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Based on observation and interview, the facility did not provide a common separation wall with rated doors. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 8:00 am, observation revealed on the 2nd floor in the the door going into the parking garage from the employee bridge, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4 and 8.2.3.2.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).

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27230

Based on observation and interview, the facility did not provide a common separation wall with rated wall construction, closers on all doors, and sealed wall penetrations. This deficient practice could affect all patients, staff, and visitors in 6 of the 92 smoke compartments.

FINDINGS INCLUDE:

4. On 05/16/13 at 9:27 am, observation revealed on the Third floor in 3218A Equipment Room, Smoke Compartment 3E, that the separation wall was non-compliant because there was no rated door on the Equipment Room. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based on observation and interview, the facility failed to properly maintain one set of fire-rated double doors in an occupancy separation wall in accordance with NFPA 101 section 18.1.2. This deficient practice could affect all patients, staff, and visitors in 1 of 12 smoke compartments.

FINDINGS INCLUDE:

1. On 05/14/2013 at 11:43 am observation revealed that the 1 ½ -hr fire-rated double doors in the 2-hr fire-rated separation wall separating the Ambulance Garage from the hospital failed to latch. This observed condition was not compliant with NFPA 101 section 18.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities-Elmbrook), Staff M15 (EUA), Staff M16 (Safety Coordinator), and Staff M22 (Mechanic). The above deficiency was also confirmed with Staff M1 (V.P. Facilities) at an exit conference on 05/15/2013 at 4:15 pm.

Based on observation and interview, that the facility did not provide compliant room finishes. This deficient practice could affect all patients, staff, and visitors in 3 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 10:15 AM, observation revealed on the 2nd floor in room 2157, that there is peg board mounted on the wall as a secondary finish and the facility could not confirm the peg board had the appropriate finish rating. The wood peg boards holds up scopes. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.3.1.

3. On 5/16/2013 at 9:05 AM, observation revealed on the basement floor in the PT area, that there was peg board mounted on the wall as a secondary finish and the facility could not confirm the peg board had the appropriate finish rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.3.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces, with no patient treatment in spaces that open to the corridor, no combustible material storage, and smoke detection in spaces that are open to the corridor. This deficient practice could affect all patients, staff, and visitors in 4 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 10:08 am, observation revealed on the 2nd floor in the 'overflow recovery', that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. The space did not have a door to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6).

2. On 5/16/2013 at 11:30 am, observation revealed on the basement floor in the corridor by the lab, that the corridor space was used for storage, and was not separated by a wall from the corridor. Storage included 3 flammable storage containers containing 55 gallon drums of alcohol and xylene This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 , and 19.7.5.5.

3. On 5/16/2013 at 11:40 am, observation revealed on the basement floor in the corridor by the lab, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1.

4. On 5/16/2013 at 1:00 pm, observation revealed on the basement floor in the entrance (south entrance) to Main Lab, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with non combustible material storage and rooms open to the corridor with the required safe-guards. This deficient practice could affect all patients, staff, and visitors in 3 of the 92 smoke compartments.

FINDINGS INCLUDE:

3. On 05/16/2013 at 1:10 pm, observation revealed on the Fifth floor in Room 5011, Utility Room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in same smoke compartment did not have smoke detection and the entire smoke compartment did not have quick-response sprinklers. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.1 .

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based on observation and interview, the facility did not provide corridor separation doors with doors that would close when pushed or pulled, and positive-latching hardware. This deficient practice could affect all patients, staff, and visitors in 12 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 3:00 pm, observation revealed on the 2nd floor at door number SC203, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

2. On 5/14/2013 at 9:10 am, observation revealed on the 2nd floor at corridor door 230 to passage W228, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

3. On 5/14/2013 at 4:45 pm, observation revealed on the 3rd floor in room 3006, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

4. On 5/15/2013 at 11:10 am, observation revealed on the 1st floor at door SW100B, that the door to the corridor was held open with a electrical hold open The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.3.

5. On 5/15/2013 at 12:45 pm, observation revealed on the 1st floor at door 1116B, radiology reception, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. Also, the door did not have a door coordinator. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

6. On 5/15/2013 at 1:05 pm, observation revealed on the 1st floor in the door to suite across from Pet/CT room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

7. On 5/15/2013 at 1:50 pm, observation revealed on the 1st floor at the door to suite east of room 1037, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

8. On 5/15/2013 at 2:30 pm, observation revealed on the 1st floor in the chute room 1024, the door to corridor, would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

9. On 5/15/2013 at 3:10 pm, observation revealed on the 1st floor at the double door to room 1071, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

10. On 5/16/2013 at 8:40 am, observation revealed on the basement floor at the door SW 0011, that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers and had an astragal to control smoke transmission, but the combination of devices prevented the doors from fully and automatically closing and latching. There was no door coordinator installed to "coordinate" closure of the two doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

11. On 5/16/2013 at 9:10 am, observation revealed on the basement floor at door SW095, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

12. On 5/16/2013 at 9:40 am, observation revealed on the basement floor at door FW002A, laundry chute room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2. .

13. On 5/16/2013 at 11:15 am, observation revealed on the basement floor at room 0023, storage, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide corridor separation doors with doors that would close when pushed or pulled, and positive-latching hardware. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 4:00 pm, observation revealed on the Third floor in the Suite 308C, Door SE344, that the corridor door would not positively self-latch. The door was equipped with a closer, which is not required by the code, but it does not hold the door in the latched position. Double doors that open into a corridor do not latch. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

2. On 05/15/13 at 4:43 pm, observation revealed on the Fourth floor,Door SE4226D , Smoke Compartment 4G, that the corridor was not compliant. The door had a bent astragal at the bottom of the door and the door coordinator was not working. These conditions prevented the door from being smoke tight. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.1.

