HospitalInspections.org

A) The Main Hospital (South Building) - Portions of the building were found to have unprotected structural steel. Review of the construction drawings listed the building as a Type B construction. Type B construction refers to building elements that are not required to be fire resistance rated but still must be non-combustible.
Documentation for the construction assemblies to comply with 19.1.6.2 and NFPA 220 1999 was not available on site (No UL Design Numbers).Example locations and conditions observed include the following:

1. Corrected 05/27/10.
2. Corrected 05/27/10.

3. The surveyor finds that portions of structural beams and columns have missing fire proofing. Example locations include:

a) South Building Penthouse - steel columns lack fireproofing - Penthouse level a column located near the entry door to Stair #5. The surveyor observed sprayed on fireproofing on the underside of the roof deck and support beams. However, the steel columns remain unprotected.

b) South Building - all interstitial spaces. The space contains a metal deck/concrete fill ceiling (floor for the occupied spaces above) and a gypsum plate which constitutes the finished ceiling for the occupied spaces below. The surveyor was unable to locate a U.L. listed design for this type of a floor/ceiling assembly. Access into the space allowed the surveyor to see fire proofed steel columns which penetrate the gypsum plate that are not completely fire proofed.
Example location - Basement Interstitial above the Kitchen freezer area.


4. 4th Floor interstitial space (which is open to the underside of the Penthouse floor) does not appear to constitute a floor ceiling assembly. The floor of the 4th floor space is a gypsum plate of unknown thickness. The floor of the Penthouse at approximately 18 feet above. The surveyor is unable to determine how this construction constitutes a 2-hour floor ceiling assembly necessary to maintain the construction type of the building to comply with NFPA 220.



B) The North Building is comprised of concrete columns, beams and waffle slab in which the pan of the slab is approximately 2 1/2" thick. The patient rooms and certain other areas contain a gypsum lath ceiling (monolithic) suspended from the concrete slab above. This appears to constitute a fire rated floor/ceiling assembly. However, due to the following this building does not comply with NFPA 220 and 19.1.6.2. for a healthcare building. General deficiencies include but are not limited to:

1). Corridors and elevator Lobby do not contain monolithic ceilings. This compromises the fire resistance rating of the floor slab. These areas contain suspended acoustical tile ceilings. Locations observed multiple floors.

2). Certain areas have spray on fireproofing on the underside of the concrete pan for the waffle slab. Surveyor was unable to obtain information concerning the U.L.listed design for this floor construction. Example location observed 3rd floor Group Room.

3). Certain areas have suspended acoustical tile ceilings where the floor pan above does not have spray on fireproofing. There are numerous recessed fluorescent light fixtures within the suspended acoustical tile ceilings that are not "tented". The surveyor notes that such "tents" over light fixtures are usually part of a fire rated floor/ceiling assembly. Locations observed: numerous floor levels at corridors and elevator lobby.


C) Documentation is not available, for the South and North health care buildings that supports the provider's indication of Type I (332) or a type II (222) Construction as required for a healthcare building of 4 or more stories.

A) South Building 2nd Floor cross corridor door located between patient rooms 2517 and 2501 (Facility Life Safety floor plan) contains a magnetic locking device. This door has no positive latching hardware (hardware was disabled or removed). The magnetic locking devices do not comply with the requirements for positive latching. This door is noted to be within a fire rated barrier that is not a smoke barrier.

B) South Building 2nd Floor pair of cross corridor doors adjacent to Lab 2156 (Facility Life Safety floor plan) These doors have no positive latching hardware (hardware was disabled or removed). These doors are noted to be within a fire rated barrier that is not a smoke barrier.




.

A. From random observations, the surveyors find that vertical openings are not enclosed and protected in accordance with 19.3.1.1 and NFPA 90A. Shafts were observed which penetrate through the interstitial space. The shafts contain an unprotected steel beam or channel just below the floor deck. The gypsum board shaft wall is attached to the bottom of the steel beam. The steel beam component makes up part of the vertical shaft enclosure and does not maintain the continuous 2-hour fire resistant separation for the shaft from a ceiling cavity (interstitial space) of adjacent spaces. This condition does not comply with 8.2.5.3. General deficiencies include but are not limited to:

1) Shafts are open to the ceiling cavities of adjacent spaces.

