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Based on observations and document review, it was determined that the facility failed to maintain the minimum Construction Type for this building. This deficient practice could compromise the fire resistant rating of the structure and affect patients, staff and visitors within a means of egress if fire compromised the structural integrity of the building.

Finding includes:

On 04/23/2019 At 8:45am during the on-site meeting accompanied by the RC, it was determined that the facility has an FSES (under the 2000 edition of the Life Safety Code) for a construction type deficiency. The building's construction type is Type II (111) consisting of concrete joist slab assembly. The slab thickness between joists is approximately 2 1/2". There is no U.L. listed design providing a 2-hour fire rating for this assembly. The building does not comply with table 19.1.6.1.

Based on observation, not all egress paths are maintained in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to maintain required means of egress can impede the use of the means of egress by building occupants during emergency conditions.

Findings include:

A. On 04/23/19 at 2:45pm while in the company of the RC it was observed that exit signage at the SW corner of the west corridor was obscurred by the placement of other signage in non-compliance with 7.10.1.8.

B. On 04/23/19 at 3:00pm while in the company of the RC it was observed that 1st floor Corridor T1013 was identified with exit signage directing exitng into/thru the NE corner of the ED Exam room suite and then into the ED treatment room suite in non-compliance with 7.5.1.2 and 19.2.5.4. Surveyor notes that the pair of doors leading from the ED Exam room suite to Corridor T1013 are single swing, into the ED suite and if exit signage is changed to direct suite occupants from the suite into Corridor T1013, the swing of the doors may not comply with 7.2.1.4.2.

C. On 04/23/2019 at 3:10pm while in the company of the RC it was observed that 1st floor Corridor W-100 east of the ED (in the Classic building) was being used for the storage of beds/gurneys along the corridor wall not in compliance with 19.3.2.1.

Based on observation, not all egress paths are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress could be impeded under emergency conditions if they are not maintained.

Finding includes:

While accompanied by the MM, observation determined that furnishings and equipment obstruct egress in designated exit access corridors in a manner prohibited by 7.1.10.2.1.

Locations and obstructing materials observed include:
1. 04/23/19 at 2:28pm: First Floor Surgical Department, all Corridors obstructed by carts, equipment, and gurneys.
2. 04/24/19 at 10:04am: Second Floor Corridor CS-222A, corridor obstructed by gurneys and equipment.

Based on observations, 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, staff and visitors if during a fire/smoke emergency the egress paths are obstructed.

Finding includes:

On 04/24/2019 while accompanied by the RC, means of egress corridors were observed containing multiple pieces of equipment and gurneys, encroaching into the corridor means of egress width. The number of gurneys exceeded that which would be "in-use" ( i.e. outside of one Operating room). This condition does not comply with 19.2.1.

Locations observed:
1. At 2:15pm 1st floor corridor adjacent to Elevators #11, 12 and 13 containing four gurneys, large bin containing cardboard waste, written on the bin was "break down bin".
2. At 2:20pm 1st floor Corridor #W1-04A containing 5 gurneys on the south side and 2 gurneys on the North side adjacent to Shaft #X1026.

Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained.

Findings include:

A. On 04/24/2019 at 9:40am while in the company of the SO it was observed that the Delayed Egress lock installed near the Basement level elevator lobby near T0B104 has required signage indicating a 15 second delay for release of the lock, but the audible voice alarm announces a 25 second delay. The signage and release of the lock are not coordinated to comply with 7.2.1.6.1.1(3) & (4).

B. On 04/24/2019 at 2:00pm while in the company of the SO it was observed that the 4th floor cross corridor doors from the service/transport elevator corridor to the patient corridor are equipped with magnetic locks indicted by staff to be controlled by security personnel to control transported patient movement out of the elevator corridor into the patient unit when deemed necessary. The doors are marked with exit signage only on the elevator corridor side and do not appear to be arranged to be unlocked in accordance with any provisions available under 19.2.2.2.4 when they are remotely locked.

Based on observation, not all exit stair enclosures are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the exit stair enclosures are not properly constructed and maintained.

Finding includes:

On 04/23/19 at 10:20am, while accompanied by the MM, observation determined that the Fifth Floor landing of the Southwest Exit Stair is used to store materials as prohibited by 7.1.3.2.3.

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required including stair components within the stair enclosure. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. On 04/24/2019 at 11:05am, while in the company of the RC, it was observed that a duct passes through the exit stair which does not serve the stair. The location is at the discharge level of the South building Stair which is used as an exit for the Classic building as well which does not comply with 7.1.3.2.1(10).

B. On 04/24/2019 at 10:10am while in the company of the RC, electrical conduit was observed within an exit stair which does not serve the stair. The location is at the 3rd floor level of the "C" Stair landing. This condition does not comply with 7.1.3.2.1(10).

C. On 04/24/2019 at 3:10pm while in the company of the RC electrical conduit and large junction box located in the stair which does not serve the stair. Location observed: Basement East Stair.

D. The distance between guardrails in exit stair enclosures was observed to be 18" which is in excess of 4" and does not comply with 19.2.2.3, 7.2.2.4.5.3.

