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Based on observations, it was determined that the facility failed to maintain the minimum Construction Type as required for a five story plus full basement building. This deficient practice could affect patients, staff and visitors in the building if the deficient structure fails due to non-compliant building structure.

The finding includes:

On April 25, 2017, during the survey walk through while accompanied by SPO, following were observed to not be in compliance with Table 19.1.6.1, 19.1.6.4 and 19.1.6.5, in the 1968 Building:

A. At 10:15 AM, exposed structure comprising of steel beams and metal decking was observed on Fourth Floor, not fire protected.

B. At 12:25 PM, exposed structure comprising of steel beams and metal decking was observed on Third Floor, not fire protected.

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

Findings include:

A. On April 25, 2017, while accompanied by the DPS, observation determined that the following deficiencies exist at the Third Floor door to Exit Stair 1, all as prohibited by 7.2.1.6.1:

1. At 10:36 AM the door was observed to be equipped with a delayed egress locking mechanism, as prohibited by 7.2.1.6.1, because the building is not fully covered by an automatic sprinkler system.

2. At 10:37 AM the sign on the door which identifies it being equipped with a delayed egress feature, was observed to not comply with 7.2.1.6.1(4) because:

a. The sign does not read "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS."

b. The letters on the sign are not 1 inch tall.

B. On April 25, 2017, while accompanied by the DPS, observation determined that egress doors from the First Floor Mother/Baby Unit are secured against egress, in a manner prohibited by 19.2.2.2.5.2(3), because the building is not fully covered by an automatic sprinkler system. Doors observed include:

1. 1:26 PM: Pair of cross-corridor doors at northeast corner of Unit.

2. 1:30 PM: Pair of cross-corridor doors at southwest corner of Unit.

C. On April 26, 2017 at 10:09 AM, while accompanied by the DPS, observation determined that the pair of cross-corridor doors at the west end of the Ground Floor Emergency Department Entry Corridor (immediately west of the Emergency Department Waiting Room Public Toilets) is secured against egress as prohibited by 19.2.2.2.5.

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

Findings include:

A. On April 25, 2017 at 10:50 AM, while accompanied by the SPO, observation determined the Second Floor, Smoke Zone 22 Exit Corridor - at the two hour separation between Smoke Zone 22 and 21, at the south end, lacks an exit sign (directing occupants toward the north) as required by 7.10.1.1.

B. On April 25, 2017 at 12:25 PM, while accompanied by the SPO, observation determined the Third Floor Smoke Zones 33 and 34 Cross Corridors lack directional exit signs at southwest and southeast exit corridors as required by 7.10.1.1.

C. On April 25, 2017 at 10:30 AM, while accompanied by the SPO, observation determined the Fourth Floor Smoke Zone 42 Exit Corridor - at the smoke barrier, at the northeast end, lacks an exit sign (directing occupants toward the northwest) as required by 7.10.1.1.

D. On April 25, 2017 at 10:40 AM, while accompanied by the SPO, observation determined the Fourth Floor Smoke Zone 43 southwest Cross Corridor Exit, lacks an exit sign (directing occupants toward the northwest and south east) as required by 7.10.1.1.


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E. On April 25, 2017 at 1:30 PM, while accompanied by the DPS, observation determined the First Floor Corridor serving Exit Stair 8, at its south end, lacks an exit sign (directing occupants toward the south) as required by 7.10.1.1.

F. On April 26, 2017 at 10:26 AM, while accompanied by the DPS, observation determined that in the Ground Floor landing within Exit Stair 6, the north door lacks a sign which reads "NO EXIT" as required by 7.10.8.3.1.

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

Findings include:

A. While accompanied by the DPS, observation determined that access panels within exit stair enclosures are not self-closing as required by 7.1.3.2.1(9)(b), Table 8.3.4.2 and NFPA 80 2010 6.4.1.1. Locations observed include:

1. April 25, 2017, 1:12 PM: First Floor landing within Exit Stair 5.

2. April 26, 2017:

a. 10:54 AM: Basement landing within Exit Stair 1.

b. 10:59 AM: Basement landing within Exit Stair 7.

B. On April 25, 2017 at 10:38 AM, while accompanied by the DPS, observation determined that a sign is mechanically fastened to the egress side of the Third Floor door to Exit Stair 1 as prohibited by NFPA 80 2010 4.1.4.2.1.