2) Shafts are not enclosed in fire rated construction

Locations include but are not limited to: South Building ventilation duct shafts at all interstitial spaces.


B. South Building shafts located adjacent to Stair # 1 and Stair #4. These are shown as mechanical rooms with access provided through an ante room from the exit stair (as indicated on the Facility Life Safety Plan). These mechanical rooms constitute vertical shafts due to the following:

1). Stair # 1 mechanical room contains ethyleneoxide ductwork for the sterilizers in the basement central supply to the roof. Stair # 4 mechanical room contains ductwork from possible Nuclear Med fume hoods in the basement to the roof. Both of these shafts do not constitute a continuous 2-hour rated enclosure due to the following:

a) Shaft is open and unseparated from ceiling cavities of adjacent spaces (the interstitial space) due to the lack of a fire rated access door from the shaft to the interstitial space.

b) Shaft is not enclosed in fire rated construction due to unprotected steel beams, columns and lintels as part of the shaft wall assembly.

c) Shaft is not enclosed in fire rated construction due to the lack of continuous fire resistant sealant at all openings and gaps between the wall and floor.


C. 1). Corrected 05/27/10.
2). Corrected 05/27/10.

D. Corrected 05/27/10.
E. Corrected 05/27/10.

A) From random observation the surveyors find that Hazardous Areas are not enclosed in accordance with 19.3.2, and 8.4, where applicable:

1) South Building, 3rd floor - Room T3112 Pantry/Food/Nutrition room. This room is present on the 2nd and 4th floors with the same condition. These rooms contain several "Retherm" units for the Medsurg floors. These units appear to be gas fueled, the rooms are greater than 100 square feet and contain equipment stored and deemed hazardous by the Authority Having Jurisdiction. These rooms do not comply with 19.1.2.7 and 19.3.2 due to the following:

a. This room is not indicated as a hazardous area on the facility's Life Safety floor plan. However, the corridor door contains a U.L. listed fire rated label.

b. The magnetic hold open on the door did not release to allow the door to close and latch upon activation of the fire alarm.

2) Corrected 05/27/10.



.

A) From random observation, the surveyors find that required exit stair enclosures do not comply with Chapter 7.

1) South Building Example location: Third floor Stair # 2 landing. construction throughout the facility is similar on every floor for every stair and does not comply with 19.2.2.3 and 7.1.3.2.

a) Most stairs have a pipe chase on one or more sides of the Stair. Some stairs also have duct shafts immediately adjacent to the stair. from random observation, the surveyors find the the stair stingers and the landing support channels penetrate the shaft wall and do not allow a continuous separation of the stair from the shafts.

2) a) Corrected 05/27/10.

b) Corrected 05/27/10.

c) Corrected 05/27/10.




.

A) From random observation the surveyors find that means of egress are not readily available at all times:

1) South Building 1st Floor contains numerous occupied rooms which lack direct access to an exit access corridor which does not comply with 19.2.5.1. None of which were not indicated as a suite on the facility Life Safety plans. Example locations as follows:

a. Radiology Department, X-ray Room # 7 and X-ray Room # 2. There are numerous other occupied spaces within this Department.

b. Interventional Radiology, Lab Stress Testing # T1030 and Room # T1021.

2) South Building, Basement, corridor # T B 008, The direction of egress, leading East, cannot be determined due to the lack of directional signage which creates a dead end corridor condition of excessive length which does not comply with 19.2.5.9. The exception as written for 19.2.5.10 does not apply.


B) From random observation the surveyors find that means of egress corridors lack access to two approved exits to comply with 19.2.5.9. Location observed:

1) South Building, 2nd Floor, contains an exit access corridor T 2157 (as shown on Facility Life Safety plan) leading to Stair # 1 through the O.R. suite.



.

A. Based on random observation during the survey walk through the surveyor noted a designated suite (as shown on the facility life safety plan) which does not comply with 19.2.5. for the size of a patient sleeping room and non sleeping room suite.

Location observed: Second floor Surgery suite (approx 13, 000s.f..) exceeds the square footage allowed by the Life Safety Code for a nonsleeping room.



.

A) Surveyor observed a lack of exit signage which does not comply with 19.2.10.1 and 7.10. Location observed:

1) South Buildng Basement corridor T 008 leading to the East. A designated means of egress corridor directs egress toward two different directions without an indication of which adjacent corridor is the indicated path of travel to an exit.