Location observed:
1. 10:15am 04/23/2019 Exit Stair W 14th floor

E. Stair arrangements were observed that continue more than one-half story below the level of exit discharge without a means to prevent travel past the level of exit discharge. This condition does not comply with 7.7.3.4.

Location observed:
1. On 04/23/2019 at 3:15pm while accompanied by the SO, Ground floor East Stair. Interviews determined that the same condition applies to the Center Stair and the West Stair.

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.

Findings include:

A. On 04/24/2019 at 10:20am while accompanied by the LE, a fire barrier door did not close to the latched position to comply with 8.3.3, 8.3.4 and NFPA 80, 2010, 6.1.4. Location observed 8th floor East end.


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B. On 04/25/19 at 8:55am, while accompanied by the MM, observation determined that a penetration by a piece of wood, through the south fire barrier wall of Second Floor Elevator Lobby E-261, is not sealed against the passage of fire as required by 8.3.5.1.

Based upon observation, Exit signs are not provided to provide clear identification of exit access. This deficient practice could affect patients, staff and visitors if there is a failure to identify available means of egress which could result in occupant confusion or inability to reach an exit during a fire/smoke event.

Finding includes:

On 04/24/2019 while accompanied by the LE, exit signage was observed to be covered or missing which does not comply with 7.10.1.2.1

Locations observed:
1. At 9:20am 8th floor, both side of fire/smoke door in exit corridor 868.
2. At 9:25am8th floor , both sides of fire/smoke door in exit corridor 890W. 10th southeast dead end corridor at 2:25PM
3. At 10:15am 7th floor, both sides of fire/smoke door at exit corridor E766.
4. At 10:23am 7th floor, at exit corridor E747A, north side exit sign missing.
5. At 10:10:33am 6th floor, at the elevator lobby.
6. At 10:42am 6th floor, at room E647A north side.
7. At 10:45am 6th floor, Service elevator lobby.
8. At 10:51am 6th floor, north side of exit corridor W663W.
9. At 2:00pm 4th floor, by smoke doors by room E450
10. At 2:05pm 4th floor, at the cross corridor by the elevator lobby and toilet E451A.


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12. At 10:15am 9th floor West end , exiting shown into the On Call suite.
13. At 9:45am 10th floor no exiting shown into Corridor W1050 from Dining
14. At 2:50pm 1st floor Corridor # X1112 lacks signage directing persons north from Corridor #E-130A
15. At 10:40am Ground floor Corridor adjacent to Elevators # 7, 6, 5 lacks exit signage in both directions.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Finding includes:

On 04/23/19 at 2:07pm, while accompanied by the MM, observation determined that the egress path at the north end of the north-south corridor immediately east of Mechanical Room E-389 is not identified by an exit sign as required by 7.10.1.1.

Based upon observation, vertical openings are not constructed and maintained to provide separation of floor levels in accordance with requirements. This deficient practice could affect patients, staff and visitors if a failure to protect vertical openings would permit the effects of a fire/smoke to expose and compromise the safety of occupants utilizing an exit stair.

Findings include:

A. On 04/24/2019, while in the company of LE, a pipe chase was found open into the Staff Locker rooms on the following floors, which does not comply with Sections 19.3.1.1 and 8.6.3(1).

1. At 9:30am 8th floor
2. At 10:05am 7th floor
3. At 10:50am 6th floor


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B. On 04/24/2019 at 1:25pm while accompanied by the RC 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. The shaft contains a hole surrounding a pipe penetration on one end and a gypsum board patch on the opposite end. Location observed: Ground floor, east wall of shaft # XG023 adjacent to Corr #GE-54A.

C. On 04/23/2019 at 10:25am while accompanied by the RC a chase was observed to not be completely enclosed with a minimum 2-hour fire rated construction at a through floor pipe penetration to comply with 8.3.5.1, 8.3.5.7, and 9.2.1. Location observed: 10th floor, east wall of Doctor's Dining room.

D. On 4/23/2019 at 10:30am while accompanied by the RC a chase was observed to not be completely enclosed with a minimum 2-hour fire rated construction due to a hole in the north wall of the chase(having 6 access panels). This condition does not comply with 8.3.5.1, 8.3.5.7, and 9.2.1. Location observed: 10th floor, east wall of Doctor's Dining room.

Based on observation, not all vertical openings in the building are protected as required. Failure to protect vertical openings between floor levels can affect building occupants' safety if smoke and fire could pass between building stories when vertical openings are not protected.

Findings include:

A. On 04/24/2019 while in the company of the SO it was observed that penetrations between floor levels could not be confirmed to be protected to afford the 2-hour rated floor-to-floor separation to comply with 8.3.5.

Locations include:
1. At 9:50am at Ground floor Equipment room T0G110, penetrations to the floor above.
2. At 1:40pm at 4th floor Room T04041, multiple open conduits thru the floor above.
3. At 2:45pm at the 5th floor SW Shell Space a non-fire rated/labeled access door was observed in the 2-hour rated corridor wall which forms the separation of the 5th floor corridor from the 4th floor because the shell space lacks a fire rated floor deck.


