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Based on observation during the survey walk-through and testing of the electric and mag locks, not all exit doors are 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 door does not open as it should.

The findings include:

On May 23, 2017 at 2:05 PM while accompanied by the SPO, it was observed that the exit discharge door # 1-20SD-1037 on the First Floor in the 7198 exit corridor did not open when pushed with more than normal force, it took more than normal force to open very slowly, not in accordance with Sections 19.2 and 7.2.14.5.1.

Based on observation during the survey walk-through, 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 maintained

Findings include:

A. On May 22, 2017, while accompanied by the DFS, observation determined that doors equipped with delayed egress locking mechanisms lack a sign, reading "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS,", required by 7.2.1.6.1(d). Locations observed include (all located on the Third Floor Mother/Baby Unit):

1. 2:08 PM: The Third Floor door to Exit Stair M.
2. 2:10 PM: The third Floor cross-corridor doors directly south of Classroom 3408 (on the east face of the north leaf).

B. On May 22, 2017 at 2:25 PM, while accompanied by the DFS, observation determined that the east face of the north leaf of the pair of cross-corridor doors immediately southeast of the Third Floor door to Exit Stair A, which is not provided with a delayed egress locking mechanism, is identified by signage as being equipped with a delayed egress lock as prohibited by 7.2.1.6.1.
C. On May 23, 2017 at 12:13 PM, while accompanied by the DFS, observation determined that the First Floor door from Exit Stair B, when in the fully open (180 degree) position, protrudes more than 7 inches into the adjacent Corridor as prohibited by 7.2.1.4.3.1.
D. On May 23, 2017 at 12:15 PM, while accompanied by the DFS, observation determined that the First Floor door from Exit Stair B does not swing in the direction of egress as required by 7.2.1.4.2(1).

Based on observation during the survey walk-through, not all stairways are constructed as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if stairways are not properly constructed.

Findings include:

On May 22, 2017 at 12:34 PM, while accompanied by the DFS, the door from the Fifth Floor landing of Exit Stair M, which leads directly to the roof, was observed to not permit re-entry to the building in a manner compliant with 7.2.1.5.9.

Based on observation during the survey walk-through and document review, not all building stories or fire compartments are provided with at least two remote exits. This deficient practice could affect patients, staff, and visitors in the building because they could be prevented from exiting the building under emergency conditions if an insufficient number of exits is provided.

Findings include:

On May 23, 2017 at 12:32 PM, while accompanied by the DFS, document review determined that building stories do not comply with 7.7.2(1) because less than half the exit stairs serving them exit directly to the exterior of the building. Locations include:
A. Sixth Floor, served by Exit Stairs A, B, and C, only Exit Stair C is provided with an exit directly to the exterior.

B. Fourth Floor, served by Exit Stairs A, B, C, M, and N, only Exit Stairs C and M are provided with an exit directly to the exterior.

Based on observation during the survey walk-through, not all dead end corridors are limited in length as required. This deficient practice could affect patients, staff, and visitors using the corridors because they could be prevented from exiting the building under emergency conditions if dead end corridors are of excessive length.

Findings include:

On May 22, 2017 at 1:51 PM, while accompanied by the DFS, observation determined that dead end corridors are present that exceed 30 feet in length as prohibited by 19.2.5.2. Locations observed include (both doors located in the Third Floor Mother/Baby Unit):

A. From the pair of locked cross-corridor doors directly west of Third Floor Telecommunications Room 3393 to the Third Floor to Exit Stair A.

B. From the pair of locked cross-corridor doors directly south of Third Floor Classroom 3408 to the Third Floor to Exit Stair A.

Based on observation during the survey walk-through, not all patient care non-sleeping suites are configured 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 patient care non-sleeping suites are not configured in a complaint manner.

Findings include:

On May 23, 2017 at 10:30 AM, while accompanied by the DFS, observation determined that the Second Floor West Surgery Suite (which includes the new Hybrid Operating Room) is in excess of 10,000 square feet in area as prohibited by 19.2.5.7.3.3.

Based on observation during the survey walk-through and record review, 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.

Findings include:

A. On May 22, 2017 at 2:05 PM, while accompanied by the SPO, observation determined that the Fifth Floor, "B" Smoke Zone compartment exit signs lacks on both sides of the smoke doors in the smoke barrier, as required by 7.10.1.1.



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B. On May 22, 2017 at 12:54 PM, while accompanied by the DFS, observation determined that the Third Floor egress path toward the south, at the east end of Corridor T3048, is not identified by exit signs as required by 7.10.1.1 because no exit sign is visible from the west end of the Corridor.

