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Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. This deficiency could affect any patients, staff, or visitors in the fire compartment housing the First Floor Imaging Department, because the condition lessens the construction type of the building.

Findings include:

A. At 1:43 PM on March 19, 2013, the construction type of the First Floor (apparent) building addition which houses X-Ray Rooms 1 and 2 was observed to be different than the rest of the building because the roof/ceiling assembly is constructed with open web steel joists and a drywall ceiling membrane in which unsealed penetrations were observed.
NEW: 1/16/14 The plaster ceiling in this room has been patched utilizing plywood which does not meet the definition of "limited-combustible" as defined in NFPA 101, 3.3.118.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any building occupants using the exit stairs because the stair enclosure could be compromised by smoke or fire, or by allowing a condition at which they could fall through the guardrails.

Findings include:

A. At 10:40 AM on March 19, 2013, rooms which are not normally occupied were observed to communicate directly with the Basement level enclosure for the Center East Exit Stair, as prohibited by 7.1.3.2.1(d). Rooms observed to open directly into the Exit Stair include:
1. The Boiler Room.
2. An Electrical Room.
B. 1. Corrected 08/27/13.
2. a. Corrected 08/27/13.
b. Corrected 08/27/13.
c. Corrected 08/27/13.
d. Corrected 08/27/13.

C. 1. Corrected 08/27/13.
2. Corrected 08/27/13.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors attempting to use the egress paths because the paths could become restricted.

Findings include:

A. At 9:08 AM on March 19, 2013, the following conditions were observed at the Fifth Floor Center "angled" wall adjacent to the Center Elevator and the Center West Exit Stair:

1. The clear width of the Corridor on both sides of the angled wall was observed to be reduced, as compared to corridor widths at either end of the wall. The angled wall is thus not arranged to avoid an obstruction to the convenient removal of building occupants as required by 19.2.3.3.

2. The door in the angled wall, when in the open (90 degree) position was observed to reduce the Corridor to less than half its required width as prohibited by 7.2.1.4.4.

B. At 10:30 AM on March 20, 2013, the following conditions were observed at the Corridor leading to the Fourth Floor south center portion of the building to the Southeast Exit Stair:
1. The two doors in the fire barrier were observed to not swing in the primary direction of egress as required by 7.2.1.4.2.
2. Corrected 08/27/13.

C. Corrected 08/27/13.

Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because key life safety components could become compromised if not protected.

Findings include:

A. During an interview held in his Office on the afternoon of March 18, 2013, the provider's Hospital's Director of Plant Operations was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. Further, during the survey walk-through, it was determined that existing records of such components were inaccurate. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. Corrected 1/16/14.

2. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, building separations, and separations between disparate construction types.

3. Corrected 1/16/14

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, ventilation shafts, and linen and/or refuse chute shafts.

5. Corrected 1/16/14

6. Corrected 1/16/14

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:


A. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

B. The fire pump was not equipped with a transfer switch at the fire pump location and was not served from the emergency generator to comply with NFPA-20, Section 6.2.

A. Emergency Department:

Based on direct observation, the afternoon od 3/19/13 while in the company of the Maintenance Technician, the surveyor finds the facility failed to provide:

1. Separation by an intervening wall the medical gas zone valves and the outlets/inlets they serve for treatment bays 1 thru 6. (NFPA 99, 1999, 4-3.1.2.3 (d)

2. Zone valves for the outlets /inlets in Triage. (NFPA 99, 1999, 4-3.1.2.3 (d)

Based on random observation during the survey walk-through not all medical gas systems comply with with NFPA 99, 1999, Chapter 4. Failure to install and maintained medical gas systems in accordance with referenced standard could result in failure of those systems, while in use or needed for critical patients.

The findings are:

A. On the afternoon of 03/19/13 The 4th floor Surgery area medical gas systems contained a master zone shut off valve located behind a lockable door and within an office. This location does not comply with NFPA 99 1999 chapter 4 for the required access to the shut off valve.

B. On the afternoon of 03/19/13 the 4th floor Operating rooms 1, 2, 3 and 4 each lacked a medical gas shut off valve. The surveyor was informed that the only shut off valve is the master located within the office. Therefore, under an emergency conditions an individual Operating room cannot be shut down without shutting down all Operating rooms. This application does not comply with NFPA 99 1999 chapter 4.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. 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.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches as required by NFPA-70, Section 517-31 thru 35. The system one line diagram was not up to date and it did not show all emergency panels or what branch each transfer switch served, and most panels were not labeled with the branch of emergency power they served. Examples include:

1. Panel E5PH is serving a mixture of all three branches, life safety, critical and equipment.

2. Panel ETS01-5 serves a mixture of life safety and critical, including room receptacles (critical) Section 517-33, and elevator cab lighting that shall be served from life safety in accordance with section 517-32.

3. Panels CP2 and CP3 are new critical panels in the remodeled northeast wings on the second and third floors, and they are serving med gas alarms and emergency lighting which shall be served by the life safety panel to comply with Section 517-32.

4. Panel E2PA did not have enough detail in the circuit description to determine if it was life safety or critical.

5 The panel at the 24 hour security desk was serving life safety (fire alarm), and critical (receptacles), and had no panel identification.

7. Panel EBPA serves a mixture of life safety and equipment.

7. Two panels in the tunnel off of mechanical room B, EBPN and EBPO were labeled as critical panels , but served mostly equipment loads.

Based on random observation during the survey walk-through the surveyor found that 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 on the fourth 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.

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

C. Corrected 08/27/13.

D. Emergency receptacles in the operating rooms on the fourth floor, and other patient bed locations were not labeled with the source panel and the circuit number in accordance with NFPA-70, Section 517-19(a). This could cause confusion during a power outage trying to locate an emergency receptacle for critical care equipment.

E. Patient bed location on the third floor in wing A were not equipped with emergency receptacles as required by NFPA-70, Section 517-18. This could effect any patient in this wing in the event of a power outage.

F. Panels in several location, including panels 5JP, 5PG, E4PK, E2PA, and several other locations, were either missing schedules or the schedules needed to be updated to comply with NFPA-70, Section 110-22. Schedules were handwritten, breakers were on but marked as spares or not labeled at all, and some panels including the panel at the 24 hour security desk and the emergency panel in the mechanical room 4 were not identified.

Based on random observation during the survey walk-through the surveyor found that portions of the elevator control system are not installed in accordance with NFPA-70, and 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).