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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 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. Corrected 04/14/2015

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.