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Based on observation during the survey walk-through, the means of egress from occupied spaces is not maintained in accordance with Code requirements. Failure to maintain means of egress for all spaces can result in confinement of occupants in a building during required evacuation.

Findings include:

On 8/9/2023, while in the company of the MOP and RDS, the following conditions were observed:

1. At 10:47 am, it was observed that the Exit door at the 1st floor Main Distribution Room was held open by tying the door lever to an outside pipe with wire to keep the door in the fully open position. This does not comply with Section 19.2.2.2.4.

2. At 10:50 am, it was observed that the exit discharge area from 1st floor Main Distribution Room's exit, the fence door at the enclosed courtyard at the northwest corner was observed locked. This does not comply with Section 19.2.2.2.4.

Based upon observation, exit discharges are not maintained in accordance with Code requirements. Failure to maintain exit discharge conditions for safe travel from the building can compromise the safety of occupants during exiting from the building.

Findings include:

On 8/9/2023, while in the company of the MOP and RDS, the following conditions were observed:

1. At 10:47 am, it was observed that a continuous and unobstructed exit discharges path from 1st floor Main Distribution Room's exit directly to the public way was not provided to comply with Section 19.2.7 and 7.7.1.

2. At 9:37 am, it was observed that a continuous and unobstructed exit discharges path from 1st floor Med-Surge unit's northwest exit directly to the public way was not provided to comply with Section 19.2.7 and 7.7.1.

3. At 9:40 am, it was observed that the concrete pavement at the exit discharges path from 1st floor Med-Surge unit's northwest exit is broken which presents a tripping hazard not in compliance with 19.2.7, 7.7.4, 7.1.6 and 7.1.10.1.

Based on observation and staff interview, illumination of exit discharge portion of the means of egress is not provided to maintain continuous illumination. Failure to maintain illumination of the means of egress can prevent safe and unimpeded access to the public way in the event of an emergency evacuation for all building occupants.

Findings include:

On 08/9/23, at 11:30 am while in the company of the MOP and RDS, it was observed that the lighting provided at the exit discharge areas throughout the building could not be confirmed that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle and comply with Section 19.2.8 and 7.8.1.4.

Based upon observation and staff interview, battery powered emergency lighting system is not maintained in accordance with Code requirements. Failure to properly performing maintenance activities can result in failure of the lighting systems due to lack of periodic inspection and maintenance affecting all occupants during an emergency event.

Findings include:

On 8/9/2023, at 10:23 am while in the company of the MOP and RDS, it was observed that the Battery-Operated Emergency Lights at the 1st floor Central Supply is not functional. This condition is not in compliance with Section 19.2.9.1 and 7.9.

Based upon observation and staff interview, exit signs are not placed appropriately to identify available exit paths. Failure to correctly identify exit paths can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.

Findings include:

On 8/9/2023, while in the company of the MOP and RDS, it was observed that proper exit signage was not provided to identify the means of egress to comply with Section 19.2.10 and 7.10. Locations observed include:

1. At 9:11 am, it was observed that proper exit signage was not provided to identify the means of egress at the 1st floor Admin wing corridor near the reception desk to be seen from the dead-end corridor.

2. At 10.33 am, it was observed that proper exit signage was not provided to identify the means of egress at entrance of the egress corridor between Receiving and Main Telephone Room.

Based upon observation, hazardous areas are not properly 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 compromise the use of the adjacent corridor for exiting.

Findings include:

On 8/8/2023, while in the company of the MOP and RDS, it was observed that areas used for storage of combustible materials and are not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2, 19.3.6.3 and 8.4. Locations observed include:

1. At 12:27 pm, portion of the Penthouse Mechanical Room was observed being used for the storage of holiday decorations.

2. At 1:03 pm, the 2nd floor Cath Lab Supply/Equipment Room was observed not to be separated by a proper door from the means of egress path.

3. At 1:19 pm, the 2nd floor Lab Supply/Equipment Room was observed not to be separated by a door from the means of egress path.

