HospitalInspections.org

Egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

A. On September 2, 2020 at 1:45pm while in the company of the CM it was observed that the south door from the 4th floor Kitchen has a magnetic locking device with a "push to exit" release on the egress side. The installation lacks the sensor to release the magnet to comply with 19.2.2.2.4(3) and 7.2.1.6.2(1).

B. On September 2, 2020 at 1:50pm while in the company of the CM it was observed that the door accessing the 4th floor Behavior Health unit from the corridor serving the Hoteling rooms was locked against egress in non-compliance with 19.2.2.2.4. (See also K293.A.3 regarding the signage to identify a second exit access from the corridor)

Egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

On September 3, 2020 at 10:15am while in the company of the CM it was observed that identified exit routes directed exiting through doors which are capable of being locked, preventing the use of the identified exit path. Locks are not installed in accordance with 39.2.1.1, 39.2.2.2, 7.1.10.1 and 7.2.1.5 at the pair of doors and the single door accessing the Therapy Gym area which leads to exterior exit doors. The Exit signage provided at the corridors direct exiting through the doors which are capable of being locked to provide egress when the dogged panic devices are set to provide a latching function.

Based on observation, dead end corridor lengths exist which exceed that permitted. This condition could require a person to traverse a longer route to reach an exit and may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

A. On September 2, 2020 while in the company of the CM, it was observed that corridors providing means of egress for occupants had dead end conditions exceeding the 30' permitted by 19.2.5.2.

Locations observed include:

1. At 10:05am at the 9th floor Elevators #9/#10/#11 Lobby.

2. At 10:35am at the 7th floor Elevators #9/#10/#11 Lobby.

3. At 10:45am at the 6th floor Elevators #9/#10/#11 Lobby and Helipad access.

4. At 1:35pm at the 4th floor Elevators #9/#10/#11 Lobby which is also the entry to the Cafeteria. Staff indicated that the doors at the Cafeteria (which are not marked with exit signage) were locked after hours to prevent access. (Surveyor notes that the corridor cannot pass through Cafeteria area which has commercial cooking appliances not in compliance with 19.3.2.5.3 open to the corridors of the area.)

5. At 2:40pm at the 3rd floor Elevators #9/#10/#11 Lobby and entry to the Peds unit which is locked against entry. (This deficiency related to K293.A.4.)

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the lighting provided. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On September 3, 2020 at 10:05am while in the company of the CM, it was observed that exit discharge lighting could not be confirmed to be of the instant-on type to provide illumination within the required 10 second period to comply with 39.2.8, 39.2.9 and 7.8 & 7.9.1.3. Not all exit discharge locations were provided with multiple fixtures (or confirmed to be fixtures with multiple lamps) to comply with 7.8.1.4. Locations observed included the south facade exit door and the north facade exit doors. Main entry east doors may be similar.

Based upon observation, exit signs are not provided to identify access to two remote exits from the building. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition.

Findings include:

A. On September 1-3, 2020 while in the company of the CM it was observed that corridors (and passages within designated suites) lacked exit signs to clearly identify access to at least two remote means of egress from the building to comply with 19.2.4.3, 19.2.10 and 7.10.

Locations include:

1. At 9:20am on September 3, 2020 it was observed that the 2nd floor area of the Charles Street Lobby lacked exit signage to identify a secondary means of egress from the area.

2. At 1:35pm on September 2, 2020 it was observed that identification of a secondary exit access was not provided at the corridor adjacent the Main Kitchen on the 4th floor.

3. At 1:50pm on September 2, 2020 it was observed that identification of a secondary exit access was not provided at the corridor serving the Hoteling rooms on the 4th floor.

4. At 2:40pm on September 2, 2020 it was observed that identification of a secondary exit access was not provided at the corridor known as "Rickter Ridge" on the 3rd floor. See K251 also relative to a dead end condition.

B. On September 2, 2020 while in the company of the CM it was observed that the exit sign at the State Street main entry lobby exterior door lacked illumination in accordance with 19.2.10 and 7.10.5.

K-293.

Based upon observation, exit signs are not provided to identify access to two remote exits from the building. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition.

Findings include:

C. On September 2, 2020 while in the company of the DE it was observed that corridors (and passages within designated suites) within the Heart Hospital building lacked exit signs to clearly identify access to at least two remote means of egress from the building to comply with 19.2.4.3, 19.2.10 and 7.10.