3. On 05/15/13 at 4:55 pm, observation revealed on the Fifth floor in the Room 5228, Door SE5227, that the corridor door would not positively self-latch. The door was equipped with a closer, which is not required by the code, but it does not hold the door in the latched position. Double doors that open into a corridor do not latch. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

5. On 05/16/13 at 12:25 pm, observation revealed on the Fourth floor in Stair #9, that the corridor door would not positively self-latch. The door was equipped with a closer, which is not required by the code, but it does not hold the door in the latched position. Stair 9 door on level four does not latch. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

6. On 05/16/13 at 1:49 pm, observation revealed on the Fourth floor in Room 4808, Smoke Compartment 4F, that the corridor door would not positively self-latch. The door was equipped with a closer, which is not required by the code, but it does not hold the door in the latched position. Door to a biohazard closet would not fully close and latch. The door opened into the corridor of the Family Birth Center. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11(Architectural Designer).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with doors with positive-latching hardware, and rated wall construction. This deficient practice could affect all patients, staff, and visitors in 20 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:02 pm, observation revealed on the 1st floor in the stair 23, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.1.1, and 8.2.5.4, and 8.2.3.2.

2. On 5/14/2013 at 1:30 pm, observation revealed on the 8th floor in stairways 15 and 16 at the 7th floor level, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there are electrical panels in the stair ways that are not 1 hour rated and exceed the 100 square inches in 100 square feet requirement electrical box openings for a rated wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

3. On 5/15/2013 at 11:50 am, observation revealed on the 1st floor at door XW115S, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the HVAC and hose cabinets are not fire rated assemblies. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

4. On 5/15/2013 at 11:55 am, observation revealed on the 1st floor at door XW115S, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the wall has a pipe going through the fire wall, parallel to the dry wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated wall construction. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 5:00 pm, observation revealed on the Fifth floor in Room 5304, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the closet shaft connected to at least two stories and the door did not have a closer or fire rating. The shaft also had straw packed into a pocket in the side wall. This observed situation is not compliant with NFPA 101 (2000 ed.), 8.2.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficient practice could affect all patients, staff, and visitors in 4 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 2:45 pm, observation revealed on the 2nd floor by smoke zone door 2K/2G, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

2. On 5/14/2013 at 0:11 am, observation revealed on the 2nd floor in the OR suite, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. The door is to release on the activation of the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

3. On 5/15/2013 at 10:40 am, observation revealed on the 2nd floor by the won door at the main entrance, that the won smoke fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. The door is to close on the activation of the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).

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27230

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficient practice could affect all patients, staff, and visitors in 4 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 2:45 pm, observation revealed on the 2nd floor by smoke zone door 2K/2G, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

2. On 5/14/2013 at 0:11 am, observation revealed on the 2nd floor in the OR suite, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. The door is to release on the activation of the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

3. On 5/15/2013 at 10:40 am, observation revealed on the 2nd floor by the won door at the main entrance, that the won smoke fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. The door is to close on the activation of the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

4. On 5/15/2013 at 3:50 pm, observation revealed on the 1st floor at the door FC1200W, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage and "no-exit" signs at that may be confused as exits. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:08 pm, observation revealed on the 1st floor at the side exits to revolving doors of south tower, that the path of egress was not readily apparent and an exit sign was not provided near the side exit doors of the revolving doors visible from straight on (to the north). This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide smoke compartments of the appropriate layout or egress configuration. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 2:50 pm, observation revealed on the 1st floor in the stair 15 exit passage, that the smoke compartment was not compliant. There is not enough room in the exit passage of stair 15 for all the patient and staff from the smoke zone to the north (to stay in the exit passage way) since the door to the old main entrance area is locked. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.1.

2. On 5/162013 at 4;00 pm, observation revealed on the 3rd floor at corridor 320C (also family waiting W305), that one could not cross into another smoke compartment. The across corridor doors to the OBYGN unit were locked and the exit doors to the pediatric walkway are not a smoke barrier in the hospital.

3. On 5/15/2013 at 2:52 pm, observation revealed on the 1st floor in the Stair 16 exit passage, that the smoke compartment was not compliant. There is not enough room in the exit passage of Stair 16 for all the patient and staff from the smoke zone to the north (to stay in the exit passage way) since the door to the south is locked. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations, and rated wall construction. This deficient practice could affect all patients, staff, and visitors in 4 of the 92 smoke compartments.

FINDINGS INCLUDE:

2. On 5/15/2013 at 5:00 pm, observation revealed on the 1st floor in the wall between the kitchen and dining room, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because has an electrical panel in it that is greater than 100 square inches in 100 square feet of area. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with closers on all doors, smoke-tight seals at meeting edges, and an adjacent smoke detector. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

2. On 5/14/2013 at 4:20 pm, observation revealed on the 3rd floor in the Labor/ Delivery Triage area by reception desk, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. There are two set of doors in this area. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.6 and 8.3.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not provide vision panels within smoke barrier doors. This deficient practice could affect all patients, staff, and visitors in 2 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 9:20 am, observation revealed on the 2nd floor at the across corridor door FW 255B (door from smoke compartment 2C to 2A), that the smoke barrier door had no vision glass. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and staff interview, the facility did not provide smoke barrier doors that were self-closing or installed with proper astragals as required in NFPA 101-Section 19.3.7 as evidenced by the following findings. This deficient practice could affect all patients, staff, and visitors in 1 of the 29 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/2013 at 11:53 am, observation revealed on the 2nd Floor that the north door of the paired opening in this smoke barrier near QC room #R232 was not equipped with a door closer. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M16 (Safety Coordinator) and Staff M20 (EUA).

