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Based upon observation, means of egress from all spaces is not maintained in accordance with requirements. Failure to provided means of egress can result in injury to patients due to confinement and lack of supervisory observation of the patient.

Findings include:

On 4/24/18 at approximately 3:15pm while in the company of the DF, it was observed that doors at the seclusion room toilet rooms and the CDU (Chemical Dependency Unit) serenity room toilet room were equipped with dead bolt locks that can prevent egress from the rooms without meeting the supervisory observation requirements. If the door is locked to prevent egress and observation by staff cannot be provided for privacy reasons, exit access from the room does not comply with 19.2.2.2.4 or 19.2.2.2.5.1.

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain continuous illumination of the means of egress. Failure to provide required lighting could affect any occupants in the building that must use the exits because 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.

Findings include:

On April 25, 2018 at approximately 2:15pm while in the company of the DF, the south exit discharge location was observed to have a single fixture with a single lamp. Other exit discharge locations at the east and west exit discharge doors were similar. Based upon interview with the DF, the fixtures could not be determined to have instant-on type lighting from an emergency source of power within 10 seconds to comply with 39.2.8, 7.8.1.4 & 7.9.1.3.

Based upon observation, exit access to the public way is not identified by exit signage. Failure to identify the complete path of egress to the public way can result in confusion and delay in exiting away from the building in the event evacuation is necessary due to a fire condition.

Findings include:

On 4/24/18 at approximately 3:00pm to 4:00pm while in the company of the DF, it was observed that 4 of 4 closed courtyards which function as the exit discharges for multiple exterior exit doors from the building do not have the exit access from the courtyard to the public way identified to comply with 7.7.3.2.

Based upon observation, fire alarm system components are not installed in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as required in the event of repairs and fire emergency and could affect all occupants of the building.

Findings include:

On April 25, 2018 at approximately 11:45am while in the company of the DF, it was observed that the #26 circuit breaker in the "Tech Panel -1" electrical panel in the IT room 125 was not provided with a mechanical lock-on device to comply with NFPA 72-2010, 10.5.5.3.

Based upon observation, the Essential Electrical System (EES) is not installed in accordance with requirements. Failure to install the EES in accordance with Code requirements can result in failure of the system to operate to provide electrical power for required life safety systems upon failure of the normal power system for all building occupants.

Findings include:

A. On April 25, 2018 at approximately 11:30am while in the company of the DF, it was observed that the Level 2 emergency generator is a required system for means of egress, exit lighting and emergency lighting and fueled by natural gas. The fuel supply for the emergency generator is not connected ahead of the building's main shut-off valve and marked as supplying an emergency generator to comply with NFPA 110-2010, 7.9.7. The building's main shut-off valve is not marked or tagged to indicate the existence of a separate emergency generator shut-off valve to comply with 7.9.8.

B. On April 25, 2018 at approximately 11:30am while in the company of the DF, a remote manual stop switch was not observed to be provided for the emergency generator to comply with NFPA 110-2010, 5.6.5.6.