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Based on observation during the survey walk-through while accompanied by facility staff, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the occupied rooms.

Findings include:

A. At 9:25am on 04/16/14 2nd floor corridor doors to several suites have hardware which do not provide latching in order to comply with 19.3.6.3.2. Example locations include:

1. Assessment Suite (pair of doors to East corridor)

2. Phase II Recovery Suite (pair of doors to South corridor)

3. Phase I Recovery Suite (pair of doors to South corridor)

4. Phase I Recovery Suite (pair of doors to North corridor)

UPDATE 10/14/14: The original correction date of 8/15/14 has not been met. However, the Assessment Suite (east) doors and the Phase II Recovery Suite (south) doors have new panic device hardware installed but lack the strike plate to permit latching. Phase I Recovery doors remain without latching hardware.


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B. Corrected 10/14/14.

Based on random observation during the survey walk-though, accompanied by facility staff, the surveyor finds that not all floors of the building have sufficient access to exits that terminate at an exterior exit discharge as required by 19.2.4.1. These deficiencies could affect patients, staff, and visitors on the cited floors in the event of an emergency evacuation.

Findings include:

A. In the morning of April 17, 2014, it was observed that more than 50% of the exit stairs that serve floors 3, 4, and 5 discharge on the level of exit discharge, which does not comply with 7.7.2. Locations observed include:

1. 5th floor - both exit stairs discharge internally.

2. 3rd and 4th floors - three of five exit stairs discharge internally.

Based on observation during the survey walk-through while accompanied by facility staff, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit discharge from the building.

Findings include:

A. Corrected 10/14/14.


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B. In the morning of April 15, 2014, on the Fourth floor, it was observed that the roofs of the exit stairs near the elevator (Stair 3) and at the north end of the north wing (Stair 1) are equipped with roof hatches that are intended to permit upward expansion of the stairs and so form the roof of the stair towers. The hatches do not maintain the stair enclosure as required by 7.1.3.2.1 as follows:

1. These hatches are not fire rated and do not have the 1 ½ hour protection required for roofs.

2. The hatches have not been maintained so are not weather or smoke tight. In the event of a fire smoke could be drawn into the stairs by the pressure differential created by the gaps in the hatches

3. Rain could enter the stair tower through the gaps in the hatch assembly and compromise the walking surfaces below.

Based on random observation during the survey walk-though, accompanied by facility staff, the surveyor finds that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

A. At 1:35 PM on April 15, 2014, on the Second floor, the corridor that connects the Surgery Department with the ICU Suite has exit signage that directs the path of egress from the corridor into the ICU suite, which is an intervening room. Without a means of egress at the west end of this corridor a dead end of approximately 80 feet is created. 19.2.5.9

B. Corrected 10/14/14.
C. Corrected 10/14/14.
D. Corrected 10/14/14.
E. Corrected 10/14/14.
F. Corrected 10/14/14.

B. NEW 10/14/14: The Gift Shop Break Room door marked as an exit was observed to have a mirror mounted on the door in non-compliance with 7.1.10.2.3.

Based on random observation during the survey walk-through while accompanied by the Facility Staff, not all designated suites comply with 19.2.5 concerning the remotely located exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Finding includes:

A. On 04/16/14 at 10:10am 2nd floor, Assessment Suite; exit access to a corridor is not indicated from the East pair of doors. This condition does not comply with 19.2.5.3 for two remotely located means of egress.

UPDATE 10/14/14: The Assessment Suite designated to be greater than 2500 sf now has the east pair of doors to a corridor marked with exit signage. (See K018A1 relative to these doors not being positive latching corridor doors.) The corridor identifies only a single path to an exit not in compliance with 19.2.5.9. The corridor leading to the north is not provided with exit signage and when this corridor path is followed it leads past two Surgery Prep bays with sliding aluminum and glass doors which are not provided with latching hardware to comply with 19.2.2.2.9.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress to comply with 19.2.10.1. and 7.10. 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 utilizing an available exit during a fire or smoke event.