Locations include:

1. At 9:00am it was observed that the 4th floor area exit signage to identify a secondary means of egress from the area, at the exit corridor intersections and in the staff elevator lobby.

2. At 9:55am it was observed that identification of a secondary exit access was not provided at the exit corridors intersections on the 3rd floor.

3. At 10:30am it was observed that identification of a secondary exit access was not provided at the exit corridors intersections on the 3rd floor.

4. At 10:50am it was observed that identification of a secondary exit access was not provided at the exit corridors intersections on the 2nd floor.

5. At 1:56pm - Exit door blocked due to construction outside clinical lab and credit union bank with no Directional exit signage installed.

Based upon observation, vertical openings beteen floor levels are not protected to maintain separation of floor levels. Failure to maintain separation of floor levels can result in fire/smoke conditions migrating to other floors of the building.

Findings include:

A. On September 2, 2020 at 9:45am while in the company of the CM it was observed that the shaft access door located at the 11th floor Penthouse level Elevator Maching Room lacked springs to provide a self-closing assembly to comply with 19.3.1, 8.6, 8.3.4.2 and NFPA 80.

B. On September 2, 2020 at 2:15pm while in the company of the CM it was observed on the 3rd floor that the Elevator #3 door was held open and signage indicated that this elevator was "Restricted Use". The elevator shaft lacked a self-closing door assembly to comply with 19.3.1, 8.6, 8.3.4.2, NFPA 80 and ANSI A17.3.

C. On September 2, 2020 at 9:45am while in the company of the CM it was observed that the shaft access door located at the 11th floor Penthouse level Elevator Machine Room lacked springs to provide a self-closing assembly to comply with 19.3.1, 8.6, 8.3.4.2 and NFPA 80.

D. On September 2, 2020 at 1:45pm while in the company of the DE it was observed at the 1st floor storage room adjacent the loading dock that three pipes penetrating the floor above with about 2" of annular space were not fire sealed to resist the passage of fire/smoke to the above floors to comply with 19.3.1, 8.6, 8.3.4.2.

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 to block exiting.

A. On September 3, 2020 while in the company of the DE it was observed that hazardous areas were not protected to comply with 19.3.2.1, 8.7.1.2 and 8.4.3.5.

Locations include:

1. At 2:12pm at the 2nd floor Soiled Utility room #2549 which is greater than 100 sq. ft., door to exit corridor has no rating and not self-closing to comply with 8.7.1.2 and 8.4.3.5.

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 to block exiting.

Findings include:

A. On September 3, 2020 at 10:20am while in the company of the CM it was observed that a sprinkler protected storage room was not provided with self-closing door assembly to comply with 39.3.2.1, 8.7.1.2 and 8.4.3.5. Location observed include the "Chargable Supplies" Storage room.

Based on observation the facility failed to correctly install cooking equipment. This deficient practice could result in the uncontrolled spread of fire and products of combustion during kitchen cooking operations, which may affect patients, staff and visitors.

On September 2, 2020 at 10:26am in the company of the SBMS it was observed the Cafeteria deep-fat fryer is installed less than 16 inches from the adjacent surface flames of the grill and that the installed vertical baffle is less than 8 inches high. NFPA 96, 2011, 12.1.2.4, 12.1.2.5 & 12.1.2.5.1

Based upon observation, the fire alarm system is not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in delayed activation and notification of occupants of a fire/smoke condition present in the building.

Findings include:

A. On September 2, 2020 while in the company of the CM, it was observed that fire alarm manual pull stations were not installed within 5' of the exit doors to comply with NFPA 72-2010, 17.14.6.

Locations observe include:

1. At 9:50am at the 9th floor exit doors (3 of 3 locations).

2. At 10:35am at the 7th floor north stair door.

3. At 11:30am at the 5th floor Stair 1N door.

4. At 11:40am at the 5th floor Stair 7W door.

B. On September 2, 2020 while in the company of the CM, it was observed that the Hoteling rooms on the 4th floor lacked visual notification appliances to comply with NFPA 72-2010, 18.5.4.6.

Based on observation, not all fire alarm initiation devices are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, the fire alarm could fail to activate under emergency conditions.