Based on observation during the survey walk-through, not all vertical openings in the building are protected as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass between building stories if vertical openings are not protected.

Finding includes:

A. On May 22, 2017 at 1:35 PM, while accompanied by the SPO, observation determined that two pipes penetrating the floor above from Janitor Closet on sixth floor was found not fire sealed to resist the transfer of fire/smoke to the seventh floor, as required by 7.1.3.2.1(9)(b), Table 8.3.4.2 and NFPA 80 2010 6.4.1.1.


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B. On May 22, 2017 at 12:48 PM, while accompanied by the DFS, observation determined that a series of utilities are present above the ceiling at the Fourth Floor landing of Exit Stair M as prohibited by 7.1.3.2.1(1). Utilities observed above the ceiling observed include:
1. A supply air duct.

2. A return air duct.

3. Data and telephone cables.

4. A telephone box.

5. Two pipes.

Based on observation during the survey walk-through, 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:

On May 22 and 23, 2017, while accompanied by the SPO, following are the observation determined not in accordance with 19.3.2.1, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1. Location observed:

A. On May 22, 2017 at 12:45 PM - 8th floor Supply Room B828. Door was wide open to the exit corridor without door closer, to keep the door closed at all times.

B. On May 23, 2017 at 9:10AM - 3rd floor Alcove in the Smoke Compartment "A" between Room #s C368G and C368H open to the exit corridor had highly combustible polythene bags with supplies and other plastic containers with polythene wraps.

C. On May 23, 2017 at 9:40AM - 4th: floor - "B" Smoke Compartment: Old nurse station which is open to the exit corridor was observed being used for storing mattresses, lounge chairs and other items.

Based on observation during the survey walk-through, not all commercial cooking equipment is installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the hospital by permitting smoke or fire to move from the kitchen to other parts of the building if the cooking equipment is not properly installed and maintained.

Findings include:

On May 23, 2017 at 1:30 PM, while accompanied by the DFS, observation determined that the deep fat fryer in Basement Kitchen TB052 is less than 16 inches from the adjacent gas-fired cooktop as prohibited by NFPA 96 2008 12.1.2.4.

Based on observation during the survey walk through 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 May 23, 2017, while accompanied by the SPO, observation determined that the HVAC ducts more than 4 feet wide were observed to have no sprinkler protection under the ducts. NFPA 13 2010 8.6.4.1.1. Location observed:

1. At 10:10 AM 3rd floor Mechanical Room.

2. At 10:40 AM 2nd floor Mechanical Room.


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B. On May 22, 2017 at 12:39 PM, while accompanied by the DFS, observation determined that 3 ducts are present, in Fifth Floor Mechanical Room T5021, which are in excess of 4 feet in width and below which sprinkler heads are not provided as required by NFPA 13 2010 8.5.5.3.1.

Based on observation during the survey walk-through, 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 if the doors are not installed and maintained as required.

Findings include:

While accompanied by the DFS, corridor doors were observed that are not positive latching as required by 19.3.6.5(1). Locations observed include:

A. May 22, 2017, 2:09 PM, Third Floor Mother/Baby Unit:

1. Pair of doors to the Caesarian Section Unit to Recovery Room 3356.

2. Pair of doors to the Caesarian Section Unit to the Passage west of Recovery Room 3356.

B. May 23, 2017, 11:04 AM: First Floor automatic sliding door to Emergency Department between Corridor T1059 and Corridor T1060.

Based on observation during the survey walk-through, not all smoke barrier partitions are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke could pass between smoke compartments if the barriers which separate them are not constructed and maintained as required.

Findings include:

On May 22 and 23, 2017, while accompanied by the SPO, observation determined that pipe or other penetrations through designated smoke barrier walls are not sealed against the passage of smoke as required by 8.5.6.2.
Locations observed includes:

A. On May 22, 2017 at 1:20 PM - 7th: floor: Opening in the smoke barrier by the Nurse Station in "B" smoke compartment was observed to be filled with foam material and open ends of the conduits not filled with fire caulking.

B. On May 22, 2017 at 1:50 PM - 6th: floor: Opening, in the smoke barrier by the Nurse Station in "B" smoke compartment and open ends of the conduits, was observed not filled with fire caulking.

C. On May 23, 2017 at 10:10 AM - 4th: floor: Opening in the smoke barrier by the Nurse Station in "B" smoke compartment was observed.