Based on observation and interview, the facility did not enclose hazardous rooms with doors with positive-latching hardware, rated wall construction, closers on all doors, and localized smoke detection device. This deficient practice could affect all patients, staff, and visitors in 15 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 4:15 pm, observation revealed on the 2nd floor in the Vascular storage room, that the door would not self-close because there was no closer on the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

3. On 5/14/2013 at 8:30 am, observation revealed on the 2nd floor in the OR soiled utility room, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

4. On 5/14/2013 at 9:45 am, observation revealed on the 2nd floor at door 2064, storage room, that the door would not self-close because there was no closer on the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

6. On 5/14/2013 at 3:20 pm, observation revealed on the 3rd floor in the room 3814, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall has a 33" by 22" electrical panel located in the one hour rated wall which exceed the 100 square inches of electrical box in a 100 square foot area of the 1 hour wall. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

9. On 5/15/2013 at 4:20 pm, observation revealed on the 1st floor in the new storage room 1214, that the door would not self-close because there was no closer on the door. In addition, the door was not rated. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not enclose hazardous rooms with doors that had positive-latching hardware, closers on all doors, and rated doors. This deficient practice could affect all patients, staff, and visitors in 16 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 2:55 pm, observation revealed on the Second floor in Room 2331, Smoke Compartment 2L, that the door would not self-close because the double doors on the Storage Closet was missing a closure and a coordinator . The room is considered hazardous because it exceeds 50 sq ft and contains a quantity of stored combustible materials considered hazardous. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

2. On 05/15/13 at 3:36 pm, observation revealed on the Second floor in 2236 Dialysis Room, that the door would not self-close because the double doors on the Dialysis Room was missing a door closure and a coordinator. The room is considered hazardous because it exceeds 50 sq ft and contains a quantity of stored combustible materials considered hazardous. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

3. On 05/16/13 at 10:05 am, observation revealed on the Third floor in Room 3036A, Soiled Linen Room, Smoke Compartment 3D, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The Soiled Linen door does not latch due to a missing closer. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

5. On 05/16/13 at 12:10 pm, observation revealed on the Fifth floor in Room 5216E, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The Hazardous Door will not latch closed to the corridor. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors and rated wall construction. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 1:38 pm, observation revealed on the 1st floor in the conference rooms 1825 and 1835, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door also did not have a required door closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

2. On 5/14/2013 at 12:45 pm, observation revealed on the 7th floor in the storage room of the pharmacy, going into the clean rooms, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute fire rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

3. On 5/15/2013 at 9:50 am, observation revealed on the 2nd floor in room 2011, medical staff office, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was not installed above the lay in ceiling. The door also was not fire rated and did not have a required door closer. Movable files were stored in this room. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

4. On 5/15/2013 at 11:00 am, observation revealed on the 1st floor in the room 1155, new storage room, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door also did not have a required door closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

5. On 5/15/2013 at 1:15 pm, observation revealed on the 1st floor in the radiology Film room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had shutter that was not installed in a one hour rated wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
______________________________________

Based on observation and interview, the facility did not provide and maintain at least 2 approved and remote exits on each floor. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 2:25 pm, observation revealed on the 2nd floor in the women's outpatient center, room 2825 exiting into the another suite (lobby) rather than into a corridor system. The other exit, into the treatment area, was locked, and therefore the egress path was not compliant. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.4.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
_____________________________________

Based on observation and interview, the facility did not provide enclosures around exit stairs with exit stairwells without openings to unoccupied rooms. This deficient practice could affect all patients, staff, and visitors in 30 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 3:40 pm, observation revealed on the 1st floor in the in the exit passage containing chute room, 1096A, housekeeping room next to 1096A and Elevator H, that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

2. On 5/16/2013 at 2:10 pm, observation revealed on the Basement floor in the stair 17, that an opening in an exit enclosure was from an unoccupied space. The unoccupied space is the basement air handler room. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
______________________________________


27230

Based on observation and interview, the facility did not provide enclosures around exit stairs with doors with positive-latching hardware. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 10:06 am, observation revealed on the First floor in Room 1468 in Smoke Compartment 2-K, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door to the Soiled Utility Room would not fully latch and close. This observed situation is not compliant with NFPA 101 (2000 ed.), 8.2.3.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
______________________________________

Based on observation and interview, the facility did not provide egress paths at all times with enough exits that discharge to the exterior, compliant egress path, doors that opened with the necessary force, door hardware that operated with a single release motion, compliant egress path, doors that were unlockable in the egress path. This deficient practice could affect all patients, staff, and visitors in 20 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:00 pm, observation revealed on the 1st floor in stair 23, that the egress path was not compliant. There was not a safe path to a public way. The path passed next to unprotected windows and unprotected ventilation air discharge. The rating of the walls are unknown. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.7.

2. On 5/13/2013 at 1:00 pm, observation revealed on the 1st floor in the south tower lobby, that less than 50% of the exits from the upper floors of the building discharged directly to the exterior. At the discharge of the stairs, the discharge door was not distinguishable from the 2 adjacent side window panels and therefore, the exit door was not readily identifiable. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7 and 7.7.

