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Based upon observation, horizontal sliding doors are not maintained to be latching to prevent rebounding when closed. Failure to maintain the latching door function can compromise the safety of occupants by not providing separation of the room from the corridor during a fire/smoke event.

The finding is::

On 12/11/19 at 9:45am, it was observed while in the company of the SO that the 2nd floor ICU rooms have horizontal sliding corridor doors equipped with latching hardware. Not all doors functioned to latch upon testing, 3 of the doors available for testing failed to latch. Locations were rooms 6, 8, & 12. A total of 16 door assemblies exist and not all were tested due to patient use of the rooms. Doors 6 & 12 were adjusted during the survey process to provide positive latching. Door 8 was adjusted several times, but failed to achieve positive latching. All doors require testing to achieve postive latching to comply with 19.2.2.2.10.

Based on observation, exit stair enclosures are not maintained separate from other areas as required. Failure to maintain fire resistive separation can compromise the use of the stair as a means of egress during a fire/smoke event adjacent the stair enclosure.

Findings include:

A. On 12/11/19 at 10:45am while in the company of the SO, it was observed that exit Stair "C" was not separated by 2-hour rated construction to comply with 7.1.3.2.1(3) at the 1st & 2nd floors. Former exterior window infills, now forming an interior wall with the recently constructed Emergency Dept. addition, are not constructed as 2-hour rated assemblies.


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B. On 12/10/2019 at 11:05am, while in the company of the FR(1) it was observed that a required exit stair does not provide a continuous protected path of travel to an exit discharge. The continuous 2-hour fire rating is compromised at the third floor intermediate landing having a wall containing vinyl siding providing an unknown U.L. listed fire resistant design. This condition does not comply with 19.3.1, 8.6.2, 7.1.3.2.1 and 7.1.3.2.2. Location observed: Third floor intermediate landing for Stair F ( landing leading to a recent mechanical room addition).

Based on observation, not all designated fire barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building where fire could pass between adjacent fire compartments if fire barriers are not properly constructed.

The finding is:

On 12/11/2019 at 10:20am while accompanied by the FR(2), a fire barrier contains multiple pipe penetrations which are not sealed against the passage of fire to comply with 8.3.5.1 and ANSI/UL 1479.

Locations observed:

1. First floor 2-hour barrier between Hospital and MOB as viewed from the Doctor's Lounge, contains 3 pipe penetrations.

2. First floor 2-hour barrier between Hospital and MOB as viewed above cross corridor doors, contains a 6" dia. pipe penetration.

Based on observation, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On 12/11/2019 at 10:45am while accompanied by the FR(2), a corridor was observed directing exiting into a suite. This condition does not comply with 19.2.5.4 and 7.5.1.2. This condition leaves a means of egress corridor containing a dead end condition which does not comply with 7.5.1.5.
Location observed: First floor corridor adjacent to the Emergency Department (E.D.) contains an exit sign above the pair of cross corridor doors leading into the E.D.

Based on observation, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On 12/10/2019 at 11:10am while accompanied by FR(1), means of egress corridors were observed containing multiple pieces of equipment stacked along walls. Materials reduce the required width of the egress path. This condition does not comply with 19.2.3.4 (4)(a) and 19.2.3.5 for a convenient removal of nonambulatory persons.
Location observed: Fourth floor, the Long Term Care unit section of the exit access corridor leading to Stair E.

Based upon observation, suites are not properly separated from corridors. Failure to properly separate the suite areas from corridors can compromise the safety of occupants by exposing corridors to a fire/smoke condition originating in the suite or providing a place of temporary refuge from a fire/smoke conditions orignating outside the suite.

Findings include:

A. On 12/11/19 at 10:10am while in the company of the SO, it was observed that the 2nd floor Minor Procedures suite cross corridor power operated doors which form the boundary of the suite were not positive latching to comply with 19.2.5.7.1.2 and 19.3.6.3.5 when the power operator ceases to function as required by 7.2.1.9.2(4).

B. On 12/11/19 at 10:55am while in the company of the SO, it was observed that the former Stage 2 recovery room suite within the Surgery Dept., now utilized as a large Clean Supply room and designated as a hazardous area on the facility life safety plans, lacked positive latching doors to comply with 19.2.5.7.1.2 and 19.3.6.3.5 when the power operator ceases to function as required by 7.2.1.9.2(4).

Based on observation, the facility failed to provide exit paths that are maintained as a continuously protected path to a public way. This deficient practice could affect staff and patients during egress due to a fire emergency evacuation from the building.

Findings include:

A. On 12/11/2019 at 1:30 pm while in the company of the FR(2) an exterior means of egress was observed in which the path is through a construction site. The means of egress does not comply with 19.2.7 and 7.7.3.2 due to the following:

1. The walking surface at the bottom of the stair discharge to the public way does not comply with 7.1.6.2 for abrupt changes in the walking surface due to the tripping hazard of a concrete curb.