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B. On 04/24/2019 at 10:25am, while in the company of the RDF an annular space for a metal conduit penetration was observed not fire stopped, located behind an area of rescue communication panel through north access hatch. The condition does not comply with 19.3.1, 8.3.5, 8.3.5.1.
Location observed: 11th floor inside Stair #2

Based upon observation, hazardous areas are not 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 and block exiting.

Finding includes:

On 04/24/2019 at 1:10pm while in the company of the SO it was observed on the 3rd floor near Janitor T03309 that a large alcove space open to the corridor was utilized for the storage of beds and deemed to constitute a hazardous area. This condition does not comply with 19.3.2.1 and 19.3.6.1.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Finding includes:

On 04/23/19, while accompanied by the MM, observation determined that doors to hazardous areas are not positive latching as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.1.4.

Locations observed include:
1. 2:20pm: First Floor Surgical Department Sterile Core B, all doors.
2. 2:34pm: First Floor Surgical Department Sterile Core C, all doors.
3. 2:42pm: First Floor Surgical Department Sterile Core A, all doors.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Finding includes:

On 04/24/19 at 1:46pm, while accompanied by the MM, observation determined that the door to the Clean Storage Room is not self-closing as required by 39.3.2.1 and Table 8.3.4.2.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:

A. On 04/25/19 at 8:21am, while accompanied by the MM, observation determined that the door to Second Floor Clean Linen Room W275B does not close to latch as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.1.4.


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B. On 04/23/2019 at 11:25am while accompanied by the RC, numerous locations of construction debris was observed within the 11th floor mechanical spaces. The accumulation of construction debris, cardboard boxes, wood pallets, rags throughout the mechanical rooms inpeeded access to the West Exit Stair. This condition does not comply with 19.3.2

C On 04/24/2019 at 1:12pm while accompanied by the RC corridor doors do not latch to a closed position which does not comply with 19.3.2.1.
Location observed: 1st floor corridor entry door(door leads to West end Cafe suite-area designated as hazardous on the life safety floor plans) located adjacent to the West Stair.

D. On 04/24/2019 at 1:50pm while accompanied by the RC it was observed that the corridor door leading from the ground floor level Pharmacy storage is locked against egress. Further the door requires two motions in order to operate the door. These conditions do not comply with 19.2.2.2.5.

Based on observation, the facility failed to install a compliant type 1 grease exhaust system. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 4/23/19 in the company of the FOM while touring 11th floor mechanical rooms it was observed that the connections between the cafeteria grease duct and the exhaust fan were made using flexible connectors which does not comply with NFPA 96, 2011, 8.1.3.4 & 5.

Example locations:

1: at 1:40pm, Pizza Hood Exhaust Mech. Room M018
2: at 1:50pm, East and West Cafe Grill Hood Exhaust Mech. Room M017

B. On 4/23/19 in the company of the FOM while touring 11th floor mechanical rooms it was observed that the field applied grease duct enclosure does not enclose the exhaust fan to comply with NFPA 96, 2011 7.7.1.5

1: at 1:40pm, Pizza Hood Exhaust Mech. Room M018
2: at 1:50pm, East and West Cafe Grill Hood Exhaust Mech. Room M017

Based upon observation, ABHR are not properly installed within a means of egress. Failure to properly place this type of material within an egress path may compromise the safety of occupants if a fire were to originate at the material and block exiting.

Finding includes:

On 04/24/2019 at 4:00pm, while accompanied by the RDF, alcohol based hand rub dispensers (ABHR) were observed installed with less than 48 inches horizontal spacing. Horizontal spacing between dispensers was measured to be 36 inches. This condition does not comply with 19.3.2.6 (4).

Locations observed: 8th floor in the exit corridor near rooms T08213, T08209 and T08218

Based on observation the facility failed to provide complete smoke detection. This deficient practice could affect patients, staff and visitors if the fire alarm detection system failed to notify building occupants in a timely manner.

Finding includes:

On 04/25/2019 while in the company of LE, the following smoke detectors were found located less than a distance of 3'-0" from an air diffuser, which does not comply with 9.6, NFPA 70 and NFPA 72-2010, 17.7.3.1.

Example locations:

1. 8th floor at 9.09am, in the exit corridor across from Room E838A.
2. 8th floor at 9:30am, in the staff elevator lobby
3. 8th floor at 9:40am, in the public elevator lobby.

Based on observation, not all portions of the building's fire alarm system are installed as required. This deficient practice could affect patients, staff, and visitors in the building because they could be unaware of a fire condition if the fire alarm system is not properly installed.

Finding includes:

On 04/24/19, while accompanied by the MM, observation determined that smoke sensing fire detectors, at doors required to release under smoke conditions and at which the ceiling is less than 24 inches above the head of the door on both sides, lack smoke detectors within 5 feet of one side of the door as required by NFPA 72 2010 17.7.5.6.5.1(A).

