HospitalInspections.org

Based on observation the facility failed to maintain access to an exit stair. Failure to maintain free exit access places staff and visitors at risk during a fire emergency.

The finding is:

On 10/27/20 at 1:45pm in the company of the DE the West Basement exit stairs was blocked by a parked housekeeping floor maintenance machine.

Egress doors are capable of being locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

It was observed at various locations that Delayed egress locking systems had been installed which are not in full compliance with 19.2.2.2.4 and 7.2.1.6.1. Locations & conditions observed include the following:

A. The building was determined to be only partially sprinkler protected (as a minimum the elevator machine rooms lacked sprinkler protection) thereby not meeting the requirements of 7.2.1.6.1.1(1) which requires the building to be "protected throughout by an approved, supervised automatic fire detection system or an approved supervised automatic sprinkler system".

B. Delayed egress locking devices (magnetic locks) lacked signage to identify the delay feature to comply with 7.2.1.6.1(4) at the following locations:

1. On 10/27/20 at 9:47am , while in the company of the VPF, it was observed that the South Stair door of the 6th floor of Olin Sang building lacked signage.

2. On 10/27/20 at 9:50am , while in the company of the VPF, it was observed that the North Stair door of the 6th floor of Olin Sang building lacked signage.

Based on observation egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

A. On 10/27/20 at 9:37am accompanied by the ADELS, doors contain delayed egress which do not comply with 7.2.1.6.1 due to the following:

1. The pair of cross corridor doors at fifth floor C5158 doors automatically reset after the alarm 7.2.1.6.1.1(3).

2. The pair of cross corridor doors at fifth floor C5158 lack signage which indicates the 15 second delay action 7.2.1.6.1.1(4).

3. A door adjacent to fifth floor C5130 lacks signage which indicates the 15 second delay action 7.2.1.6.1.1(4).

4. Fifth floor exit stair doors lack signage which indicates the 15 second delay action 7.2.1.6.1.1 (4).

Based on observation not all doors in exit access corridors or other means of egress are available at all times for egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising the direction of egress within a room or exit access corridor.

The finding is:

B. On 10/27/20 at 10:36am while accompanied by the ADELS means of egress doors were observed which lack proper egress hardware to comply with 19.2.2.2.4. Location observed: fourth floor corridor access doors from OB Triage contain manual hold open devices which does not comply with 7.2.1.8.2

Based on observation the facility failed to maintain self-closing door to an exit stair. Failure to maintain self-closing doors places staff and visitors at risk during a fire emergency.

The finding is:

On 10/27/20 at 1:50pm in the company of the DE the Basement exit door to Stair 7 was blocked open with piece of broom handle.

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required including stair components within the stair enclosure. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. On 10/26/20 at 1:05pm while accompanied by the ADELS, guardrails at landings were observed in exit stair enclosures in which the height of the guard did not comply with 19.2.2.3, 7.2.2.4.5.2. Please note that exception (3) applies to the stair and not the landing.

Example location observed:
1. Exit Stair #7 12th floor

B. On 10/26/2020 at 1:05pm while accompanied by the ADELS, guardrails were observed in exit stair enclosures in which the distance between rails was in excess of 4". This condition does not comply with 19.2.2.3, 7.2.2.4.5.3.

Example location observed:
1. Exit Stair #7 12th floor

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required including stair components within the stair enclosure. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. On 10/27/2020 at 11:10 AM while accompanied by the ADELS, exit stair was observed with a door opening into an unoccupied storage room. This condition does not comply with 19.2.2.3, 7.1.3.2.1(9). Location observed: Fourth floor Stair #3 landing containing a door to NICU storage room C4435 (life safety drawings).

B. On 10/27/20 at 10:14am while accompanied by the ADELS exit stair was observed which does not maintain a minimum 2-hour fire rated enclosure to comply with 7.1.3.2.1(3). Locations and conditions observed:

1. At 10:14am Stair #1 Fifth floor contains piping, heating water supply lines, low voltage wiring, duct work above suspended acoustical tile ceilings which do not serve the stair and do not maintain the 2-hour enclosure.

2. At 11:16am Stair # 3 Fourth floor:

i. Contains piping, conduit, low voltage wiring, duct work above suspended acoustical tile ceilings which do not serve the stair and do not maintain the 2-hour enclosure.

ii. Contains a hole in the wall above the ceiling in a corner of the landing adjacent to the low voltage wiring penetration which still has the pull line.

Based upon observation, emergency lighting is not maintain in accordance with Code requirements. Failure to maintain the emergency lighting provided for the facility can result in the inability of occupants to find exits during failure of the normal lighting system.