3. On 5/14/2013 at 8:00 am, observation revealed on the 2nd floor in the OR suite, that the egress door was locked with an access control magnetic lock that was not compliant with the code. The 'push to exit button' was not labeled on the wall next to the switch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.1.6.2.

4. On 5/14/2013 at 8:10 am, observation revealed on the 2nd floor in the Recovery Room, that the egress path was not compliant. The double doors out of the Recovery Suite and into the Surgery Corridor could not be opened manually (currently automatic only). The doors did not latch to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.2.7 and 7.7.

5. On 5/14/2013 at 8:20 am, observation revealed on the 2nd floor in room 284 doors, that the door in the path of egress opened when a force of 31 pounds pounds was applied, which exceeded the maximum 30 pounds needed to open an exit door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.5.

6. On 5/14/2013 at 9:30 am, observation revealed on the 2nd floor in the door SW 2064, that the egress door was locked with an access control magnetic lock with a motion sensor to release, but there was not a manual release switch within 5' of the door that killed power to the magnet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.1.6.2.

7. On 5/14/2013 at 10:20 am, observation revealed on the 2nd floor in the door SW 246, that the egress door was locked with an access control magnetic lock with a motion sensor to release, but there was not a manual release switch within 5' of the door that killed power to the magnet. In addition, the door did not latch to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.1.6.2.

8. On 5/14/2013 at 3:20 pm, observation revealed on the 3rd floor at door ST 309, that the egress door was locked with an access control magnetic lock with a motion sensor to release, but there was not a manual release switch within 5' of the door that killed power to the magnet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.1.6.2.

9. On 5/14/2013 at 4:00 pm, observation revealed on the 3rd floor in the when exiting out of PNAC unit, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a push bar (panic hardware) that when pushed, did not open the door unlock the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4.

10. On 5/15/2013 at 7:40 am, observation revealed on the 2nd floor in the associate walkway door SWA2000, going east, that the door was locked from the egress side. The door going east to the hospital was locked and only openable by pass key. This is a required exit, with an exit sign above the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4.

11. On 5/15/2013 at 8:10 am, observation revealed on the 2nd floor in the the 4 exits to 51st street by the parking garage, that the door threshold on one side of the door was 7 inches to sidewalk. This floor must be level within 1/2" on both sides of a door for a distance not less than the width of the widest door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.3, exception 2.

13. On 5/15/2013 at 8:30 am, observation revealed on the 2nd floor in the exit from the OR penthouse to the parking garage, that the door (gate) was locked from the egress side. A key is required to exit the rooftop. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4.

14. On 5/15/2013 at 9:30 am, observation revealed on the 1st floor in the door by old discharge lobby by the bank, that the door in the path of egress did not swing in the direction of egress travel and the occupancy load of the egress was estimated to be at least 50 persons. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.2.

15. On 5/16/2013 at 4:20 pm, observation revealed on the 3rd floor in the LDR area, that the path of egress required travel through two delayed egress locks (DEL) to exit the building. DEL's were located on the path from Elevator F to Stair 12. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4 (exception 2).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
______________________________________



27230

Based on observation and interview, the facility did not provide egress paths at all times with travel interruption at stairs that go below the level of exit discharge, the required signage, and locks that release in less than 15 seconds. This deficient practice could affect all patients, staff, and visitors in 30 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/13 at 8:55 am, observation revealed on the Second floor in the Stair #13, Smoke Compartment 2R, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. The stairway was missing a gate at Level G to stop passage to other levels. This observed situation is not compliant with NFPA 101 (2000 ed.), 7.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
______________________________________

Based on observation and staff interview, the facility failed to maintain exit access to 2 of 4 stairwell exits due to obstruction caused by two delayed egress exit access doors that did not conform to NFPA 101, sections 7.2.1.6.1(c). This deficient practice could affect all patients, staff, and visitors in 2 of 12 smoke compartments.

FINDINGS INCLUDE:

1. On 05/1/2013 at 9:15 am, observation revealed that (ii) the doors in the East leaf of cross-corridor doors adjacent to PACU 2A332, and the West leaf of cross-corridor doors adjacent to the Soiled Utility Room 2B346 on the 2nd Floor did not open when tested with an application of a 15 pound force to the release device. The doors required a force of 20 pound force to initiate the irreversible process of releasing the latch, which is higher than the allowable maximum of 15 pound force.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities-Elmbrook), Staff M15 (EUA), Staff M16 (Safety Coordinator), and Staff M22 (Mechanic). The above deficiency was also confirmed with Staff M1 (V.P. Facilities) at an exit conference on 05/15/2013 at 4:15 pm.

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 4:05 pm, observation revealed on the 2nd floor in the OR corridor, that the clear and unobstructed width of the corridor was 7'-6" because a CR machine stuck out into the 8 feet wide corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.

2. On 5/15/2013 at 9:20 am, observation revealed on the 1st floor in the across corridor sliding doors northeast of old main entrance, that the clear and unobstructed width of the corridor is 8 feet wide, but the sliding doors do not break and swing open to 41.5 inches in the clear width for each door. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
______________________________________

Based on observation and interview, the facility did not ensure corridor doors provided the required clear width. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 8:11 am, observation revealed on the 2nd floor in the recovery door, that the door(s) in the exits/corridor was narrower than the required 32" minimum clear width. The door(s) were 30 inches in actual clear width. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
______________________________________



27230

Based on observation and interview, the facility did not ensure corridor doors provided the required clear width. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/13 at 10:44 am, observation revealed on the Third floor, Door SW3050, Smoke Compartment 3B, that the door(s) in the exits/corridor was narrower than the required 32" minimum clear width. The corridor door was only 36" did not meet the 44" requirement. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.2.3.5.