Locations observed:
1. 10:32am: Fifth Floor door at north end of Corridor C502.
2. 10:57am: Third Floor door at north end of Corridor X3065.

Based on observation, not all portions of the building's fire alarm system are installed to provide a manual means of activation. This deficient practice could affect patients, staff, and visitors in the building because they could be unaware of a fire condition if the fire alarm system is not properly installed.

Finding includes:

On 04/24/2019, while accompanied by the RDF observation determined that a second means of egress into the Main building (Classic building) is through fire doors. There are no manual fire alarm activation stations at the locations to comply with 19.3.4.2.1 and 9.6.2.3.

Locations observed:
1. 9:30am, 14th floor to classic building.
2. 9:40am, 12th floor to classic building.

Based on observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required.

Finding includes:

On 04/24/19 at 1:28pm, while accompanied by the MM, observation determined that the following deficiencies exist at the Fire Alarm Control Panel. located in the Basement Mechanical Room:

1. The breaker serving the Fire Alarm Control Panel is not labeled "FIRE ALARM" as required by NFPA 72 2010 10.5.2.2.
2. The breaker serving the Fire Alarm Control Panel is not provided with red marking as required by NFPA 72 2010 10.5.2.3.
3. The breaker serving the Fire Alarm Control Panel is not provided with a listed breaker locking device as required by NFPA 72 2010 10.5.5.3.

Based on observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required.

Finding includes:

On 04/24/19 at 1:50pm, while accompanied by the MM, observation determined that the following deficiencies exist at the Fire Alarm Control Panel. located in the Basement Mechanical Room:

1. The breaker serving the Fire Alarm Control Panel is not labeled "FIRE ALARM" as required by NFPA 72 2010 10.5.2.2.
2. The breaker serving the Fire Alarm Control Panel is not provided with red marking as required by NFPA 72 2010 10.5.2.3.
3. The breaker serving the Fire Alarm Control Panel is not provided with a listed breaker locking device as required by NFPA 72 2010 10.5.5.3.

Based on observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required.

Finding includes:

On 04/25/19 at 10:23am, while accompanied by the MM, observation determined that the location of the branch circuit disconnecting means for the NAC Panel located in the First Floor PACU Clean Utility Room is not identified on it as required by NFPA 72 2010 10.6.5.2.1.

Based on observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required.

Finding includes:

On 04/25/19 at 8:42am, while accompanied by the MM, observation determined that the location of the branch circuit disconnecting means for the NAC Panel located in Second Floor Electrical Closet E260A is not identified to comply with NFPA 72 2010 10.6.5.2.1.

Based on observation, the facility failed to maintain a complete building fire suppression system. This deficient practice could affect patients, staff and visitors if it result in the delayed response and suppression of a fire event, which affects building occupant safety.

Findings include:

A. On 04/24/2019 at 10:15am while in the company of the SO it was observed at the 1st floor Au Bon Pain cooler that materials on shelving did not maintain the minimum 18" clearance below the sprinkler head to comply with NFPA 13-2010, 8.5.5.

B. On 04/24/2019 at 2:15pm while in the company of the SO it was observed that the 5th floor Mechanical room contained combustible storage under ducts wider than 4' and did not have sprinkler protection under the ducts to comply with NFPA 13-2010, 8.5.5.3.1.

Based on observation, the facility failed to provide a complete automatic sprinkler system where installed. This deficient practice could affect patients, staff, and visitors in the building because the automatic sprinkler system may fail to extinguish a fire if it is not properly installed.

Findings include:

A. On 04/24/19, while accompanied by the MM, observation determined that materials are being stored less than 18 inches below standard pendant sprinkler heads as prohibited by NFPA 13 2010 8.5.6.1.

Locations observed include:
1. 1:50pm: Third Floor Clean Supply Room C-338.
2. 2:33pm: First Floor Orthopedic Storage Room C-100A.

B. On 04/24/19 at 1:52pm, while accompanied by the MM, observation determined that ceiling tiles in Third Floor Soiled Holding Room C-334 are out of place or missing, thus compromising the coverage of the room by standard pendant sprinkler heads, as prohibited by NFPA 13 2010 8.6.4.1.1.


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C. On 4/24/19 at 9:30am in the company of FOM it was observed that the Morgue extremities cooler in room CE-1 basement is not provide with automatic fire sprinkler protection as required by NFPA 13, 20108.1.1 (1).

Based on observation and staff interview the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Finding includes:

On 4/24/19 at 1:15pm in the company of the FOM It was observed in the Emergency Department corridor T1038 was provided with skylight ceiling pockets which are not provided with automatic sprinkler protection as required by 8.5.7 and 8.6.7.

Based on observation the facility failed to maintain installed sprinkler heads or sprinkler piping. This deficient practice could affect patients, staff and visitors if fire were to spread due to insufficient sprinkler coverage or lack of sprinkler maintenance.