Findings include:

On 10/28/20 at 9:40am while in the company of the VPF & ADELS it was observed that the interior of the facility was provided with battery powered means of egress/ emergency lighting. Periodic testing documentation for monthly 30 second testing and annual 90 minute testing of the systems to comply with NFPA 101-2012, 7.9.3.1.1(5) was not available for review.

Based on observation, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The finding is:

On 10/27/20, at 11:25am while accompanied by the ADELS it was determined that battery-powered emergency lights are not provided in all critical care areas to comply with NFPA 99-2012, 6.3.2.2.11.4 and NFPA 70-2011, 517-63A.
Example location observed: C-Section Rooms which appeared to contain emergency lighting which is on the generator.

Exit signs are not maintained in accordance with Code requirements. Failure to maintain exit signs can compromise the ability of occupants to find available exits from the building during a required evacuation due to a fire/smoke event.

Findings include:

On 10/28/20 at 9:35am while in the company of the VPF & ADELS it was observed that a minimum of 7 of 8 exit signs observed did not have the internal illumination of the sign functioning to comply with 39.2.10 and 7.10.5.2.1.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

The finding is:

On 10/26/20 at 12:50pm while accompanied by the ADELS, a corridor was observed which contains an exit sign that does not comply with 7.8.1.2 and 19.2.8.
Location observed: Fifth floor corridor adjacent to Stair #7 and rooms L504 and L500 (life safety floor plans) exit sign is not lit.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

The finding is:

On 10/27/20 at 1:15pm while accompanied by the ADELS, a suite was observed which lacks an exit sign to comply with 7.8.1.2 and 19.2.8.
Location observed: Second floor Outpatient Holding.

Based on observation the facility failed to maintain a complete shaft enclosure. Failure to maintain the building systems enclosure places patients, staff and visitors at risk during a fire emergency.

The finding is

A. On 10/27/20 at 9:40am in the company of the DE the facility failed to maintain the twelve-story ventilation shaft as seen in the 12th Floor Mechanical Room L1219 at the shaft enclosure adjacent to the Stair 7. The enclosure has a non-fire rated access panel and cement block breach under the installed fire damper.


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Based an observations, not all exit doors are installed or maintained to permit egress and provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency.

The finding is:

B. On 10/26/20 at 1:15pm, while accompanied by the ADELS, it was determined that not all exit components are provided with elements which maintain the fire resistant rating of the enclosure. Surveyor observed in numerous locations exit stair door hardware components which did not provide a fire rated door assembly. This does not comply with the requirements of NFPA 101, 19.3.1, 19.3.1.3.

Locations observed:
1. Exit Stair #7, fifth floor
2. Exit Stair #6, fifth floor

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

Findings include:

A. On 10/28/20 at 9:35am while in the company of the VPF & ADELS, it was observed that the western-most sprinkler protected storage room lacked a self-closing door assembly to comply with 39.3.2.1, 8.7.1.2 and 8.4.3.5. The observed door was also observed to have a taped strike plate to prevent latching.

B. On 10/28/20 at 9:40am while in the company of the VPF & ADELS, it was observed that a sprinkler protected office contained the storage of a minimum of three full 30+ gallon bags of soiled linens and the door to the room was not a self-closing door assembly to comply with 39.3.2.1, 8.7.1.2 and 8.4.3.5.

Several smoke detectors throughout the hospital are located adjacent to air handling system supply diffusers. Failure to locate devices appropriately may result in devices failing to initiate an alarm in the event of an emergency. If alarm initiating devices do not function properly, then the building occupants may not be alerted to an emergency which may result in occupants' safety being compromised.

Findings include:

A. It was observed at various locations that detectors are located where airflow may prevent normal operation of the device as stated in NFPA 72 2012 17.7.4.1. Locations & conditions observed include the following:

1. On 10/27/20 at 11:26am , while in the company of the VPF, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in Clean Utility room 115 in the southeast corner on the Basement floor of the of the Olin Sang building.

Several smoke detectors throughout the hospital are located adjacent to air handling system supply diffusers. Failure to locate devices appropriately may result in devices failing to initiate an alarm in the event of an emergency. If alarm initiating devices do not function properly, then the building occupants may not be alerted to an emergency which may result in occupants' safety being compromised.

Findings include:

A. It was observed at various locations that detectors are located where airflow may prevent normal operation of the device as stated in NFPA 72-2012, 17.7.4.1. Locations & conditions observed include the following:

1. On 10/26/20 at 1:20pm , while in the company of the VPF, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the Lab in the northeast corner on the 11th floor of the Frankel building.