.

A. The surveyors find, from document review and facility walk through, that definitive floor plans showing necessary elements for evacuation and areas of refuge to comply with 19.7.2.2. lack nessary information for certain locations on various floor levels. The Life Safety floor plans provided by the facility representatives appeared comprehensive however, information pertaining to direction of travel for exit access (dead end corridor issues) and locations and sizes of suites (to comply with 19.2.5) appeared to conflict with the provided Life Safety floor plans.

.

A) During fire alarm testing on 5/20/09, the surveyor observed doors which did not operate properly under activation of the fire alarm to comply with NFPA 72 and/or NFPA 101:

1) South Building First Floor: Corridor door at Outpatient registration T1204 which is on a magnetic hold open device, failed to close from fire alarm activation.

2) South Building First Floor: Cross corridor doors ajdacent to ER # 23 (Facility Life Safety plan) at Outpatient registration T1204 which are on magnetic hold open devices, failed to close from fire alarm activation.

3) South Building First Floor: Cross corridor doors ajdacent to Break room T1128 (Facility Life Safety plan) which are on magnetic hold open devices, failed to open upon fire alarm activation.

4) South Building First Floor: Cross corridor doors leading to Breast Center Reception T1220 (Facility Life Safety plan) failed to close completely upon fire alarm activation. These doors are on magnetic hold open devices, with the right side door (from the corridor side) failing to completely close.


.

A) By direct observation, the facility failed to provide fire sprinkler protection at the following locations:

1. Corrected 05/27/10.

2. Corrected 05/27/10.

3. Sprinkler coverage is not provide for the patient room wardrobes North and South Buildings.

4. Corrected 05/27/10.


20224


B) From random observation, the surveyors find that sprinkler systems are not installed and maintained in accordance with NFPA 13-1999.

1) The surveyors find that sprinkler heads are missing excutcheons or ceiling trim pieces at random locations (corridors and rooms) on every floor through out the facility. This condition is not being detected and abated by sprinkler inspection and maintenance that is required by NFPA 25. Example locations - South Building Stair # 4 Basement level - two sprinkler heads lack escutcheons. 2nd floor, Labor and Delivery corridor T2149 adjacent to the nurses station, sprinkler head lacks escutcheon.

2) The surveyors find that sprinkler heads are coated with dust or lint at random locations (but particularly in rooms: that are not visited very often, upper level mechanical spaces, and Basement Level spaces such as the Central Supply. This condition is not being detected and abated by sprinkler inspection and maintenance that is required by NFPA 25.


C) 1). Corrected 05/27/10.

2) Corrected 05/27/10.


.

A). Based on direct observation, the facility failed to provide:

1. A remote alarm annunciator for 3 of 3 fire pumps at a point of constant attendance. (NFPA 20, 1999, 7-4.7)


.

A) Not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. For example furnishings and equipment were observed stored in 8'-0" wide exit access corridors. These objects obstruct paths of egress which does not comply with 19.2.3.3. and 7.1.10.2.2. Locations observed:

1. South Building 2nd Floor Labor and Delivery, corridor adjacent to Birth Room T2128 contains - numerous carts, equipment, and materials observed for the length of the corridors.

2. 4th floor C-Section area - contained
furniture and equipment, including a couch.


.

A. 1. Corrected 05/27/10.


20224


B). The Surveyor finds that manual medical gas shutoff (zone) valves were located in the same room as the station outlets and inlets they serve which does not comply with NFPA 99 1999 4.3.1.2.3.(d). Locations observed:

1. South Building 1st floor, Emergency Department, medgas shutoff valves are located adjacent to the station outlets within the patient they serve. Surveyor observed a zone valve adjacent to patient ER bay # 15 and adjacent to Trauma.


.

A) Based on direct observation, the facility failed to provide:

1. A remote alarm annunciator for the North Building emergency generator at a constantly attended work station. (NFPA 99, 1999, 3-4.1.1.15 (b)

2. Corrected 05/27/10.

A). Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.


.

A) Based on direct observation, the facility failed to provide:

1. Elevator Phase I & II firefighter service requirements for all elevators. (A17.1, 211.3)

2. A means to automatically disconnect the main power supply to elevators prior to the application of water from the activation of the fire sprinkler system in their machine rooms. (A17.1, 102.2.c.3).