Findings include:

A. On 04/23/2019 at 10:06am while accompanied by the RC ductwork was observed located above the elevator controllers #8 and #9. The duct forms an obstruction to adequate sprinkler protection for those disconnects. This condition does not comply with NFPA 13 2010 8.1. Location observed: Elevator Penthouse above 14th floor.

B. On 04/24/2019 at 11:45am while accompanied by the RC, a corridor with a lay-in slatt finished ceiling was observed having large continuous gaps between the slatts. There was no "batting" above the finished ceiling which will allow smoke development above the ceiling and delay activation of the sprinkler system which does not comply with NFPA 13 2010, 8.15.19 for sprinkler installations below ceilings.
Location observed: 1st floor Corridor W-135

Based upon observation, the facility failed to maintain a compliant sprinkler system provided through inspection and testing of sprinkler components. This deficient practice could affect patients, staff and visitors if an impairment within the system's water pressure would go unnoticed until a fire/smoke event.

Findings include:

A. On 04/24/2019 while accompanied by the RDF, it was observed that the same manufacturer's date is on all gauges at the top of sprinkler riser's inside stairwells. The observed manufacturer's date is 2008. There is no record of recalibration or testing within the past 5 years to comply with NFPA 25, 2011, 5.3.2.1.

Example locations observed:
1. At 9:10am, Exit Stair #3.
2. At 10:28am, Exit Stair #2, 11th floor.

B. On 04/24/2019 at 10:52am while accompanied by the RDF a concealed sprinkler head was observed missing a cover plate which does not comply with NFPA 25 2011 5.2.1.1.1, 5.2.1.1.2 and NFPA 13 2010 6.2.7.3.

Location observed: 10th floor in Soiled Utility room T10103

Based upon observation and staff interview, portions of the building sprinkler system have been removed from service or impaired and Interim Life Safety Measures (ILSM) are not being followed to compensate for the temporary loss of the sprinkler system. Failure to follow defined ILSM puts all occupants at risk if a fire/smoke condition were to originate within the affected area because suppression systems are not available to control the incident.

Finding includes:

On 04/24/2019 at 11:10am while in the company of the SO it was observed that the 2nd floor Patient room T02212 and adjacent area are part of a construction project where the ceiling has been removed and the sprinkler system had been shut down to make sprinkler revisions. Maintenance Staff indicated the sprinkler zone had been drained and out of service since 7:30am and the duration of the shut-down was not identified. The posted Interim Life Safety Measures for the project called for a continuous Fire Watch by the Contractor. Contractors or assigned Hospital staff were not present at the location to indicate a continuous Fire Watch was implemented to comply with the Hospital's established ILSMs and NFPA 25-2011, 15.5.2

Based upon observation and staff interview, corridor doors and doors between defined suites are not maintained to be positive latching to comply with requirements. Failure to provide positive latching doors can allow the effects of a fire/smoke condition to migrate from one side of the wall to the other and compromise the safety of occupants on the other side.

Finding includes:

On 04/23/2019, while accompanied by RC, it was observed that multiple door locations serving as corridor doors of suites and doors between suites at the 1st floor level did not have functioning positive latching hardware to comply with 19.2.5.7.1.2 and 19.3.6.3.5.

Example locations observed include:
1. At 2:00pm at the NE pair of corridor doors of the ED treatment room suite.
2. At 2:15pm at the East pair of doors between the Peds ED suite and the ED treatment room suite.
3. At 2:30pm at the SW pair of doors of the Peds ED suite in the defined 3-hour barrier wall.
4. At 2:40pm at the cross corridor pair of doors in the 2-hour barrier between the ED building and the Parkside building.
5. At 2:50pm at the SW pair of corridor doors of the ED Triage suite and the NE pair of doors between the Triage suite and the ED Exam room suite.

Based upon observation, corridor doors are not maintained to be positive latching to comply with requirements. This deficient practice could affect patients, staff and visitors if a failure to provide positive latching doors can allow the effects of a fire/smoke condition to migrate from one side of the wall to the other and compromise the safety of occupants on the other side.

Findings include:

A. On 04/24/2019 at 10:20am while in the company of the SO it was observed that the 1st floor retail Pharmacy was enclosed by a non-rated aluminum & glass corridor wall that was identified by building plans as being 1-hour rated construction. The pair of corridor doors were not positive latching to comply with 19.3.6.3.5.

B. On 04/24/2019 at 11:00am, while accompanied by the SO, it was observed that the 2nd floor far east Family room, which contains an elevator serving the Yachtman building and the Tower building, has a Tower building corridor door that does not have functioning positive latching hardware to comply with 19.3.6.3.5.

C. On 04/24/2019 at 3:00pm while in the company of the SO it was observed that the 6th floor Tower east Service Elevator Corridor is a defined suite, but is marked as a means of egress for the Classic building in non-compliance with 19.2.5.4.

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor doors are not properly installed and maintained.

Finding includes:

While accompanied by the MM, observation determined that corridor doors are not positive latching as required by 19.3.6.5(1).