4. At 1:27 pm, the 2nd floor ICU area dead-end corridor was observed being used for the storage of combustible materials and is not separated from the means of egress path.

Based on observation smoke detectors are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation during an emergency. If devices do not function properly, then building occupants may not be alerted to an emergency in a timely manner.

Findings include:

A. While in the company of the MOP and RDS, it was observed at various locations that smoke detectors are located where airflow may prevent normal operation of the device as written in 2010 Edition of NFPA 72, Section 17.7.4.1. Locations observed include:

1. On 8/8/23 at 12:35 pm, a smoke detector was observed within 3'-0" of an HVAC supply/return register at the 2nd floor Mail Room.

2. On 8/8/23 at 12:41 pm, a smoke detector was observed within 3'-0" of an HVAC supply/return register at the 2nd floor HVI Procedure corridor.

3. On 8/9/23 at 9:05 am, a smoke detector was observed within 3'-0" of an HVAC supply/return register at the 1st floor Office near Pastoral Care.

4. On 8/9/23 at 9:27 am, a smoke detector was observed within 3'-0" of an HVAC supply/return register at the 1st floor EKG Room.

5. On 8/9/23 at 11:06 am, a smoke detector was observed within 3'-0" of an HVAC supply/return register at the 1st floor Corridor near Cafeteria entrance.

B. On 8/9/2023, at 11:02 am while in the company of the MOP and RDS, a smoke detector was observed loose and falling from the ceiling at 1st floor Corridor near Linen Room. This condition is not in compliance with 2010 Edition of NFPA 72, Section 17.7.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 8/9/2023, at 9:42 am while in the company of the MOP and RDS, missing ceiling tiles were observed at the EVS Room at 1st floor Med-Surge wing. This condition can delay activation of a sprinkler head by allowing heat and combustive materials to bypass the sprinkler. This condition does not comply with 2010 Edition of NFPA 13, Section 8.6.4.1.

B. On 8/9/2023, while in the company of the MOP and RDS, missing or loose escutcheon were observed around the annular opening for a concealed sprinkler in the ceiling. This does not comply with 2010 Edition of NFPA 13, Section 6.2.7. Example locations observed:

1. At 9:19 am, EVS Room at 1st floor C Wing near Nuclear Med area.

2. At 11:06 am, 1st floor Corridor near Cafeteria entrance.

C. While in the company of the MOP and RDS, it was observed that clearance between sprinkler heads and storage/storage shelf is not provided 18" or more in accordance with 2010 Edition of NFPA 13, Section 8.5.6.1. Example locations include:

1. On 8/8/23 at 12:46 pm, 2nd floor Clinical Engineering Room in the HVI Procedure area.

2. On 8/9/23 at 9:55 am, 1st floor Behavioral Health Storage.

3. On 8/9/23 at 10:15 am, privacy partition installed at the 1st floor Pharmacy customer window.

4. On 8/9/23 at 10:23 am, 1st floor Clinical Supply.

5. On 8/9/23 at 10:30 am, 1st floor Linen Room.

6. On 8/9/23 at 10:32 am, 1st floor Receiving.

7. On 8/9/23 at 10:39 am, 1st floor IT Department Storage.

8. On 8/9/23 at 10:57 am, 1st floor Kitchen Storage.

Based upon document review, fire drills are not being conducted in accordance with Code requirements. Failure to conduct and document fire drills can compromise the safety of any building occupants during emergency evacuation.

Findings include:

On 8/8/2023, at 11:15 am while in the company of the MOP and RDS, it was observed that the documentation of acknowledgment regarding signal receipt by the Fire Department or monitoring agency is not available in accordance with Section 19.7.1.4 through 19.7.1.7.

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

Findings include:

On 8/9/2023, at 11:47 pm while in the company of the MOP and RDS, it could not be confirmed through direct observation that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with 2011 Edition of NFPA 70, Section 250.104 (B).