.

A) The Main Hospital (South Building) - Portions of the building were found to have unprotected structural steel. Review of the construction drawings listed the building as a Type B construction. Type B construction refers to building elements that are not required to be fire resistance rated but still must be non-combustible.
Documentation for the construction assemblies to comply with 19.1.6.2 and NFPA 220 1999 was not available on site (No UL Design Numbers).Example locations and conditions observed include the following:

1. Corrected 05/27/10.
2. Corrected 05/27/10.

3. The surveyor finds that portions of structural beams and columns have missing fire proofing. Example locations include:

a) South Building Penthouse - steel columns lack fireproofing - Penthouse level a column located near the entry door to Stair #5. The surveyor observed sprayed on fireproofing on the underside of the roof deck and support beams. However, the steel columns remain unprotected.

b) South Building - all interstitial spaces. The space contains a metal deck/concrete fill ceiling (floor for the occupied spaces above) and a gypsum plate which constitutes the finished ceiling for the occupied spaces below. The surveyor was unable to locate a U.L. listed design for this type of a floor/ceiling assembly. Access into the space allowed the surveyor to see fire proofed steel columns which penetrate the gypsum plate that are not completely fire proofed.
Example location - Basement Interstitial above the Kitchen freezer area.


4. 4th Floor interstitial space (which is open to the underside of the Penthouse floor) does not appear to constitute a floor ceiling assembly. The floor of the 4th floor space is a gypsum plate of unknown thickness. The floor of the Penthouse at approximately 18 feet above. The surveyor is unable to determine how this construction constitutes a 2-hour floor ceiling assembly necessary to maintain the construction type of the building to comply with NFPA 220.



B) The North Building is comprised of concrete columns, beams and waffle slab in which the pan of the slab is approximately 2 1/2" thick. The patient rooms and certain other areas contain a gypsum lath ceiling (monolithic) suspended from the concrete slab above. This appears to constitute a fire rated floor/ceiling assembly. However, due to the following this building does not comply with NFPA 220 and 19.1.6.2. for a healthcare building. General deficiencies include but are not limited to:

1). Corridors and elevator Lobby do not contain monolithic ceilings. This compromises the fire resistance rating of the floor slab. These areas contain suspended acoustical tile ceilings. Locations observed multiple floors.

2). Certain areas have spray on fireproofing on the underside of the concrete pan for the waffle slab. Surveyor was unable to obtain information concerning the U.L.listed design for this floor construction. Example location observed 3rd floor Group Room.

3). Certain areas have suspended acoustical tile ceilings where the floor pan above does not have spray on fireproofing. There are numerous recessed fluorescent light fixtures within the suspended acoustical tile ceilings that are not "tented". The surveyor notes that such "tents" over light fixtures are usually part of a fire rated floor/ceiling assembly. Locations observed: numerous floor levels at corridors and elevator lobby.


C) Documentation is not available, for the South and North health care buildings that supports the provider's indication of Type I (332) or a type II (222) Construction as required for a healthcare building of 4 or more stories.

A) South Building 2nd Floor cross corridor door located between patient rooms 2517 and 2501 (Facility Life Safety floor plan) contains a magnetic locking device. This door has no positive latching hardware (hardware was disabled or removed). The magnetic locking devices do not comply with the requirements for positive latching. This door is noted to be within a fire rated barrier that is not a smoke barrier.

B) South Building 2nd Floor pair of cross corridor doors adjacent to Lab 2156 (Facility Life Safety floor plan) These doors have no positive latching hardware (hardware was disabled or removed). These doors are noted to be within a fire rated barrier that is not a smoke barrier.




.

A. From random observations, the surveyors find that vertical openings are not enclosed and protected in accordance with 19.3.1.1 and NFPA 90A. Shafts were observed which penetrate through the interstitial space. The shafts contain an unprotected steel beam or channel just below the floor deck. The gypsum board shaft wall is attached to the bottom of the steel beam. The steel beam component makes up part of the vertical shaft enclosure and does not maintain the continuous 2-hour fire resistant separation for the shaft from a ceiling cavity (interstitial space) of adjacent spaces. This condition does not comply with 8.2.5.3. General deficiencies include but are not limited to:

1) Shafts are open to the ceiling cavities of adjacent spaces.