Findings include:

A. Exit signs are not provided to identify the 2nd means of egress from corridors to comply with 19.2.5.9. Locations noted include the following:

1. On 04/16/14 at 2:45pm 2nd floor corridor East of Assessment Suite was observed to lack a means to identify both egress paths in order to comply with 18.2.5.9. a single exit sign was observed leading to the Endo Corridor.

UPDATE 10/14/14: When leaving the east pair of doors from the Assessment Suite, the corridor has only one exit access identified with signage to the south (Endo Corridor). The corridor to the north is not provided with exit signage to define the second exit access from the corridor to comply with 19.2.5.9. See also the update under K042 relative to this corridor exit access.

Based on random observation during the survey walk through while accompanied by the Electrical Contractor and the Plant Operations Secretary, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA-72. This could affect all occupants of the building if the fire alarm system did not operate properly during a fire emergency.

Findings include:

A. Corrected 10/14/14.

B. Panel ELL1A in wiring closet #9 had a circuit breaker serving a fire alarm panel that was not marked in red and was not equipped with a circuit breaker lock to meet the requirements of NFPA-72, Section 1-5.2.5.2.

UPDATE 10/14/14: The breaker has been marked with red, but the mechanical lock-on device has not been provided by 6/10/14 in accordance with the 8/18/14 Plan of Correction.


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C. 04/16/14 during testing of the fire alarm system, the visual and audible notification devices did not operate in a manner to give warning in accordance with NFPA 72 4-4. Locations and conditions include:

1. Second floor Endo suite, surveyor was unable to hear any audible devices anywhere within this suite.

2. Second floor assessment, surveyor was unable to hear an audible device within the area.

3. Second floor Phasr I and Phase II Recovery lacks a visual notification device.



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4. Fourth floor Nurses' Station, it was observed that the audible signal was not readily discernable over the ambient noise.

D. Corrected 10/14/14.

Based on random observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors. The installation does not comply with NFPA 13 1999

Basement:

By direct observation while in the company of the Manager of Facility's the surveyor finds the:

A. Corrected 10/14/14.

B. Afternoon of 4/16/14, the Electrical Room B5 is not provided with sprinkler protection and does not qualify for the exception for elimination of sprinkler protection as listed in NFPA 13, 1999, 5-13.11. The room enclosure lacks sealing of the pipe/conduit penetrations and rated doors in the barrier separating the electrical room and the room containing the batteries for the UPS and various pipe supplies.

UPDATE 10/14/14: The doors and penetration sealing work have been completed, but the cover to separate the piping which passes through this room was observed not to be reinstalled following the work.

C. Corrected 10/14/14.
D. Corrected 10/14/14.


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E. 04/16/14 2:15pm 2nd floor "Center" Mechanical room located between Stair # 3 and Surgery Waiting contained a sprinkler pipe improperly anchored to the bottom of a duct. The pipe was observed to be shaking due to vibration from the duct.

UPDATE 10/14/14: A new support was observed to be installed, but at least two support locations where still being supported by the ductwork. Additional supports may be required due to pipe configuration when duct supported hanger are removed.

F. Corrected 10/14/14.
G. Corrected 10/14/14.
H. Corrected 10/14/14.


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I. Corrected 10/14/14.

J. At 9:25 AM on April 17, 2014, in the Basement, it was observed that the Boiler Operator's Office located in the Autoclave Room addition lacks sprinkler protection as required by NFPA 13 1999 5-1.1(1).

UPDATE 10/14/14: Sprinkler protection was observed to be provided at the Boiler Operator's Office but upon inspection above the ceiling it was observed that sprinkler piping consisted of two lengths of flexible piping installed end-to-end without support and not in accordance with the listing for this type sprinkler piping.

Based upon random observation during the survey walk through while accompanied by Facility Staff the surveyor finds that HVAC systems do not comply with NFPA 90A 1999 and/or ASHRAE.