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

Findings include:

On April 26, 2017, while accompanied by the SPO, observation determined that the following hazardous rooms are not protected as required by 39.3.2.1, Table 8.3.4.2, and NFPA 80 2010 6.1.3.

A. At 10:05 AM, Electrical conduits penetrating the wall and ceiling in the Electrical closet in the two story building.

B. At 11:10 AM, Mechanical Room in the four story building has openings, ducts and pipes penetrating the one hour wall.

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

Findings include:

On April 25, 2017 at 2:12 PM, while accompanied by the DPS, observation determined that the Second Floor Surgery Department door to the former Break Room, now a storage room, is not positive latching as required by 19.3.2.1, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

Based on observation during the survey walk-through, not all portions of the building's fire alarm system are installed and maintained as required. This deficient practice could affect patients, staff, or visitors in the building because the fire alarm system could fail to activate under emergency conditions if the components are not properly installed and maintained.

Findings include:

A. On April 25, 2017, while accompanied by the SPO, observation determined that smoke detectors are located where air flow could prevent their operation as prohibited by NFPA 72 2010 17.7.4.1. Locations observed include:

1. 10:45 AM: Fourth Floor exit corridor by Room Numbers 482 and 489.

2. 1:15 PM: First Floor Smoke Zone 12 exit corridor between Smoke Zones 11 and 12.


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B. On April 25, 2017, while accompanied by the DPS, observation determined that smoke detectors are located where air flow could prevent their operation as prohibited by NFPA 72 2010 17.7.4.1. Locations observed include:

1. 10:47 AM: Second Floor Surgical Director's Office.

2. 10:48 AM: Second Floor Surgical Consult Room (directly south of Surgical Director's Office).

3. 2:10 PM: Second Floor Surgical (North) Corridor.

Based on observation during the survey walk through the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On April 26, 2017 at 9:59 AM, while accompanied by the DPS, observation determined that the walls of the ground Floor Emergency Department Data Closet are not complete to the underside of the deck above, thus compromising sprinkler coverage of the space by the smoke detector located there in a manner prohibited by NFPA 13 2010 8.6.4.1.1.


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B. On April 25, 2017 at 10:00 am accompanied by the ADPS, it was observed in the ambulance garage that the fire sprinkler protection is obstructed when the overhead doors are in the open position. This is not in compliance with NFPA 13, 2010, 8.5.5.2.

Based on the observations and interviews, it was determined that the facility failed to maintain the sprinkler system as required. This deficient practice could affect patients, staff and visitors in the building if the sprinkler system failed to activate due to lack of maintenance.

Findings include:

On April 26, 2017, while accompanied by SPO, following test and inspection documents were not available for review, as required by 9.7.5, 9.7.7, 9.7.8 and NFPA 25.

A. Annual Sprinkler inspection.

B. Five year gages inspection.

C. Five year Check Valve Internal Inspection.

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

Findings include

On April 25, 2017 at 12:49 PM, while accompanied by the DPS, observation determined that the First Floor ICU northeast door is not positive latching as required by 19.3.6.3.5(1).

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

Findings include:

A. On April 25, 2017, while accompanied by the SPO, observation determined that pipe or other penetrations through designated smoke barrier walls are not sealed against the passage of smoke as required by 8.5.6.2. Locations observed include:

1. 10:20 AM, Fourth Floor Smoke barrier between Smoke Zones 42 and 43, above ceiling above cross-corridor doors.

2. 10:25 AM, Fourth Floor smoke barrier between Smoke Zones 42 and 43, above ceiling above in Room 468 drywall was missing, space around HVAC Duct, pipe penetrations are not sealed and at the metal deck flutes at the junction of exposed beam and metal deck are not sealed.

3. 12:45 PM, Third Floor smoke barrier between Smoke Zones 33 and 34, above ceiling drywall was missing, pipe penetrations and at the metal deck flutes at the junction of exposed beam and metal deck.

4. 11:00 AM, Second Floor smoke barrier between Smoke Zones 22, above ceiling space around HVAC Duct, pipe penetrations arenot sealed and at the metal deck flutes at the junction of exposed beam and metal deck.

5. 1:35 PM, Basement Smoke Zone B2 two hour fire barrier and the Atrium: Metal deck flutes at the junction of exposed beam and metal deck and 90 Minutes door was compromised with two holes at the top for latching device.

6. 1:50 PM, Basement Nutrition room, metal deck flutes at the junction of exposed beam and metal deck.