Locations observed include:
1. 04/24/19 at 2:35pm: First Floor corridor door to Operating Room 7.
2. 04/24/19 at 2:36pm: First Floor corridor door to Operating Room 5.
3. 04/24/19 at 2:37pm: First Floor corridor door to Operating Room 4.
4. 04/25/19 at 2:35pm: Second Floor corridor door to Office E-262.

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

Findings include:

A. On 04/25/19 at 8:16am, while accompanied by the MM, observation determined that the pair of doors from the Second Floor Elevator Lobby W-280 are secured against egress in a manner prohibited by 19.2.2.2.4.


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B. On 04/23/2019 while accompanied by the RC corridor doors do not latch to a closed position which does not comply with 19.3.6.3.

Locations observed:
1. At 8:50am 12th floor pair of corridor entry doors from "Service" Elevator Lobby, this "Lobby" is deemed as a public use space since there is no prevention to the public use of these elevators on any floor.
2. At 10:50am 5th floor pair of corridor entry doors from "Service" Elevator Lobby, this 'Lobby" is deemed as a public use space since there is no prevention to the public use of these elevators on any floor.

Based upon observation, fire/smoke barrier walls are not maintained to afford the required/indicated hourly protection rating. This deficient practice could affect, patients, staff and visitors if a failure to maintain fire/smoke barrier wall construction can result in the spread of fire/smoke condition to adjacent zones intended to function as areas of refuge for building occupants.

Findings include:

A. On 04/24/2019 at 9:45am while in the company of the SO it was observed at the Ground floor 2-hour rated fire/smoke barrier wall above the cross corridor doors accessing the Classic building near T0G103B that a large conduit sleeve was not sealed to comply with 8.3.5.


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B. On 04/24/2019 at 10:14am, while accompanied by the RDF, open metal conduit was observed not fire stopped at penetration of smoke barrier wall. Additionally approximately 3 inch wide strip of drywall was missing above the conduit. This is not in accordance with 19.3.7.3, 8.4.4. Location observed: 11th floor, inside patient room T11218, above ceiling tile.

C. On 04/24/2019 at 11:10am, while accompanied by the RDF, approximately 24 x 36 inch section of smoke barrier wall was observed missing at the penetration of large conduit. This is not in accordance with 19.3.7.3, 8.4.4. Location observed: 10th floor, in Multi-Purpose room T10107 above the ceiling tile.

D. On 04/24/2019 at 2:00pm while accompanied by the RDF, one leaf of a pair of fire rated cross corridor double doors was observed which failed to latch into the frame when released from the door hold open magnet. Top edge of the door is hitting the door frame and does not fully close. These conditions are not in accordance with 19.3.7.8 and 8.5.4. Location observed: 7th floor, in exit corridor adjacent to room T07220

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

Finding includes:

While accompanied by the MM, observation determined that pipe or other penetrations in smoke barrier walls are not sealed against the passage of smoke as required by 8.5.6.2.

Locations observed include:
1. 04/24/19 at 1:48pm: Third Floor smoke barrier above cross-corridor doors at west end of Corridor C-331B.
2. 04/24/19 at 1:59pm: Third Floor smoke barrier above cross-corridor doors at west end of Corridor C-331C.
3. 04/25/19 at 9:20am: Second Floor smoke barrier above cross-corridor doors at east end of Corridor C-201B.

Based on observation, the facility failed to provide access to fire protection appliances within the ventilation duct system. This deficient practice could affect patients, staff and visitors during a fire event if failure to install and maintain this installation would result in the passage of fire and products of combustion from one fire compartment to another.

Finding includes:

On 04/23/2019 at 11:30am while accompanied by the RC it was identified that the installed access doors located at a chase for inspection and maintenance of the fire dampers within a shaft are of a size and location which does not allow access to the fire protection devices within the shaft. There are 6 wall mounted acess panels on the outside of the chase. These panels are positioned in a manner which does not allow for the complete opening of the duct access panels. The inability to access dampers for inspection and maintenance does not comply with NFPA 80-2010, 19.2.3. It was observed that fire damper inspections do not identify these as inaccessible or include these dampers.

Location observed:
1. 10th floor private dining room, East wall.

Based on observation during the survey walk through the facility failed to correctly separate components for the elevator systems. This deficient practice could affect patients, staff and visitors if during a fire event 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.

Findings include:

A. On 04/23/2019 at 10:10am while accompanied by the RC, a room dedicated to HVAC units and equipment which has a separate use from the elevator machine room was observed open to the machine room as follows:

1. The Life safety floor plans indicate that the mechanical room is not separated from the elevator machine room by fire rated construction to comply with ANSI/ASME A17.3 2008 edition, section 2.2.1.
2. There are unprotected openings in the non rated wall between the rooms.
Location observed: Elevator Penthouse PH003, 04 and Mechanical room PH001 and 008 above the 14th floor

B. On 04/23/2019 at 2:43pm while accompanied by the RC, equipment is located within the elevator machine room as follows:

1. Multiple Cafe kitchen grease ducts are located within the space of the elevator machine room which does not comply with ANSI/ASME A17.3 2008 edition, section 2.2.1 and 2.2.5.
2. There is an "expansion tank" for fan coil units, hvac units, electrical panels all located within the machine room which do not serve the machine room.
Location observed: 11th floor Elevator Machine room

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Finding includes:

On 04/25/2019 at 10:00am during document review with the RC and SO, Facility fire drill documentation for the past 12 months did not indicate that drills are held with sufficient frequency and locations to familiarize all staff with drill procedures. Documentation does not indicate that staff on other floors are familiar with basic fire response procedures to comply with 19.7.1. and 4.7.2.