Several smoke detectors throughout the hospital are located adjacent to air handling system supply diffusers. Failure to locate devices appropriately may result in devices failing to initiate an alarm in the event of an emergency. If alarm initiating devices do not function properly, then the building occupants may not be alerted to an emergency which may result in occupants' safety being compromised.

Findings include:

A. It was observed at various locations that detectors are located where airflow may prevent normal operation of the device as stated in NFPA 72-2012, 17.7.4.1. Locations & conditions observed include the following:

1. On 10/26/20 at 1:50pm , while in the company of the VPF, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser above the cross-corridor doors in the east hallway on the 6th floor of the Kurtzon building

Based on observation the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Findings include:

A. On 10/27/20 at 11:45am , while in the company of the VPF, it was observed that fire suppression coverage was not installed in Electrical Room OS5A on the Basement floor of the of the Olin Sang building. The door, frame, and assembly for the electrical room were labeled for 20 min fire rated construction, which does not provide the 2-hour enclosure requirements to meet the exception listed in NFPA 13-2010, 8.15.10.3


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B. On 10/27/20 at 1:20pm in the company of the DE the surveyor finds the lack of fire sprinkler protection for the building's traction elevator machine room. NFPA 13, 2010, 8.1.

Based on observation the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The finding is:

On 10/27/20 at 11:27am in the company of the DE the surveyor finds the lack of fire sprinkler protection for the building's traction elevator machine room. NFPA 13, 2010, 8.1.1

Based on observation the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The finding is:

On 10/27/20 at 9:57am in the company of the DE the surveyor finds the lack of fire sprinkler protection for the building's traction elevator machine room. NFPA 13, 2010, 8.1.1

Based upon observation and staff interview, the sprinkler system is not maintained in accordance with Code requirements. Failure to maintain the sprinkler system can result in failure of the sprinkler system to function as intended during a fire event.

Findings include:

A. It was observed at various locations where sprinklered rooms had ceiling tile that was not installed in the grid system to provide a separation from the above ceiling cavity to provide effective operation of the sprinkler head to comply with NFPA 13-2010, 8.6.4.1.1. Locations & conditions observed include the following:

1. On 10/27/20 at 11:52am , while in the company of the VPF, ceiling tiles were observed not installed in the grid system in Storage Room OS37 immediately west of the south stair on the Basement floor of the Olin Sang building.

2. On 10/27/20 at 12:00pm , while in the company of the VPF, ceiling tiles were observed not installed in the grid system in Storage Room OS38 immediately west of the south stair on the Basement floor of the Olin Sang building.

Based upon observation and staff interview, the sprinkler system is not maintained in accordance with Code requirements. Failure to maintain the sprinkler system can result in failure of the sprinkler system to function as intended during a fire event.

Findings include:

A. On 10/28/20 at 9:35am while in the company of the VPF & ADELS the sprinklered MRI equipment room was observed to have ceiling tile that was not installed in the grid system to provide a separation from the above ceiling cavity to provide effective operation of the sprinkler head to comply with NFPA 13-2010, 8.6.4.1.1.

B. On 10/28/20 at 9:45am while in the company of the VPF & ADELS it was indicated by the facility site manager that inspection, testing and maintenance records for the sprinkler system were not available for review to comply with NFPA 25-2011, 4.3.1. It could not be determined that required periodic inspection and testing was being performed. by the building owner.

Based upon observation and record document review, portable fire extinguishers are not documented to be inspected and maintained in accordance with Code requirements. Failure to document inspection and maintenance of portable fire extinguishers can result in failure of equipment to perform as intended when needed during a fire event.

Findings include:

On 10/28/20 at 9:40am while in the company of the VPF & ADELS it was observed that portable fire extinguishers are not documented to be inspected on a monthly basis because inspection tags are not initialed & dated to comply with NFPA 10-2010, 7.2.1.2 and 7.2.4.

Based upon record document review, the facility does not provide documentation of follow-up actions to resolve deficiencies observed during fire drills. Failure to provide documentation of follow-up actions to deficient staff response to fire drills can result in failure of staff to perform appropriately during an actual fire/smoke condition to provide the greatest degree of safety for occupants.

Findings include:

On 10/27/20 at 1:00pm while in the company of the ADELS, during record document review, it was noted that numerous records for fire drills indicated a "NO" response to response questions dealing with "suspending activities", "closing doors", "informing patients", and knowing the "RACE/PASS procedures". Lack of training or instruction for deficient staff response to fire drills does not comply with NFPA 101-2012, 19.7.2.3.