2. The walking surface to the public way does not comply with 7.1.6.3 for a uniform level surface due to the use of a loose gravel walking path providing a sloped and uneven means of egress not suitible for wheeled equipment or foot traffic.

3. The exterior walking surface to the public way is not reliable under full instant of use such as ice, snow, rain which does not comply with 7.1.10.1.

Location observed: Exit Stair C exterior discharge along a path directly adjacent to the Emergency Department construction site.

B. On 12/11/2019 at 11:30am while in the company of the FR(2) an exterior means of egress was observed in which the path is obstructed by a parking block used for a parking space. The means of egress does not comply with 19.2.7 and 7.7.3.2 for a clear unobstructed path to the public way.
Location observed: Exit Stair A exterior discharge,

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 12/11/2019 at 10:20am, while accompanied by the FR(2) it was determined that illumination is not provided to comply with 7.8.2.2 and 7.9.1 .
Locations observed: 1st floor, exterior discharge from Stair C to the public way

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 12/11/2019 while accompanied by the FR(2), a corridor was observed which lacks a designated access to two remote exits and therefore produces a dead end condition. This does not comply with 7.10 and 19.2.10.1.
Locations observed:

1. At 9:30am First floor corridor adjacent to Nuc Med and Staff Lounge with a view toward Wound Care suite.

2. At 1:50pm First floor corridor adjaceont to Stair F exiting with a view south toward Hospital Main entry.

3. At 11:20am First floor corridor adjacent to the Radiology and Emergency Department suite with a view toward the Hospital main entry.

Based upon observation, vertical openings are not constructed and maintained to provide separation of floor levels in accordance with requirements. Failure to protect vertical openings can permit the effects of a fire/smoke event to expose and compromise the safety of occupants utilizing an exit stair.

The finding is:

On 12/10/'2019 at 2:25pm while accompanied by the FR(1) a shaft wall was observed to not be completely enclosed with a minimum 2-hour fire rated construction to comply with 8.3.5.1, 8.3.5.7, and 9.2.1.
Locations observed:

1. Elevator machine room for West Wing
2. Elevator machine room for South Wing

Based upon observation, not all the hazardous areas were separated from the remainder of the building in accordance with requirements. These deficiencies could affect patients, visitors and staff if smoke and fire were not contained within the hazardous area room if a smoke/fire event were to occur within the hazardous area room.

Findings include:

A. On 12/11/19 at 10:56am while in the company of the SO, it was observed that the Surgery Clean Supply room adjacent the Soiled Holding room lacked positive latching corridor doors to comply with 19.3.6.3.5 when the power operator ceases to function as required by 7.2.1.9.2(4).

B. On 12/11/19 at 11:15am while in the company of the SO, it was observed that OR #4 is utilized for storage and designated as a hazardous area on the facility life safety plans. The change of function for this room to a hazardous area function requires the room to be separated by 1-hour construction to comply with 18.3.2.1. The wall separation of this room could not be confirmed to be 1-hour rated and the doors to be minimum 3/4-hour rated, self-closing, positive latching door assemblies at the corridor and the door from the sub-sterile core area.

C. On 12/11/19 at 1:10pm while in the company of the SO, it was observed that exit access corridors are being used for storage of equipment and supplies and hazardous areas are not separated from the means of egress corridors to comply with 19.3.2.1, 39.3.2.1, 8.7.1.2, and 7.1.10.1.
Locations observed include:

1. The Surgery corridors are used for storage of equipment & supplies.
2. The Basement level corridors (Business occupancy) are used for storage of misc. equipment and supplies.
3. The Basement level hazardous area (Building Services shop) is not provided with positive latching corridor door hardware and the closer is equipped with a hold-open feature.

D. On 12/11/19 at 10:55am while in the company of the SO, it was observed that the Former Stage 2 recovery room is utilized as a large Clean Supply room. The change of function for this room into a hazardous area function requires the room to be separated by 1-hour rated construction including minimum 3/4-hour rated self-closing door assemblies to comply with 18.3.2.1. A change of function is evaluated as new construction including under any earlier additions of the code.

Based on observation, not all portions of the building's fire alarm system contain components for occupant notification as required. This deficient practice could affect patients, staff, or visitors in the building by the delay in awareness of fire alarm conditions thereby not providing a prompt compartment evacuation.

The finding is:

On 12/11/2019 at 1:25 pm while in the company of the FR(2) fire alarm visual devices could not be viewed within means of egress areas such that spacing does not comply with 18.5.4.3.1 NFPA 72 2010. Location observed: First floor Hospital main lobby/Temporary Emergency Dept Waiting containing one visual device unable to be viewed from opposite end of the area.