For example:
Main building:
1. ER - 12/18/18, 4th quarter
2. Kitchen - 2/27/19 1st quarter
3. Ground floor - 07/31/18 - 3rd quarter
4. 8th floor, East - 06/13/18 - 2nd quarter

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Finding includes:

On 04/25/2019 at 10:00am during document review with the RC and SO, Facility fire drill documentation for the past 12 months did not indicate that drills are held with sufficient frequency and locations to familiarize all staff with drill procedures. Documentation does not indicate that staff on other floors are familiar with basic fire response procedures to comply with 19.7.1. and 4.7.2.

Example locations:
Main building
1. ER - 12/18/18, 4th quarter
2. Kitchen - 2/27/19 1st quarter
3. Ground floor - 07/31/18 - 3rd quarter
4. 8th floor, East - 06/13/18 - 2nd quarter

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Finding includes:

On 04/25/2019 at 10:00am during document review with the RC and SO, Facility fire drill documentation for the past 12 months did not indicate that drills are held with sufficient frequency and locations to familiarize all staff with drill procedures. Documentation does not indicate that staff on other floors are familiar with basic fire response procedures to comply with 19.7.1. and 4.7.2.

For example:
Main building-
1. Kitchen - 2/27/19 1st quarter
2. Ground floor - 07/31/18 - 3rd quarter
3. 8th floor, East - 06/13/18 - 2nd quarter

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Finding includes:

On 04/25/2019 at 10:00am during document review with the RC and SO, Facility fire drill documentation for the past 12 months did not indicate that drills are held with sufficient frequency and locations to familiarize all staff with drill procedures. Documentation does not indicate that staff on other floors are familiar with basic fire response procedures to comply with 19.7.1. and 4.7.2.

For example:
Main building-
1. ER - 12/18/18, 4th quarter
2. Kitchen - 2/27/19 1st quarter
3. Ground floor - 07/31/18 - 3rd quarter
3. 8th floor, East - 06/13/18 - 2nd quarter

Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

Finding includes:

On 04/25/2019 at 9:30am while in the company of the RC and SO, documentation for fire rated doors was reviewed. The following information was not available:
There is no indication a complete fire door inspection was conducted for 2018 pertaining to the ED Building in order to comply with 7.2.1.15.3.

Based on observation, the medical gas piping system is not maintained in compliance with NFPA 99. The deficient practice could affect patients, staff and visitors if not providing direct access to system components which would prevent staff form these services.

Finding includes:

On 04/24/2019 at 10:06am, while accompanied by the RDF observation determined a cleaning cart was parked in front of med gas zone valves. This condition does not comply with NFPA 99 2012, 5.1.4.8.4 and 5.1.4.8.5.

Location observed: 11th floor adjacent to T11103

Based on observation, the medical gas piping system is not installed in compliance with NFPA 99. This deficient practice could affect patients requiring assistance from these services.

Finding includes:

On 4/24/19 at 9:30am in the company of the FOM it was observed in the Basement Mechanical room BC-16 that the Category 1 oxygen, medical air and medical vacuum systems piping are supported without isolation from dissimilar metals in non-compliance with NFPA 99, 2012, 5.1.10.11.4.

Based on observation, the facility failed to install and maintain its piped-in medical gas system in the manner required. This deficient practice could affect patients, staff, and visitors in the building because the medical gas piping system could fail to operate when needed if not properly installed and maintained.

Findings include:

A. On 04/23/2019 at 11:00am while accompanied by the RC, observation determined that medical gas piping located above the finished ceilings of patient rooms are not labeled to comply with NFPA 99, 2012 5.1.11.1.2(2). Example locations: Room #1451, #1245

B. On 04/24/2019 while accompanied by the RC, observation determined that medical gas station outlets are located in which there is not a complete wall between the outlets and the shut off valve suppling them. This condition does not comply with NFPA 99 2012, 5.1.4.8(3).

Locations observed:
1. At 1:35pm Ground floor Nuc Med Suite lacks a door between station outlets and shut off valve.
2. At 1:10pm Ground floor CT and Xray Suite.

C. On 04/24/2019 while accompanied by the RC, observation determined that a medical gas shut off valve is not labeled with a complete list of all the station outlets supplied. This condition does not comply with NFPA 99 2012, 5.1.4.8.8 and 5.1.11.2.

Location observed:
1. At 1:10pm Ground floor CT and Xray Suite, shut off valve does not include Patient recovery bays.

Based on observation, not all basic electrical components are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical system could fail to operate properly when needed if the electrical components are not properly installed and maintained.