Based on observation, portions of the medical gas piping systems are not installed properly. Failure to follow installation guidelines could result in misuse or lack of proper attachment. This deficient practice could affect patients and staff by compromising the medical gas system.

Findings include:

A. It was observed at various locations that the medical gas pipe installation is not supported as required by NFPA 99-2012, 5.1.10.4. Locations & conditions observed include the following:

1. On 10/27/20 at 12:02pm , while in the company of the VPF, it was observed that the medical gas pipe installation is not supported as required above the ceiling in the west corridor on the Basement floor of the Olin Sang building because it was in contact with other system piping/conduit.

Based on observation, portions of the medical gas piping systems are not installed properly. Failure to follow installation guidelines could result in misuse or proper attachment. This deficient practice could affect patients and staff by compromising the medical gas system.

Findings include:

A. It was observed at various locations that the medical gas pipe installation is not supported as required by NFPA 99-2012, 5.1.10.4. Locations & conditions observed include the following:

1. On 10/26/20 at 2:02pm , while in the company of the VPF, it was observed that the medical gas pipe installation is not supported as required above the ceiling in the northeast corner on the 5th floor of the Frankel building because it was in contact with other system piping/conduit.

B. It was observed that portions of the medical gas pipe system support other utilities which is prohibited by NFPA 99-2012, 5.1.11.2.1. Locations & conditions observed include the following:

1. On 10/26/20 at 2:08pm , while in the company of the VPF, it was observed that the medical gas pipe system in the northeast corner on the 5th floor of the Frankel building supports other utilities above the ceiling.

Based on observation, portions of the facility lack identification of the medical gas piping systems. Failure to label this installation could result in misuse or disruption of medical gas services. This deficient practice could affect patients and staff if services were unexpectantly disrupted.

Findings include:

A. It was observed at various locations that portions of the medical gas pipe system are not labeled to identify the content within as stated within NFPA 99-2012, 5.3.11.1.1. Locations & conditions observed include the following:

1. On 10/27/20 at 12:02pm , while in the company of the VPF, it was observed that the medical gas pipe system is not labeled as required above the ceiling in the west corridor near Storage Room OS37 on the Basement floor of the Olin Sang building.

2. On 10/27/20 at 2:12pm , while in the company of the VPF, it was observed that the medical gas pipe system is not labeled as required above the ceiling at the Nurses' Station where the corridors intersect in the CCU on the 8th floor of the Olin Sang building.

Based on observation, the facility failed to install and maintain its piped-in medical gas system in the manner required. This deficient practice could affect patients, staff, and visitors in the building because the medical gas piping system could fail to operate when needed if not properly installed and maintained.

The finding is:

On 10/27/20 at 9:50am accompanied by the ADELS, observation determined that medical gas station outlets are located in which there is not a complete wall between the outlets and the shut off valve suppling them. This condition does not comply with NFPA 99-2012, 5.1.4.8(3).

Location observed: Fourth floor, O.B. Triage

Based on observation, the facility failed to install and maintain its piped-in medical gas system in the manner required. This deficient practice could affect patients, staff, and visitors in the building because the medical gas piping system could fail to operate when needed if not properly installed and maintained.

The finding is:

A. On 10/26/20 at 2:25pm while accompanied by the ADELS, observation determined that medical gas station outlets are located in which there is not a complete wall between the outlets and the shut off valve suppling them. This condition does not comply with NFPA 99 2012, 5.1.4.8(3).

Location observed: Fifth floor Dialysis suite.

Based on observation, portions of the facility lack identification of the medical gas piping systems. Failure to label the installation could result in misuse or disruption of medical gas services. This deficient practice could affect patients and staff if services were unexpectantly disrupted.

Findings include:

B. It was observed at various locations that portions of the medical gas pipe system are not labeled to identify the content within as stated within NFPA 99-2012, 5.3.11.1.1. Locations & conditions observed include the following:

1. On 10/26/20 at 2:02pm , while in the company of the VPF, it was observed that the medical gas pipe system is not labeled as required above the ceiling in the northeast corner on the 5th floor of the Frankel building.

Based on observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed

Findings include:

A. Exposed electrical junction boxes are installed without covers and are therefore not installed in compliance with NFPA 70-2011, 314.28(C). Locations include:

1. On 10/27/20 at 9:53am , while in the company of the VPF, it was observed that a coverplate was missing on an exposed electrical wall box in the commons area at the far north end of the 6th floor of the Olin Sang building.

2. On 10/27/20 at 10:45am , while in the company of the VPF, it was observed that a coverplate was missing on an exposed electrical wall box in the electrical closet immediately west of the south stair on the 3rd floor of the Olin Sang building.