Based on observation during the survey walk through the facility failed to maintain components for the elevator recall systems. Failure to install and maintain this installation could result in delayed activation and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

On 5/23/17 at 8:45AM accompanied by the HT & P, it was observed in the penthouse elevator machine rooms (T10002 & T10004) for elevators 1 thru 4 that the fire sprinkler heads, heat detectors and smoke detectors have a significate amount of dust accumulation and foreign material and T10002 the heat detectors are not installed within 2 feet of the sprinkler heads. This is not in compliance with NFPA 25, 5.2.1.1.1, NFPA 72, 14.5, NFPA 72, 21.4 & ANSI A17.3

Based on document review and interview, the facility failed to verify the transmittal of fire alarm to the fire alarm minitoring company of local fire department. This deficient practice could affect patients, staff and visitors if the fire department failed to respond promptly during an emergency due to mal function of fire alarm system.

Finding Includes:

On May 23, 2017, at 11:05 AM while accompanied by the SPO and during the document review process, it was determined that the facility's monthly/quarterly fire drills do not meet the requirement of verifying the transmittal of fire alarm to the fire alarm monitoring company or the local fire department at the conclusion of the fire drills.NFPA 101, 19.7.1.6.

Based on observation during the survey walk-through, not all portions of the medical gas system are installed as required. This deficient practice could affect patients, staff, and visitors in the building because the medical gas system could fail to operate properly if not installed in a compliant manner.

Findings include:

On May 23, 2017, while accompanied by the DFS, medical gas shut-off valves were observed to not be separated from the outlets they serve by a wall with a door as required by NFPA 99 2012 5.1.4.8(1). Locations observed include:

A. 8:54 AM: Third Floor Caesarian Section Unit Recovery Room 3356, shut-off valves in connecting Passage.

B. 11:14 AM: First Floor Special Procedures Unit Recovery Room, unnumbered, directly south of Procedure Room 7 (Room D140G, shut-off valves in connecting Passage.

Based on observation during the survey walk-through, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

Findings include:

While accompanied by the DFS, observation determined that the Life Safety and Critical Branches of the building's Type 1 EES are not separate and distinct from each other, as required by NFPA 99 2012 6.4.2.2.3 and 6.4.2.2.4 and by NFPA 70 2011 517-32 and 517-33, because the Electrical Panels listed below include both Life Safety and Critical loads. Electrical Panels in which this condition was observed include:

A. May 22, 2017 at 1:20 PM: Fourth Floor Electrical Panel NLPL4, located in Corridor T4042; Circuit 4 serves the building fire alarm system while other breakers serve loads that are not part of the Life Safety Branch.

B. May 23, 2017, 9:33 AM: Second Floor Electrical Panel NCB 2PE, located in the Corridor on the east side of the Cardiac Cath Unit; Circuits 21 and 29 serve medical gas alarm panels while other breakers serve loads that are not part of the Life Safety Branch.

C. May 23, 2017 at 1:14 PM: First Floor Electrical Panel XR, located in the Imaging Department, one circuit serves the Fire Alarm Control,Panel while other breakers serve loads that are not part of the Life Safety Branch.

Based on observation during the survey walk-through and staff interview, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

Findings include:

On May 22, 2017,while in the company of the SPO it was observed that the electrical receptacle in the soiled utility rooms were installed within 6' of the sink and could not be verified to be GFCI protected to comply with NFPA 70-2011, 210.8(B)5. Locations observed:

A. On May 22, 2017 at 1:05 PM- 8th Floor - Room B815.

B. On May 22, 2017 at 1:25 PM - 7th: Floor - Room B715.

C. On May 22, 2017 at 1:40 PM - 6th: floor - Room B615.


Surveyor: Bender, William

D. While accompanied by the DPS, observation determined that critical care patient beds lack electrical receptacles served by the Normal Power Branch of the building's Type 1 Essential Electrical System (EES) are provided as required by NFPA 70 2011 517-19(A). Locations observed include:

1. May 22, 2017, Third Floor Mother/Baby Unit:

a. 2:12 PM: Caesarian Section Room T3071.

b. 2:14 PM: Caesarian Section Room T3048.

2. May 23, 2017, Second Floor Surgical Department:

a. 10:28 AM: Operating Room 7.

b. During an interview held at 10:30 AM in Second Floor Surgical Department Operating Room 7, staff confirmed that all Surgical Department Operating Rooms lack electrical receptacles served by the normal power branch of the building's Type 1 EES.

3. May 23, 2017, First Floor Emergency Department:

a. 11:08 AM: Treatment Room 10.

b. During an interview held at 11:10 AM in First Floor Emergency Department Treatment Room 10, staff confirmed that all Emergency Department Treatment Rooms lack electrical receptacles served by the normal power branch of the building's Type 1 EES.


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