2. On 05/16/13 at 12:42 pm, observation revealed on the Fifth floor in Room 5056 & 5052, that the door(s) in the exits/corridor was narrower than the required 32" minimum clear width. The doors were only 22.5" in width. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.2.3.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
______________________________________

Based on observation and interview, the facility did not provide corridor doors with the required clear width. This deficient practice could affect all patients, staff, and visitors in 2 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:13 pm, observation revealed on the 1st floor in the side doors to the revolving doors of the south tower, that the door(s) in the exits/corridors used by residents was narrower than the required 41.5" minimum clear width. Door(s) 36 inches wide were located 12 to 13 feet to the side of the revolving door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5.

2. On 5/16/2013 at 9:00 am, observation revealed on the basement floor in the door between living area and gym of the PT area , that the door(s) in the exits/corridors used by residents was narrower than the required 41.5" minimum clear width. The door(s) were 36 inches wide. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
______________________________________

Based on record review and staff interview, the Hospital Facility including the Pavlic Center did not provide fire drills at unexpected (random) times as required by NFPA 101. This deficient practice could affect all patients, staff, and visitors in 29 of the 29 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/2013 at 2:00 pm, record review of the facility's fire drills over the past twelve months, revealed that three of four First shift fire drills, four of the four Second shift drills, and three of the four Third shift drills were conducted within an hour of each other. Per NFPA 101 section 4.7.5 and Section 19.7.1.2, the facility must conduct fire drills once per quarter per shift at unexpected times. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities - Elmbrook) and Staff M17 (Lead Boiler).

First Shift Data:
a) Fire drill held on 1/31/12 was at 08:10 am.
b) Fire drill held on 4/30/12 was at 08:00 am.
c) Fire drill held on 7/31/12 was at 08:15 am.
d) Fire drill held on 11/12/12 was at 8:25 am.

Second Shift Data:
a) Fire drill held on 2/29/12 was at 3:55 pm.
b) Fire drill held on 6/25/12 was at 4:00 pm.
c) Fire drill held on 8/30/12 was at 3:00 pm.
d) Fire drill held on 12/11/12 was at 4:00 pm.

Third Shift Data:
a) Fire drill held on 3/23/12 was at 6:30 am.
b) Fire drill held on 5/17/12 was at 6:30 am.
c) Fire drill held on 9/26/12 was at 6:21 am.

Pavlic Center Data: (Day operation only, 1st shift)
a) Fire drill held on
b) Fire drill held on
c) Fire drill (missing)
d) Fire drill held on 6/13/13 was at __:__ am/pm

27230

Based on observation and interview, the facility did not provide a fire alarm system and smoke detector that was installed according to NFPA 72. This deficient practice could affect all patients, staff, and visitors in 25 of the 92 smoke compartments.

FINDINGS INCLUDE:

3. On 05/15/13 at 4:05 pm, observation revealed on the Third floor in the Room 3239A, that the electrical circuit that provided power to the fire alarm panel was not marked in red. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11(Architectural Designer).

Based on record review and interview, the facility did not maintain the fire alarm system according to NFPA 72 requirements with required testing. This deficient practice could affect all patients, staff, and visitors in 12 of 12 smoke compartments.

FINDINGS INCLUDE:

2. On 5/15/2013 between 2:30 pm, record review revealed that the maintenance and inspection records of the fire alarm system were not available to verify that (i) the Semi-Annual visual inspection of smoke detectors was performed in accordance with NFPA 72 section 7-3.1, and (ii) one Semi-Annual load voltage test of fire alarm panel storage batteries was performed in between the Annual Fire Alarm Testing and Inspection, in accordance with NFPA 72 section 7-3.2. The next Semi-Annual Visual Inspection is due around August 15 through August 20, 2013. This observed situation was not compliant with NFPA 101 section 9.6.1.7.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff M15 (EUA), and Staff M22 (Mechanic). The above deficiency was also confirmed with Staff M1 (V.P. Facilities) at an exit conference on 05/15/2013 at 4:15 pm.

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkling, sprinklers that were close to the ceiling, sprinklers located the appropriate distance apart, and sprinklers free of obstructions near the ceiling. This deficiency occurred in 12 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 2:17 pm, observation revealed on the 2nd floor in the closet next to room 2823C, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The closet is 12 inches deep, 8 feet wide, and 8 feet tall with a 3 foot wide entrance door. This observed situation was not compliant with NFPA 101 (2000 ed.).

2. On 5/14/2013 at 10:00 am, observation revealed on the 2nd floor in shower of room 2087 in the OR area, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because corridor walls are not 1 hour rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception).

3. On 5/14/2013 at 11:55 am, observation revealed on the 7th floor in the shower stalls of the patient rooms, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because corridor walls are not 1 hour rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception).

4. On 5/14/2013 at 2:15 pm, observation revealed on the 8th floor in the former janitor closet, room 8031, that the sprinkler was placed farther than 22" below the ceiling. The sprinkler was located 30" below the ceiling. This situation would delay release of water and does not satisfy listing requirements. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-5.4.1.

8. On 5/15/2013 at 9:00 am, observation revealed on the 2nd floor in stair 32, that the stair was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The sprinkler was missing at the bottom of the stairs. This observed situation was not compliant with NFPA 101 (2000 ed.).

