 at 2:05 PM while accompanied with DE, it was observed that pipes and conduits penetrating the rated walls at the following locations had voids around them and were not sealed with fire/smoke resistance in accordance with Sections 19.3.2, 19.3.5.9 and 8.7.1.

1. Lower Level - Wall between Mechanical room and Soiled Utility Room.
2. Lower Level - Electric room had about fifteen (15) 1" holes through exit corridor wall and adjoining walls.




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B. On 10/23/18 at 9:55 AM while accompanied by ME, it was determined that on the third floor, east wing, equipment room ceiling contained two holes in the ceiling that was not fire stopped. This does not comply with Section 19.3.2.

C. On 10/23/18 at 10:05 AM while accompanied by ME, it was determined that on the third floor, IT closet contained a 2" conduit in the ceiling and a broken ceiling tile that was not fire stopped. This does not comply with Section 19.3.2.

D. On 10/23/18 at 11:06 AM while accompanied by ME, it was determined that on the second floor, OB, OR tech storage room door was not installed with a door closer. This does not comply with Section 19.3.2.

E. On 10/23/18 at 11:25 AM while accompanied by ME, it was determined that on the second floor, IT closet contained a missing ceiling tile that was not fire stopped. This does not comply with Section 19.3.2.

F. On 10/23/18 at 1:35 PM while accompanied by ME, it was determined that on the second floor, storage room door adjacent to neurosurgery on-call room did not latch to the door frame when tested. This does not comply with Section 19.3.2.

Based on an observation, the facility failed to properly install all required initiating devices to provide a functioning fire alarm system. This deficient practice could affect patients, staff and visitors if smoke was not detected and the fire alarm system did not operate due to the placement of a smoke detector.

Findings include:

On 10/23/18 while accompanied by DE, it was observed several smoke detectors that were located less than 3-feet from a HVAC diffusers which does not comply with 9.6, and NFPA 72 2010 Edition, Section 17.7.6.3.2. Locations observed:
A. At 1:45pm, First Floor: Equipment room
B. At 10:40 am, Lower Level: Soiled Utility Room

Based on observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building if the fire alarm system would fail to operate properly during a fire event.

Findings include:

On 10/23/18 at 9:45 AM while accompanied by ME, it was determined that on the third floor Mechanical Room a heat detector was hanging loose from the electrical box. This does not comply with NFPA 72, Section 10.3.2.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Finding includes:

On 10/24/18 at 9:10 AM while accompanied by the DE, it was observed that sprinkler protection is not provided in the two story Main Entrance Vestibule. This is in non-compliance with NFPA 13, 2010, 8.1.

Based on observation during the survey walk through the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The findings are:

On 10/23/18 accompanied by the EOS, it was observed that sprinkler protection is not provided at the following locations. This is in non-compliance with NFPA 13, 2010, 8.1.

1. 10:43 AM in the PACU air handling unit equipment room under duct at the outside air intake plenum. (NFPA 13, 2010, 8.5.5.3.1)
2. 11:15 AM Emergency Department Walk-in entry vestibule.
3. 1:10 PM at the 3rd floor stair 3 ceiling pocket. (NFPA 13, 2010, 8.6.7)
4. 1:49 PM at the loading dock under open overhead door. (NFPA 13, 2010, 8.4.2 (3))

Based on observation during survey walk-through, the sprinkler system is not maintained. This deficient practice could affect patients, staff, and visitors in the building if the sprinkler system failed to activate in the event of a fire emergency.

Finding includes:

A. On 10/24/18 at 10:15 AM while accompanied by the DE, observation determined that the FDC Check Valve internal inspection was not documented that it was inspected within five years, in accordance with 2011 Edition of NFPA 25, 5.2.1.1.2(5).




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B. On 10/24/18 at 11:00 AM during document review and interview, it was determined that the facility's sprinkler system has not been inspected and tested per NFPA 25, section 5.1.1.2.

Based on observation, not all sprinkler system components are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building if the sprinkler system failed to operate properly during a fire event.

Findings include:

On 10/23/18 at 9:50 AM while accompanied by ME it was determined that on the third floor, east wing, nourishment station contained a large gap around the sprinkler escutcheon ring that was not properly sealed. This does not comply with NFPA 13, Section 6.2.7.

Based on an observation, not all corridor doors are being maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass through a door from a room located on an exit corridor.

Findings include:

On 10/23/18 at 1:10 PM while accompanied by ME, it was determined that on the second floor, on-call room door contained 4 holes in the door at the door handle location. This does not comply with Section 19.3.6.3.

Based on an observation, not all smoke barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from one smoke compartment to another during a fire event.

Findings include:

On 10/23/18 at 10:15 AM while accompanied by ME, it was determined that on the third floor, smoke barrier, north corridor contained two conduit sleeves that were not firestopped. This does not comply with Section 19.3.7.3. and 8.5.

Based on observation during the survey walk through the facility failed to install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:
On 10/23/18 at 10:15 AM accompanied by the EOS, it was observed in the penthouse elevator machine room for elevators 1 thru 4 that heat detectors are not installed within 2 feet of each of six outboard sprinkler heads for elevator shutdown. (NFPA 101, 2012, 19.5.3 / ANSI A17.1, 2007, 2.8.3.3.2 & NFPA 72, 2010, 21.4.2)