3. On 10/27/20 at 11:00am , while in the company of the VPF, it was observed that a coverplate was missing on an exposed electrical wall box in the electrical closet immediately west of the south stair on the 2nd floor of the Olin Sang building.

4. On 10/27/20 at 11:39am , while in the company of the VPF, it was observed that a coverplate was missing on an exposed electrical wall box in the mechanical room at the far north end on the Basement floor of the Olin Sang building.

5. On 10/27/20 at 11:52am , while in the company of the VPF, it was observed that a coverplate was missing on an exposed electrical wall box in Storage Room OS38B immediately west of the south stair on the Basement floor of the Olin Sang building.

Based upon observation, electrical systems are not maintained in accordance with Code requirements. Failure to maintain electrical systems in accordance with Code requirements can result in disruption of services and restrict immediate access for maintenance.

Findings include:

On 10/28/20 at 9:35am while in the company of the VPF & ADELS it was observed that the MRI equipment/electrical room was used for unrelated storage which blocked access and reduced working space to less than 3'-0" at electrical panels in non-compliance with NFPA 70-2011, 110.26.

Based on observation and staff interview the facility lacks a complete identifiable Category 1Essential Electrical System (EES). Failure to provide and maintain this system places patients, staff and visitors at risk during a utility failure.

The finding is:

A. On 10/27/20 at 10:30am in the company of the DE in the Directors 12th Floor Office the facility could not confirm that a complete EES was provided with separate and identifiable Life Safety, Critical and Equipment Branches. Identified during the facility walk through electrical branch panels were not clearly identified.


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Based upon direct observation during the survey walk-thru, electrical systems are not maintained in conformance with Code requirements. Failure to maintain the electrical system can lead to confusion when selected components require shut-down for maintenance and power circuits cannot be accurately identified.

The finding is:

B. On 10/26/20 at 1:25pm while in the company of the ADELS, a critical care patient room was observed containing no electrical outlets powered by the critical branch of the essential electrical system. The surveyor was informed by the facility staff that general anesthesia is used. The existing outlets are not identified as to the panel which served them. The condition does not comply with NFPA 70-2011, 408.4, for the installation of emergency critical powered outlets.
Location observed: Interventional radiology procedure room, Third floor

Based on observation and staff interview the facility lacks a complete identifiable Category 1Essential Electrical System (EES). Failure to provide and maintain this system places patients, staff and visitors at risk during a utility failure.

The finding is:

On 10/27/20 at 10:30am in the company of the DE in the Directors 12th Floor Office the facility could not confirm that a complete EES was provided with separate and identifiable Life Safety, Critical and Equipment Branches. Identified during the facility walk through electrical branch panels were not clearly identified.

Based upon direct observation during the survey walk-thru, electrical systems are not maintained in conformance with Code requirements. Failure to maintain the electrical system can lead to confusion when selected components require shut-down for maintenance and power circuits cannot be accurately identified.

The finding is:

On 10/27/20 at 10:00am while in the company of the ADELS, critical care patient rooms/areas contained emergency outlets which did not identify the electrical panel which served them. This condition was observed within all critical care patient areas. The condition does not comply with NFPA 70-2011, 408.4. Example locations observed: PACU and SICU

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On 10/27/20 at 10:30am while in the company of the ADELS, the surveyor observed that the majority of critical care patient areas with the exception of the NICU, lack electrical receptacles served by normal power to comply with NFPA 70-2011, 517-19(A).
Example locations observed:

1. OR # 3 (the only OR which surveyor was able to gain access - all others in use).

2. PACU

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

Findings include:

A. On 10/27/20 at 9:59am , while in the company of the VPF it was observed that typical patient toilet rooms on the 6th floor of the Olin Sang building are not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(1).

B. On 10/27/20 at 10:04am , while in the company of the VPF, it was observed in the 6th floor staff break room south of the nurses' station that a receptacle is within 6'-0" of a sink fixture and is not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).

C. On 10/27/20 at 11:32am , while in the company of the VPF, it was observed in the Basement room labeled OS17 that a receptacle is within 6'-0" of a sink fixture and is not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).

Based upon observation, critical power receptacles are not labeled in compliance with Code requirements. This condition does not allow the ability to readily and accurately identify circuits to maintain critical power for patients if disconnection or maintenance is required.

The finding is:

On 10/27/20 at 2:06pm , while in the company of the VPF, it was observed that the red outlets in typical CCU Patient rooms on the 8th floor of the Kurtzon building were not labeled to identify the panel and circuit from which they are fed to comply with NFPA 70-2011, 517-19(A).