9. On 5/15/2013 at 9:10 am, observation revealed on the 1st floor in the SW canopy, that the area was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Cars (combustibles) were parked under the old main entrance canopy. 6 cars were parked there, with 3 of them remaining more than 20 minutes and 1 more than 2 hours unattended. This observed situation was not compliant with NFPA 101 (2000 ed.).

14. On 5/16/2013 at 8:55 am, observation revealed on the basement floor in the 'Car' room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Sprinkler coverage did not extend to the back porch. This observed situation was not compliant with NFPA 101 (2000 ed.).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
______________________________________



27230

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with ceilings sealed above the sprinklers to collect heat, non-sprinkled rooms that met permitted exceptions, all rooms sprinkled when the code required full sprinkling, and sprinklers located at the appropriate distance from the ceiling. This deficient practice could affect all patients, staff, and visitors in 30 of the 92 smoke compartments.

FINDINGS INCLUDE:

3. On 05/15/13 at 10:02 am, observation revealed on the First floor in the ER18, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Sprinkler coverage was also missing towards Room #1. This observed situation is not compliant with NFPA 101 (2000 ed.).

5. On 05/15/13 at 3:46 pm, observation revealed on the Third floor in East 362, Smoke Compartment 3G, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with a 2-hour rated construction. The balcony of the Chapel was found not to be fully sprinkler protected. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception).

6. On 05/15/13 at 4:05 pm, observation revealed on the Third floor in Room 3239B, that a sprinkler was located too low to provide adequate water coverage to the ceiling area. Sprinklers can be a maximum of 12" below an unobstructed ceiling. This observed situation is not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

7. On 05/15/13 at 4:07 pm, observation revealed on the Third floor in the all the third floor patient bathrooms in Smoke Compartment 3G, that the rooms were not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The patient bathrooms were missing adequate sprinkler coverage that would reach the shower area. This observed situation is not compliant with NFPA 101 (2000 ed.).

8. On 05/15/13 at 4:36 pm, observation revealed on the Fourth floor in the all the fourth floor patient bathrooms in Smoke Compartment 4G, that the rooms were not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The patient bathrooms were missing adequate sprinkler coverage that would reach the shower area. This observed situation is not compliant with NFPA 101 (2000 ed.).

9. On 05/15/13 at 4:39 pm, observation revealed on the Fourth floor in Room 4239A, that a sprinkler was located too low to provide adequate water coverage to the ceiling. Sprinklers can be a maximum of 12" below an unobstructed ceiling. This observed situation is not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

10. On 05/15/13 at 4:49 pm, observation revealed on the Fifth floor in the all the fifth floor patient bathrooms in Smoke Compartment 5E, that the rooms were not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The patient bathrooms were missing adequate sprinkler coverage that would reach the shower area. This observed situation is not compliant with NFPA 101 (2000 ed.).

11. On 05/15/13 at 4:59 pm, observation revealed on the Fifth floor in the Room 5239A, that a sprinkler was located too low to provide sprinkler coverage to the ceiling area. Sprinklers can be a maximum of 12" below an unobstructed ceiling. This observed situation is not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

12. On 05/15/13 at 1:00 pm, observation revealed on the Second Third, Fourth , Fifth and Sixth floor in the patients rooms - second floor rooms: 2321,2323,2332,2300 & 2243; third floor rooms: 3327,3329,3331,3333 & 3330; fourth floor rooms: 4322,4237,4234,4233 & 4232; fifth floor rooms: 5047,5043,5044,5050 & 5049; sixth floor rooms: 6253,6251,6249,6315 & 6317; that the sprinkler was placed farther than 22" below the ceiling. The metal pan ceiling allows heat to pass through the holes when there is no insulation on the metal pans. The condition was observed throughout the above mentioned floors. This situation would delay release of water and does not satisfy listing requirements. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-5.4.1.

13. On 05/15/13 at 5:12 pm, observation revealed on the Fifth floor in the Stair #1, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. There was no sprinkler coverage at the top of Stair #1. This observed situation was not compliant with NFPA 101 (2000 ed.).

14. On 05/15/13 at 5:34 pm, observation revealed on the Sixth floor in the all the sixth floor patient bathrooms I , that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The patient bathrooms were missing adequate sprinkler coverage that would reach the shower area . This observed situation was not compliant with NFPA 101 (2000 ed.).

15. On 05/16/13 at 8:11 am, observation revealed on the Second floor in the ICU Room 2402, Smoke Compartment 2Q, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included a Medical Gas Column. This condition was found throughout the patient rooms in the ICU. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

16. On 05/16/13 at 8:49 am, observation revealed on the Second floor in the 2445A-B data closets, Smoke Compartment 2R, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The data closet was not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 ed.).

17. On 05/16/13 at 9:12 am, observation revealed on the Second floor in the Stair 6, that sprinkler protection was not provided at Skylight in Canopy overhang outside Stair 6. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.8.1.

18. On 05/16/13 at 9:33 am, observation revealed on the Third floor in the 3207A&B Utility Closets, that a sprinkler was located too low to provide adequate sprinkler protection to the ceiling area. Sprinklers can be a maximum of 12" below an unobstructed ceiling. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

20. On 05/16/13 at 10:10 am, observation revealed on the Third floor in the Room 3080 & Room 3071 Room, Smoke Compartment 3B, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. It was noted that sprinkler coverage in the shower areas was missing. This observed situation was not compliant with NFPA 101 (2000 ed.).