Findings includes:

C. On September 2, 2020 while accompanied by the DE, observation determined that fire alarm initiating devices (smoke detectors) are located so that airflow from HVAC diffusers within 3'-0" thus preventing their operation as prohibited by NFPA 72 2010 17.7.4.1.

Locations includes

1. At 9:10am it was observed at the 4th floor Heart Hospital building exit corridors.

2. At 9:45 am it was observed at the 3rd floor Heart Hospital building exit corridors.

3. At 10:20am it was observed at the 2nd floor Heart Hospital building exit corridors.

4. At 1:27pm it was observed at the Basement level that the 3 elevator bank lobby of the main building lacks smoke detector for elevator recall.

5. At 1:33pm it was observed at the Basement level that Elevator #4 lobby of the main building lacks smoke detector for elevator recall.

A. 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.

1. On September 3, 2020 at 9:20am while in the company of the CM it was observed that the 2nd floor Charles Street Lobby ceiling did not provide separation from the above ceiling cavity at the east and west edges to resist the passage of heat and smoke to the above ceiling cavity to provide containment of the space to provide effective response of the sprinkler system to comply with NFPA 13-2010, 4.1 and 3.3.6.


14416


2. On September 2, 2020 at 9:25am in the company of the SBMS the surveyor finds the lack of fire sprinkler protection at the top landing of stair 4ST. NFPA 13, 2010, 8.1.1 & 8.15.3.2.1

3. On September 2, 2020 at 9:30am in the company of the SBMS the surveyor finds the lack of fire sprinkler protection for the facilities traction elevator machine room for elevators 1, 2, & 3. NFPA 13, 2010, 8.1.1

4, On September 2, 2020 at 10:05am in the company of the SBMS the surveyor finds the lack of fire sprinkler protection for the facilities traction elevator machine room for elevator 5. NFPA 13, 2010, 8.1.1

5. On September 2, 2020 at 10:40am in the company of the SBMS the surveyor finds the lack of fire sprinkler protection for the newly installed Pharmacy Box Picker with storage space for combustibles greater than 100 square feet. NFPA 13, 2010, 8.1.1

6. On September 2, 2020 at 10:45am in the company of the SBMS the surveyor finds the fire sprinkler protection is obstructed by the relocated shelving in the Pharmacy. NFPA 13 2010, 8.5.5.2

A. Based on observation the facility lacks correct signage for the use of Class K fire extinguishers in the Kitchen and Cafeteria. This deficient practice could affect patients, staff and visitors during a kitchen cooking grease fire event.

1. On September 2, 2020 at 10:15am in the company of SBMS the surveyor finds that the installed K fire extinguisher by the walk-in coolers lack signage for the correct sequence and use of the extinguisher. NFPA 96, 2011, 10.2.2

2. On September 2, 2020 at 10:25am in the company of SBMS the surveyor finds that the installed K fire extinguisher located by the cafeteria grill obstructed from view and lacks the signage for the correct sequence and use of the extinguisher. NFPA 10, 2010 6.1.3.3.1 & NFPA 96, 2011 10.2.2

Based on observation the facility failed to provide rooftop equipment with electrical outlet receptacles for servicing of rooftop equipment.

On September 2, 2020 at 9:55am in the company of the SBMS the surveyor finds the facility failed to install ground fault service receptacles for the rooftop equipment located on the roof that has the heliport. NFPA 70, 2011, 210.63 & 210.8 (B) 3

Based upon observation, oxygen cylinders are stored near combustibles in non-compliance with Code requirements. Failure to properly store oxygen cylinders can result in an oxygen-rich environment contributing to a rapid progression of a fire condition.

Findings include:

A. On September 3, 2020 at 1:40pm at the 1st floor Loading dock which was observed being used as a storage room and also storing 13 "E" sizes Oxygen tanks and 8 large Med Gas Tanks in non-compliance with NFPA 99-2012, 11.3.2.3(2).


13755


B. On September 2, 2020 at 11:15am while in the company of the CM it was observed that multiple tanks in two separate 6-tank racks for E-size tanks of oxygen were located within 5'-0" of combustible at the 5th floor Labor/Delivery Storage room near Elevators #1/#2/#3 in non-compliance with NFPA 99-2012, 11.3.2.3(2). Multiple tanks were not otherwise stored together in an enclosed non-combustible cabinet of minimum 1/2-hour rating to comply with 11.2.3.2(3).