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Based on observations during the tour of the north facility on the afternoon of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, the facility failed to maintain the egress corridor. The egress corridor contained medical gas outlets at radiology holding, which opens into the imaging department's egress pathway. Patient care cannot occur in an egress corridor.
Corridors shall be separated from all other areas by partitions complying with 18.3.6.2. through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observations during the tour of the north facility on the morning of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, the facility failed to provide an exit sign marking the exit path at 1) northwest electrical room and 2) end of emergency corridor and 3) exit sign was too far from the exit doors - near the emergency department fast track rooms. Exit, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Based on observations during the tour of the north facility on the afternoon of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, the facility failed to assure that door opening in smoke barrier was smoke resistant. Smoke barrier door did not close at 1) second floor ' s emergency department, near vending machines and 2) central utility plant ' s smoke barrier and 3) third floor - west side smoke compartment doors.

Based on observations during the tour of the north facility on the afternoon of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, the facility failed to assure the integrity of hazardous room. The room was sprinklered. fourth floor east medical records door was missing a closure.

Based on observations during the tour of the north facility on the afternoon of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, the facility failed to maintain proper clearance from the fire sprinkler head. Rolling file cabinet ' s tops were less than 18 " underneath sprinkler head in the fourth floor east medical records.




Based on observations during the tour of the north facility on the morning of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, the facility ' s fire sprinkler system did not comply with NFPA 13. No sprinkler head existed at 1) fifth floor west communication closet, 2) fourth floor east communication closet, 3) second floor toilet, near control room, 4) second floor storage, near education, 5) second floor IT closet near emergency and ICU departments.




Based on observations during the tour of the north facility on the afternoon of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, accompanied by the Director of Plant Operations, the facility failed to maintain the fire sprinkler system. At first floor mechanical room for cath lab, the sprinkler head was tucked into the duct insulation.

Based on observations during the tour of the north facility on the afternoon of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, the facility did not have reliable fire extinguishers. Pressure gauge reading was under charged at third floor elevator lobby ' s extinguisher.

Based on observations during the tour of the north facility on the morning of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, ' Time clock " #10 circuit was supplied with power from the life safety branch of the essential electrical system and needs to be moved to the another panel.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observations during the tour of the north facility on the afternoon of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, accompanied by the Director of Plant Operations, the facility failed to provide acceptable location for alcohol based hand rub dispensers at some locations. Dispenser was installed over an ignition source (electrical outlets) at outside of ICU 4.

Based on observations during the tour of the north facility on the afternoon of 10/14/2014, accompanied by the Interim Director of Plant Operations and maintenance staff, accompanied by the Director of Plant Operations, the facility failed to provide acceptable location for alcohol based hand rub dispensers at some locations. Dispenser was installed over an ignition source (electrical outlets) at outside of ICU 4.