21. On 05/16/13 at 10:20 am, observation revealed on the Third floor in the Room 3070 , that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. There is no sprinkler coverage provided to the shower. This observed situation was not compliant with NFPA 101 (2000 ed.).

23. On 05/16/13 at 12:15 pm, observation revealed on the Fifth floor in the Room 5606A, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Big pipe chase not sprinkler protected in men's toilet room. This observed situation was not compliant with NFPA 101 (2000 ed.).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers at required exterior locations, sprinklers mounted flush with ceilings, proper ceiling enclosures, and valves with proper supervision. This deficient practice could affect all patients, staff, and visitors in 10 of the 29 smoke compartments.

FINDINGS INCLUDE:

3. On 05/15/2013 at 12:25 pm observation revealed that the 1st floor Entrance W5 had an exterior overhang that was not sprinkler protected. The building is fully-sprinkler protected and the connected over-hang was approximately twenty-five (25) feet by forty (40) feet in surface area. Over-hangs or canopies greater than four (4) feet are required to be sprinkle protected. This observed situation is not compliant with NFPA 13 (1999 edition) section 5-13.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities - Elmbrook) and Staff M7 (EUA).

4. On 05/15/2013 at 12:40 pm observation revealed that the Entrance E4 had an exterior overhang that was not sprinkler protected. The connected building is fully-sprinkler protected. Over-hangs or canopies greater than 4' are required to be sprinkle protected. This observed situation is not compliant with NFPA 13 (1999 edition) section 5-13.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities - Elmbrook) and Staff M7 (EUA).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, access to fire dampers, and compliant fire dampers. This deficiency occurred in 4 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 10:10 am, observation revealed on the 2nd floor in the Cath lab office, , that airflow between the corridor and this room was not neutral. There was supply into the room, but no return. Air was being returned in the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.), 2-3.11.1.

3. On 5/16/2013 at 1:50 pm, observation revealed on the basement floor in the Electrical Vault from WL 09 to WL10, that a service opening of sufficient size was not provided adjacent to the fire damper to permit maintenance and resetting the device. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A, (1999 ed.) 2-3.4.1.

4. On 5/16/2013 at 2:30 pm, observation revealed on the basement floor in the Electrical Transfer Vault near WL 09 & WL 10, that a duct with a fire damper that penetrated the rated ceiling did not have retaining angles and could not be confirmed it was installed according to its listing instructions. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A (1999 ed.), 3-3.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not maintain a kitchen hood system as required by NFPA 96. This deficient practice could affect all patients, staff, and visitors in 15 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 5:49 pm, observation revealed on the Second floor in Room E267, Smoke Compartment 2N, that the kitchen hood suppression system was not compliant. There were four abandoned grease ducts in the shaft that are no longer being used. Staff could not verify any fire termination system at the end of the grease ducts. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.6 and 9.2.3 and NFPA 96.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as flammability or sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water, and verification of rated hanging materials. This deficiency occurred in 5 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 12:30 pm, observation revealed on the 7th floor in the curtains in the Hospice area, that loosely hanging fabric was installed that did not have a manufactures flame spread label and the facility was unable to verify that it met the appropriate listing. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.1 and 10.3.1.

2. On 5/14/2013 at 4:30 pm, observation revealed on the 3rd floor in the tub rooms of south west area of OBYGN, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water at the solid plastic strip of curtain above the holes of the tub curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.5 and NFPA 13 (1999 ed.) 5-6.5.2.3.

3. On 5/15/2013 at 10:45 am, observation revealed on the 1st floor in room 1151, that loosely hanging fabric was installed that did not have a manufactures flame spread label and the facility was unable to verify that it met the appropriate listing. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.1 and 10.3.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide cubical curtains that permit the designed distribution of sprinkler water. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/13 at 1:55 pm, observation revealed on the Fifth floor in Room 5856, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to water due to the lack of clearance. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.5.5 and NFPA 13 (1999 ed.) 5-6.5.2.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based on observation and interview with staff, the facility did not provide smoke removal system for anesthetizing locations. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.
FINDINGS INCLUDE:

1. On 05/14/13 at 8:45 am, observation revealed in Operation Room (OR) area, Cysto-1, that an automatic smoke removal system was not installed for this anesthetizing location. This observed situation was not compliant with NFPA 99 (1999 edition), 5-4.1.3.

The above observed condition was confirmed with concurrent observation and interview with Staff M3 (HVAC tradesman), Staff M9 (Mechanic), Staff M13 (Risk Analyst), and Staff M7 (Architect EUA).

ITEM #1
Based on observation and interview, the facility did not ensure that corridors did not have excessively long dead-ends as permitted by the code. This deficient practice could affect all patients, staff, and visitors in 3 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 1:52 pm, observation revealed on the 2nd floor in the corridor 2829 (labeled passage) near elevator F, that a dead end corridor of 34 feet was observed. The surveyor observed that it would be practical and feasible to alter the layout to provide a corridor without a dead end. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.10.

2. On 5/14/2013 at 3:40 pm, observation revealed on the 3rd floor in the corridor by elevator FF on the 3rd floor, that a dead end corridor of 46 feet is created by locking of across corridor doors. In addition, the dead end corridor creates a smoke barrier area that does not have a pathway out. The surveyor observed that it would be practical and feasible to alter the layout to provide a corridor without a dead end. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.10.

3. On 5/16/2013 at 12:08 pm, observation revealed on the Basement floor in the Entrance (south entrance) to Main Lab, that a dead end corridor of 40 feet was observed. The surveyor observed that it would be practical and feasible to alter the layout to provide a corridor without a dead end. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.10.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).