Based on observation, not all smoke barrier door assemblies are maintained to close completely in the frame. Failure to provide doors to close completely can prevent the door from restricting the passage of smoke during a fire/smoke event.

The finding is:

On 12/11/19 at 10:05am while in the company of the SO, it was observed that a door coordinator did not permit the doors to completely close in proper sequence to comply with 19.3.7.8 and 8.5.4.1. Location observed; The single swing pair of smoke barrier doors located between the 2nd floor Surgery family waiting rooms.

Based on observation, the facility failed to correctly separate components for the elevator systems. Failure to separate areas dedicated to the function of the elevators during emergency use could result in a malfunction which leads to a delayed use by the fire department. This deficient practice could affect patients, staff and visitors during a fire event.

The findings include:

A. On 12/10/2019 at 1:10pm while accompanied by the F.R.(1), areas which have a separate function from the elevator machine room were observed open to the machine room as follows:

1. There is no separated use space from the elevator machine room by fire rated construction to comply with ANSI/ASME A17.3 2008 edition, section 2.2.1 for items which are stored on shelving within the room and the adjacent open vestibule containing a horizontal filing cabinet. None of the items are existing and essential to the operation of the building.
2. There is an unprotected storage room open to the elevator penthouse due to the room's entry door which does not maintain a required 2-hour separation from the elevator machine room and shaft.
3. There is an unprotected 2-hour fire rated shaft open to the machine room due to an unprotected vertical duct run within the machine room which does not comply with ANSI/ASME A17.3 section 2.2.5(b) 2008 edition.
Location observed: Elevator Penthouse for Elevators #1,2 and 3 West Wing.

B. On 12/10/2019 at 2:10pm while accompanied by the F.R.(1), multiple pieces of equipment, pipes and wiring, which has a separate use from the elevator machine room was observed open to the machine room as follows:

1. There is an air handling unit, electrical panels, an exhaust fan unit and a soiled linen chute all located within the machine room which do not serve the machine room. ANSI/ASME A17.3 2008 edition section 2.2.1.
2. There are unprotected 2-hour fire rated shafts open to the machine room due to multiple unprotected vertical duct runs within the machine room which does not comply with ANSI/ASME A17.3 section 2.2.5(b) 2008 edition.
Location observed: South Wing Elevator Penthouse.

Based on observation the facility failed to maintain the fire resistive construction of a linen chute and discharge room. Failure to maintain these installations could result in the uncontrolled spread of fire. This deficient practice could affect patients, staff and visitors.

Findings include:

A. On 12/11/19 at 10:30am while in the company of the SO, it was observed that the chute access door at the 2nd floor Stage 2 recovery wing charge room was disconnected and therefore not self-closing to comply with 19.5.4.1.


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B. On 12/11/19 at 11:20am in the West Building Basement level, Linen Chute Discharge Room accompanied by the BME, the surveyor finds the west wall below the chute discharge has been damaged.

Based on staff interview the facility lacks complete bonding of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients and staff.

The finding is:

On 12/11/19 at 2:00pm accompanied by the BEE, it could not be confirmed through observation and staff interview that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B).

Based on observation the facility lacks isolation of the medical gas piping systems from dissimilar materials. Failure to install and maintain this installation could result in the piping system failure. This deficient practice could affect patients and staff.

The finding is:

On 12/11/19 at 11:15am in the West Building Basement Pump Room accompanied by the BME, the surveyor finds the medical gas pipe installation is not supported by copper tube hangers and supports in contact with the piping are not plastic-coated. NFPA 99, 2012, 5. 1. 10. 11. 4. 4

Based on observation the facility lacks identification of the medical gas piping systems. Failure to label this installation could result in misuse or attachment. This deficient practice could affect patients and staff.

The finding is:

On 12/11/19 at 11:15am in the West Building Basement Pump Room and Materials Management Receiving accompanied by the BME, the surveyor finds the medical gas pipe installation is not labeled to identify the content within. NFPA 99, 2012, 5. 1. 11. 1

Based upon observation, electrical receptacles are not provided in accordance with Code requirements. Failure to provide the required number and electrical distribution of critical area receptacles can compromise patient safety in the event of disruption of the electrical systems.

The finding is:

On 12/11/19 at 11:20am while in the company of the SO, it was observed in the Operating Rooms #8 & #9 available for inspection (and #4 if used as an OR) that receptacles are not available from both the emergency electrical system and the normal electrical system to comply with NFPA 70-2011, 517-19(A). It was indicated that separate receptacles are not otherwise fed from at least two different transfer switches of the emergency electrical system as permitted by NFPA 70-2011, 517-19(A), Exception No. 2.