2) Shafts are not enclosed in fire rated construction

Locations include but are not limited to: South Building ventilation duct shafts at all interstitial spaces.


B. South Building shafts located adjacent to Stair # 1 and Stair #4. These are shown as mechanical rooms with access provided through an ante room from the exit stair (as indicated on the Facility Life Safety Plan). These mechanical rooms constitute vertical shafts due to the following:

1). Stair # 1 mechanical room contains ethyleneoxide ductwork for the sterilizers in the basement central supply to the roof. Stair # 4 mechanical room contains ductwork from possible Nuclear Med fume hoods in the basement to the roof. Both of these shafts do not constitute a continuous 2-hour rated enclosure due to the following:

a) Shaft is open and unseparated from ceiling cavities of adjacent spaces (the interstitial space) due to the lack of a fire rated access door from the shaft to the interstitial space.

b) Shaft is not enclosed in fire rated construction due to unprotected steel beams, columns and lintels as part of the shaft wall assembly.

c) Shaft is not enclosed in fire rated construction due to the lack of continuous fire resistant sealant at all openings and gaps between the wall and floor.


C. 1). Corrected 05/27/10.
2). Corrected 05/27/10.

D. Corrected 05/27/10.
E. Corrected 05/27/10.

A) From random observation the surveyors find that Hazardous Areas are not enclosed in accordance with 19.3.2, and 8.4, where applicable:

1) South Building, 3rd floor - Room T3112 Pantry/Food/Nutrition room. This room is present on the 2nd and 4th floors with the same condition. These rooms contain several "Retherm" units for the Medsurg floors. These units appear to be gas fueled, the rooms are greater than 100 square feet and contain equipment stored and deemed hazardous by the Authority Having Jurisdiction. These rooms do not comply with 19.1.2.7 and 19.3.2 due to the following:

a. This room is not indicated as a hazardous area on the facility's Life Safety floor plan. However, the corridor door contains a U.L. listed fire rated label.

b. The magnetic hold open on the door did not release to allow the door to close and latch upon activation of the fire alarm.

2) Corrected 05/27/10.



.

A) From random observation, the surveyors find that required exit stair enclosures do not comply with Chapter 7.

1) South Building Example location: Third floor Stair # 2 landing. construction throughout the facility is similar on every floor for every stair and does not comply with 19.2.2.3 and 7.1.3.2.

a) Most stairs have a pipe chase on one or more sides of the Stair. Some stairs also have duct shafts immediately adjacent to the stair. from random observation, the surveyors find the the stair stingers and the landing support channels penetrate the shaft wall and do not allow a continuous separation of the stair from the shafts.

2) a) Corrected 05/27/10.

b) Corrected 05/27/10.

c) Corrected 05/27/10.




.

A) From random observation the surveyors find that means of egress are not readily available at all times:

1) South Building 1st Floor contains numerous occupied rooms which lack direct access to an exit access corridor which does not comply with 19.2.5.1. None of which were not indicated as a suite on the facility Life Safety plans. Example locations as follows:

a. Radiology Department, X-ray Room # 7 and X-ray Room # 2. There are numerous other occupied spaces within this Department.

b. Interventional Radiology, Lab Stress Testing # T1030 and Room # T1021.

2) South Building, Basement, corridor # T B 008, The direction of egress, leading East, cannot be determined due to the lack of directional signage which creates a dead end corridor condition of excessive length which does not comply with 19.2.5.9. The exception as written for 19.2.5.10 does not apply.


B) From random observation the surveyors find that means of egress corridors lack access to two approved exits to comply with 19.2.5.9. Location observed:

1) South Building, 2nd Floor, contains an exit access corridor T 2157 (as shown on Facility Life Safety plan) leading to Stair # 1 through the O.R. suite.



.

A. Based on random observation during the survey walk through the surveyor noted a designated suite (as shown on the facility life safety plan) which does not comply with 19.2.5. for the size of a patient sleeping room and non sleeping room suite.

Location observed: Second floor Surgery suite (approx 13, 000s.f..) exceeds the square footage allowed by the Life Safety Code for a nonsleeping room.



.

A) Surveyor observed a lack of exit signage which does not comply with 19.2.10.1 and 7.10. Location observed:

1) South Buildng Basement corridor T 008 leading to the East. A designated means of egress corridor directs egress toward two different directions without an indication of which adjacent corridor is the indicated path of travel to an exit.