Findings include:

A. 04/16/14 at 1:15pm 2nd floor "Center" mechanical room adjacent to Surgery Waiting room contains a fire damper and/or combination damper that is not installed within the plane of the fire barrier. A damper is installed well beyond the plane of the 2-hour fire/smoke barrier. A built out angled gypsum board box is constructed out from the barrier wall. A duct penetrates it having an access panel and damper installation at the face of the angled box. This installation does not comply with the damper manufacturer's requirements and/or NFPA 90A.

B. 04/16/14 at 1:15pm 2nd floor "Center" mechanical room adjacent to Surgery Waiting and a corridor. The 2-hour barrier above the corridor entry door contains duct penetrations. The ducts lack damper installations and access panels to comply with NFPA 90A.

1. The same barrier is incomplete above the duct penetrations with only sheet metal forming the barrier from the top of the duct to the underside of the deck above. Therefore the ducts are improperly supported which does not comply with NFPA 90A 2-3.1.4.

UPDATE 10/14/14: The wall around the ducts appears to have been closed with double layer gypsum board on each side to provide proper barrier construction but the damper installation did not appear to follow required installation details due to the lack of angle support on both sides of the barrier. Access doors were installed. Although staff believed this correction was completed and ready for review, the PoC indicated that this deficiency would not be completed until 12/31/14.

2. Corrected 10/14/14.

C. Corrected 10/14/14.

Based on random observation during the survey walk through while accompanied by the Maintenance Electrician, (on the first day of the survey), and the Electrical Contractor, (on the second day of the survey), and the Plant Operations Secretary, the surveyor found that the emergency electrical system installation did not meet all requirements of NFPA-70, NFPA-99, and NFPA-110. This could affect any occupant of the facility if a transfer switch fails and all branches of emergency power and normal power are lost are lost.

Findings include:

A. It was observed that the original hospital was not equipped with a separate transfer switch for each branch of emergency power as required by NFPA-70, Section 517-30.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute the 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 while accompanied by the Electrical Contractor and the Plant Operations Secretary, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. Emergency power for the original hospital is not separated into three branches as required by NFPA-70, Section 517-30 through 517-35. All 120-208 volt load is served from a single transfer switch and it was observed that the panels served from this transfer switch were a mixture of life safety, critical and equipment branch loads.

B. The later additions to the hospital have transfer switches for each branch of emergency power, but several of the panels are serving loads that should be on other branches for example:

1. Emergency panel ELL2A in electrical room 10 serves mixed loads.

2. Emergency panel LP1-A in room IS-3 serves mixed emergency loads.

3. Emergency panel 5A in 5th floor west machine room serves mixed loads.

4. Emergency panel 4A in the far west wing serves mixed loads.

5. Emergency panel EMLA in the front lobby serves mixed emergency loads.

Based on random observation during the survey walk through while accompanied by the Maintenance Electrician, (on the first day of the survey), and the Electrical Contractor, (on the second day of the survey), and the Plant Operations Secretary, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. The elevator cab lights were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and the elevator cab lighting disconnects in the elevator equipment rooms were not properly labeled in accordance with NFPA-70, Section 620-53.

B. The The original hospital patient rooms were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19. This could effect all patients in this area if the transfer switch failed and no normal or emergency power was available at the bed locations.

C. The C-section rooms, the Operating rooms, the recovery rooms, the original ER rooms, and procedure rooms were not equipped with normal receptacles to meet the requirements of NFPA-70, Section 517-19.

D. Emergency receptacles were not labeled in all critical care areas such as the Cardiac Cath Lab, Phase 2 Recovery rooms, and the Eye Surgery rooms as required by NFPA-70, section 517-19.

Based on random observation during the survey walk through while accompanied by the Maintenenance Electrician and the Plant Operations Secretary, the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

A. The elevator machine rooms did not have a heat detector within 2' of each sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

UPDATE 10/14/14: Heat detectors were observed to be installed at all elevator machine room sprinkler heads as required except for the following:

1. Elevator #3 - Kitchen freight elevator, was not yet completed.
2. Elevator #19 - New Lobby elevator, was not installed within 2' of the sprinkler.

B. The elevators were not equipped with elevator recall initiated by smoke detectors in the elevator machine rooms, and lobbies in accordance with ANSI A17.1/A17.3.