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B. On April 25, 2017, while accompanied by the DPS, observation determined that pipe or other penetrations through designated smoke barrier walls are not sealed against the passage of smoke as required by 8.5.6.2. Locations observed include:

1. 10:03 PM, Third Floor Smoke barrier between Smoke Compartments 31 and 32, above ceiling above cross-corridor doors.

2. 1:00 PM, First Floor smoke barrier between Smoke Compartments 12 and 14, above ceiling above cross-corridor doors.

Based on observation during the survey walk through the facility lacks complete protection of ventilation ducts through fire rated barriers. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

On April 25, 2017 at 12:30 pm accompanied by the ADPS, it was observed in penthouse #3 that access panels are not provided for inspection, maintenance of the through floor ventilation duct and fire damper installation. This is not in compliance with NFPA 80, 2010, 19.2.3.

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

Findings include:

A. On April 25, 2017, while accompanied by the SPO, observation determined that the Life Safety and Critical Branches of the building's Type 1 EES are not separate and distinct from each other, as required by NFPA 99 2012 6.4.2.2.3 and 6.4.2.2.4 and by NFPA 70 2011 517-32 and 517-33, because the Electrical Panels listed below include both Life Safety and Critical loads. Electrical Panels in which this condition was observed include:

1. 11:05 AM - Endoscopy Surgery - Smoke Zone 12, on Second Floor.

2. 12:50 PM - Med. Surgery - Smoke Zone 24 on First Floor.


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B. On April 25, 2017, while accompanied by the DPS, observation determined that the Life Safety and Critical Branches of the building's Type 1 EES are not separate and distinct from each other, as required by NFPA 99 2012 6.4.2.2.3 and 6.4.2.2.4 and by NFPA 70 2011 517-32 and 517-33, because the Electrical Panels listed below include both Life Safety and Critical loads. Electrical Panels in which this condition was observed include:

1. 10:11 AM: Third Floor Electrical Panel EM-8.

2. 10:35 AM: Second Floor Electrical Panel EM-5.

3. 1:05 PM: First Floor Electrical Panel EM1/4C.

4. 2:25 PM: Second Floor Electrical Panel EM-2-2.

C. On April 25, 2017 at 2:16 PM, while accompanied by the DPS, observation determined Operating Rooms lack battery-powered emergency lights required by NFPA 99 2012 6.3.2.2.11.1 and NFPA 70 2011 517-63A. Locations observed include:

1. 1:37 PM: First Floor Mother/Baby Unit Caesarian Section Room.

2. Second Floor Surgical Department:

a. 2:16 PM: Operating Room 1.

b. 2:20 PM: Operating Room 2.

c. 2:24 PM: Operating Room 3.

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

Findings include:

A. While accompanied by the DPS, observation determined that critical care patient beds lack electrical receptacles served by normal power as required by NFPA 70 2011 517-19(A). Locations observed include (all Second Floor):

1. 11:05 AM: PACU, 3 bays.

2. 11:09 AM: Stage II Recovery, 3 bays.

3. 11:13 AM: Pre-Op, 5 bays.

4. 2:15 PM: Operating Room 1.

5. 2:19 PM: Operating Room 2.

6. 2:23 PM: Operating Room 3.

B. On April 25, 2017, while accompanied by the DPS, observation determined that electrical receptacles served by the Critical Branch of the building's Type 1 Essential Electrical System (EES) are not labeled as to the Electrical panel and Circuit which serves them as required by NFPA 70 2011 517-19(A). Locations observed include (all Second floor):

1. 11:06 AM: PACU, 3 bays.

2. 11:10 AM: Stage II Recovery, 3 bays.

3. 11:14 AM: Pre-Op, 5 bays.

4. 2:16 PM: Operating Room 1.

5. 2:20 PM: Operating Room 2.

6. 2:24 PM: Operating Room 3.

Based on observation during the survey walk-through, not all power and extension cords are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment could fail to operate when needed if the electrical service to them is interrupted by damaged power cords.

Findings include:

On April 25, 2017, while accompanied by the DPS, observation determined that the following deficiencies exist within the First Floor Mother/Baby Unit Caesarian Section Room:

A. A surge protector was observed to be plugged into a high wall receptacle and allowed to hanging place, thus making it subject to damage as prohibited by NFPA 70 2011 400.8(7).
B. The power cords for a piece of medical equipment was observed to be partially separated at the connection to the equipment as prohibited by NFPA 70 2011 400.8(7).