Findings include:

A. While accompanied by the MM, observation determined that life safety electrical loads are served by Critical Branch of the building's Type 1 Essential Electrical System, and not be the Life Safety Branch. This condition does not comply with NFPA 99 2012 6.4.2.2.3.2 and NFPA 70 2011 517-32(C).

Example locations observed:
1. 04/24/19 at 10:14am: Penthouse Electrical Panel 6CR3:
a. Circuit 15 serves Fire alarm Fan Shutdown.
b. Circuit 17 serves Ansul Fire Panel.

2. 04/24/19 at 10:51am: Fifth Floor command Center Server Room, Electrical Panel 5CRB-13:
a. Circuit 35 serves NAC Panel.
b. Circuit 41 serves Pre-Action Sprinkler System.

3. 04/24/19 at 1:37pm: Third Floor Electrical Closet C322B, Electrical Panel 3CR5, Circuit 42 serves Fire Alarm.
4. 04/24/19 at 1:55pm: Third Floor Electrical Closet C338A, Electrical Panel 3CR4, Circuit 12 serves NAC Panel.
5. 04/24/19 at 2:22pm: First Floor Anesthesia Storage Room C-141, Electrical Panel 1CR11, Circuit 29 serves Flex 500 Fire Alarm.
6. 04/25/19 at 9:17am: Second Floor Electrical Panel 2CR17, Circuit 1 serves NAC Panel.
7. 04/25/19 at 10:22am: First Floor PACU Clean Utility Room C-131, Electrical Panel 1CR8, Circuit 35 serves Fire Alarm.

B. On 04/25/19 at 10:08am, while accompanied by the MM, observation determined that a Dorado (information technologies) System is served by Circuits 10 and 12 of Life Safety Electrical Panel 2LS7, located in Second Floor Electrical Closet CS224 as prohibited by NFPA 99 2012 6.4.2.2.3.2 and NFPA 70 2011 517-32(C).

Based upon observation, electrical systems are not installed and maintained in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to install and maintain the building's electrical systems could result in electrical shock hazards or loss of essential power for life support or means of egress lighting.

Findings include:

On 04/24/2019 at 9:22am while in the company of the RC it was determined that electrical panels contain mixed electrical loads supplying both Life Safety, Critical and Normal Branch. This does not comply with NFPA 99-2012, 6.4.2.2.3 and NFPA 70 2011 517-32.

A pattern is shown by example locations and example loads:
1. 2nd floor Critical Branch Panel 2CR-15 circuit #25 contains a fire alarm NAC panel.
2. Basement Critical Branch Panel BCR-11 contains multiple circuits for emergency corridor lighting.
3. 5th floor Critical Branch Panel in room E562 contains multiple circuits for emergency corridor lighting

Based on observation, not all electrical receptacles are installed as required. this deficient practice could affect patients, staff, and visitors in the building because electrical power may not be available for use when required if they are not installed properly.

Findings include:

A. While accompanied by the MM, observation determined that critical care patient beds lack at least 1 branch circuit served by the hospital's normal power system as required by NFPA 70 2011 517-19(A).

Locations observed include:
1. 04/24/19 at 11:10am: Third Caesarian Section Room 2.
2. 04/24/19 at 2:29pm: First Floor Operating Room 15.
3. 04/25/19 at 11:20am: First Floor ASC Operating Room 4.

B. While accompanied by the MM, observation determined that electrical receptacles, served by the emergency power system, are not labeled as to electrical panel and circuit as required by NFPA 70 2011 517-19(A).

Locations observed include:
1. 04/24/19 at 11:11am: Third Floor Caesarian Section Room 2.
2. 04/24/19 at 11:14am: Third Floor Caesarian Section Recovery Room, all Bays.
3. 04/24/19 at 9:47am: Second Floor NICU, all Bays.

Based on observation and staff interview, the facility failed to provide a compliant Type 1 Essential Electrical System. This deficient practice could affect patients, staff and visitors during a utility power failure.

Finding includes:

On 4/24/19 at 10:00am in the company of FOM it was observed that exterior emergency generators 5A & 5B are not provided with battery powered emergency lighting as required by NFPA 110, 2010, 7.3.1.

Based on observation, the facility failed to provide a compliant Type 1 Essential Electrical System. This deficient practice could affect patients, staff and visitors if during a utility power failure proper shut offs were not available.

Finding includes:

On 4/24/19 at 2:20pm in the company of the FOM it was observed that the building emergency generator is not provided with a remote emergency stop station required by NFPA 110, 2010, 5.6.5.6.

Based upon observation, medical gas storage is not in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to properly store medical gases were to permit stored gases to contribute to the accelarated spread or intensity of a fire at the location.

Finding includes:

On 04/24/2019 at 10:50am while in the company of the SO it was observed that cylinder racks for 12 tanks, 4 tanks & 2 mobile cart stands for E-size tanks which constitute greater than 300 cu. ft., was located in the 2nd floor Clean Supply room T02123 and were not separated from combustible storage to comply with NFPA 99-2012, 11.3.2.3.