ITEM #2
Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies, and suite travel distance under the required limits. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

2. On 5/14/2013 at 3:50 pm, observation revealed that stair 10 doors, which serves 8 stories, did not allow re-entry from the stair enclosure to the interior of the building per NFPA 101, 7.2.1.5.2.

3. On 5/15/2013 at 2:40 pm, observation revealed on the 1st floor in the stair 16, that stair 16 doors, which serves 8 stories, did not allow re-entry from the stair enclosure to the interior of the building per NFPA 101, 7.2.1.5.2 for at least the first 3 floors.

4. On 5/16/2013 at 8:45 am, observation revealed on the basement floor in room 0012L, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance through 2 intervening rooms of the suite is 72 feet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.8.

5. On 5/16/2013 at 9:20 am, observation revealed on the basement floor in the pool room of PT/OT area, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance is 115 feet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.8.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Item #1:

Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in an exterior means of egress so the path would still be illuminated if any single fixture or bulb failed with egress paths with redundant lighting per NFPA 101 (2000 ed.) section 39.2.8. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/13/13 at 12:45 pm, observed revealed that from Stair 29 that the path of exit discharge was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 ed.), section 39.2.8 and 7.8.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

Item #3:

Based on observation and staff interview, the facility did not provide illumination of the means of egress in accordance with NFPA 101 (2000 ed.) section 39.2.9. This deficient practice could affect all patients, staff, and visitors in 3 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/14/13 at 4:50 pm, observation revealed that Stair 1 lighting was unreliable due to a non-functional light bulb. Per NFPA 101 - 2000 Edition, sections 39.2.9 and 7.9.2.5, the emergency exit lighting system must be either continuously in operation or be capable of repeated automatic operation without manual intervention. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

ITEM #1

Based on observation and interview, the facility did not enclose hazardous rooms with doors that had positive-latching hardware, closers on all doors, and rated doors per NFPA 101 (2000 ed.) section 40.3.2. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:
2. On 05/13/13 at 12:40 pm, observation revealed in Room S009, that the 60 minute fire rated door (FS009S) would not latch. This observed situation is not compliant with NFPA 101 (2000 ed.), 40.3.2 and 8.4.1.

3. On 05/13/13 at 2:12 pm, observation revealed that Door FS014N fire rated at 45 minutes, did not support the 2 hour fire rated wall the door assembly was located within. This observed situation is not compliant with NFPA 101 (2000 ed.), 40.3.2 and 8.4.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

ITEM #2

Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in the exterior means of egress so the path would still be illuminated if any single fixture or bulb failed with egress paths with redundant lighting per NFPA 101 (2000 ed.) section 40.2.8. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:
1. On 05/13/13 at 12:45 pm, observed revealed that from S009 that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 ed.), section 40.2.8 and 7.8.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

Outstanding items remaining after V.V. on 7/10/2013:
Item #3:

Based on observation and staff interview, the facility did not provide exit doors which were operable with only one function as listed in NFPA 101-Section 7.2.1.5.4 and as evidenced by the following finding. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 05/14/2013 at 12:56 pm, observation revealed that on the exit discharge door from PT (in the east wall) was equipped with a panic device and a lever latch with positive latching. To egress through this door required the operation of both pieces of hardware; this does not meet code minimum standards of NFPA 101 (2000 ed.) section 39.2.1 and 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M2 (Chief Tradesman) and Staff M20 (EUA).

Item #5:

Based on observation and staff interview, the facility did not provide a waiting area that was enclosed within the Ambulatory Surgery Center tenant space as evidenced by the following finding. This deficient practice could affect all of the occupants using this space. Population varies from several staff to 20 visitors/staff using in this space.

FINDINGS INCLUDE:

On 05/14/2013 at 12:11 pm, observation revealed on the 4th Floor that the waiting area of the Ambulatory Surgery Center was not contained within the one-hour fire barrier enclosure per NFPA 101 (2000 ed.) section 21.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M2 (Chief Tradesman) and Staff M20 (EUA).

27230

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, electrical panels with complete directories, closed electrical raceways, fixed wiring rather than extension cords, and working clearances at electrical panels. This deficient practice could affect all patients, staff, and visitors in 12 of the 92 smoke compartments.

FINDINGS INCLUDE:

2. On 05/15/13 at 3:58 pm, observation revealed on the Third floor in Corridor 308C, that electrical panel breaker(s) were not labeled to identify the loads they fed. Breakers #10 and #18 were in the "on position" but were noted as spares on the panel labeled Emergency 3/XE. Breaker #28, in Panel 3-F located next to Panel 3/XE, was in the "on position" but labeled as a spare. This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-22.

9. On 05/16/13 at 10:17 am, observation revealed on the Third floor in Room W335, Electrical Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Electric Panel 3/C was missing the identification card for all breakers. Panel MDP-12-W did not have breaker #4 identified but it was in the "on position". Panel EC3C had breakers #31 and #33 labeled as spares but both breakers were in the "on position". This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-22.

10. On 05/16/13 at 10:22 am, observation revealed on the Third floor in Corridor 3030C outside room 3078, Smoke Compartment 3A, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel L31 had breakers #8 &-#18 labeled as spares but the breakers were in the "on position". This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-22.

11. On 05/16/13 at 12:56 pm, observation revealed on the Fifth floor in Stair 15, level 5, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panels 5/B had breakers #8,#12 & #17 in the "on position" but not identified. This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-22.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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