.

A. The surveyors find, from document review and facility walk through, that definitive floor plans showing necessary elements for evacuation and areas of refuge to comply with 19.7.2.2. lack nessary information for certain locations on various floor levels. The Life Safety floor plans provided by the facility representatives appeared comprehensive however, information pertaining to direction of travel for exit access (dead end corridor issues) and locations and sizes of suites (to comply with 19.2.5) appeared to conflict with the provided Life Safety floor plans.

.

A) During fire alarm testing on 5/20/09, the surveyor observed doors which did not operate properly under activation of the fire alarm to comply with NFPA 72 and/or NFPA 101:

1) South Building First Floor: Corridor door at Outpatient registration T1204 which is on a magnetic hold open device, failed to close from fire alarm activation.

2) South Building First Floor: Cross corridor doors ajdacent to ER # 23 (Facility Life Safety plan) at Outpatient registration T1204 which are on magnetic hold open devices, failed to close from fire alarm activation.

3) South Building First Floor: Cross corridor doors ajdacent to Break room T1128 (Facility Life Safety plan) which are on magnetic hold open devices, failed to open upon fire alarm activation.

4) South Building First Floor: Cross corridor doors leading to Breast Center Reception T1220 (Facility Life Safety plan) failed to close completely upon fire alarm activation. These doors are on magnetic hold open devices, with the right side door (from the corridor side) failing to completely close.


.

A) By direct observation, the facility failed to provide fire sprinkler protection at the following locations:

1. Corrected 05/27/10.

2. Corrected 05/27/10.

3. Sprinkler coverage is not provide for the patient room wardrobes North and South Buildings.

4. Corrected 05/27/10.


20224


B) From random observation, the surveyors find that sprinkler systems are not installed and maintained in accordance with NFPA 13-1999.

1) The surveyors find that sprinkler heads are missing excutcheons or ceiling trim pieces at random locations (corridors and rooms) on every floor through out the facility. This condition is not being detected and abated by sprinkler inspection and maintenance that is required by NFPA 25. Example locations - South Building Stair # 4 Basement level - two sprinkler heads lack escutcheons. 2nd floor, Labor and Delivery corridor T2149 adjacent to the nurses station, sprinkler head lacks escutcheon.

2) The surveyors find that sprinkler heads are coated with dust or lint at random locations (but particularly in rooms: that are not visited very often, upper level mechanical spaces, and Basement Level spaces such as the Central Supply. This condition is not being detected and abated by sprinkler inspection and maintenance that is required by NFPA 25.


C) 1). Corrected 05/27/10.

2) Corrected 05/27/10.


.

A). Based on direct observation, the facility failed to provide:

1. A remote alarm annunciator for 3 of 3 fire pumps at a point of constant attendance. (NFPA 20, 1999, 7-4.7)


.

A) Not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. For example furnishings and equipment were observed stored in 8'-0" wide exit access corridors. These objects obstruct paths of egress which does not comply with 19.2.3.3. and 7.1.10.2.2. Locations observed:

1. South Building 2nd Floor Labor and Delivery, corridor adjacent to Birth Room T2128 contains - numerous carts, equipment, and materials observed for the length of the corridors.

2. 4th floor C-Section area - contained
furniture and equipment, including a couch.


.

A. 1. Corrected 05/27/10.


20224


B). The Surveyor finds that manual medical gas shutoff (zone) valves were located in the same room as the station outlets and inlets they serve which does not comply with NFPA 99 1999 4.3.1.2.3.(d). Locations observed:

1. South Building 1st floor, Emergency Department, medgas shutoff valves are located adjacent to the station outlets within the patient they serve. Surveyor observed a zone valve adjacent to patient ER bay # 15 and adjacent to Trauma.


.

A) Based on direct observation, the facility failed to provide:

1. A remote alarm annunciator for the North Building emergency generator at a constantly attended work station. (NFPA 99, 1999, 3-4.1.1.15 (b)

2. Corrected 05/27/10.

A). Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.


.

A) Based on direct observation, the facility failed to provide:

1. Elevator Phase I & II firefighter service requirements for all elevators. (A17.1, 211.3)

2. A means to automatically disconnect the main power supply to elevators prior to the application of water from the activation of the fire sprinkler system in their machine rooms. (A17.1, 102.2.c.3).


.