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Based on observations, it was determined that the facilities failed to maintain the minimum Construction Type for this building. This deficient practice could compromise the fire resistant rating of the structure and affect staff and visitors in within a means of egress.

The finding is:

On 07/18/2018 at 11:20 am, during the survey walk through while accompanied by DSBE, unprotected steel structure was observed which does not comply with Table 19.1.6.1, 19.1.6.4 and 19.1.6.5.

Location observed: 4th floor Nurse Station (located across from room # A425). Above the nurse station's central computer table several steel beam sections lack fire proofing.

Based upon observation and staff interview, door locking systems are not installed in accordance with Code requirements. Failure to install locking devices in accordance with requirements can prevent or cause undue delay in exiting or evacuation procedures when required.

Findings include:

A. Doors equipped with Delayed Egress locking systems do not remain unlocked after release until manually reset as required by 7.2.1.6.1.1(3)(d). Upon testing and discussion with facility staff, it was observed and indicated that Delayed Egress locks automatically relock in lieu of requiring manual resetting at the following locations:

1. On 7/17/18 at 3:17pm while in the company of the CPE & MS, it was observed that the 1st floor Stair S16 door from the Labor & Delivery.

2. On 7/17/18 at 3:15pm while in the company of the CPE & MS, it was observed that two other doors from the Labor & Delivery area into the surgery semi-restricted corridor.

3. On 7/18/18 at 10:00am while in the company of the CPE & MS, it was observed that the door at the north corridor entering the surgery semi-restricted area.

4. On 07/18/2018 at 2:50pm while in the company of the DSBE and MS, First floor it was observed at the cross corridor doors in the exit passageway adjacent to room #E160.

5. On 07/18/2018 at 3:00pm while in the company of the DSBE and MS, First floor it was observed at the control doors near Post Partum.

B. On 7/18/18 at 9:20am while in the company of the CPE & MS, it was observed that doors equipped with magnetic locking devices other than Delayed Egress locking systems are not compliant with 7.2.1.6.2(2) Access Controlled Egress Door Assemblies. Magnetic lock which was not operational at the time it was observed but could not be determined how it was controlled. (On/Off key switches or security control and sensors not present.) Location and condition observed: 1st floor East Tower S17 Stair door magnetic lock sensor.

C. On 7/18/18 at 11:05am while in the company of the CPE & MS it was observed that the tunnel access door located in the Storage room west of the Maintenance Shop in the Basement level of the 350 Building was provided with a hasp lock in non-compliance with 7.2.1.5.3.

D. On 7/18/18 at 1:15pm while in the company of the DSBE, SPM & MS it was observed that some of the wire cages in the basement of the 350/400 Building storage area were provided with padlocks which could prevent egress in non-compliance with 7.2.1.5.3.

Based upon observation and staff interview, door locking systems are not installed in accordance with Code requirements. Failure to install locking devices in accordance with requirements can prevent or cause undue delay in exiting or evacuation procedures when required.

Findings include:

A. Doors equipped with magnetic locking devices other than Delayed Egress locking systems are not fully compliant with 7.2.1.6.2 Access Controlled Egress Door Assemblies.

Locations and conditions observed include:

1. On 7/18/18 at 2:10pm while in the company of the DSBE, SPM & MS, it was observed that the 1st floor South Building Purchasing Dept. inner vestibule door was equipped with a magnetic lock which was not operational at the time it was observed but could not be determined how it was controlled. (On/Off key switches or security control and sensors not present.) The installation does not comply fully with 7.2.1.6.2.

2. On 7/18/18 at 2:35pm while in the company of the DSBE, SPM & MS, it was observed that the 1st floor South Building Dietary corridor (exit passageway) exterior door was equipped with a magnetic lock which was not operational at the time it was observed but could not be determined how it was controlled. (On/Off said to be controlled by building security system but sensors not present.) The installation does not comply fully with 7.2.1.6.2.

Based upon observation and staff interview, exit stairs are not identified correctly at all locations. Failure to be consistant with stair identification could cause confusion for building occupants and emergency personnel during evacuation or rescue procedures.

The finding is:

A. On 7/18/18 at 10:50am while in the company of the CPE & MS it was observed that Stair "S17" in the East Tower was identified by two signs at the Basement level as Stair "S1" in lieu of Stair "S17". This is not in accordance with 19.7.3 relative to the maintenance of means of egress.


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Based on observation during the survey walk-through, not all stair components used within an exit stair are constructed to provide a safe means of egress. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

The finding is:

B. On 07/17/2017 at 1:45pm while accompanied by the DSBE the distance between guardrails in exit stair enclosures was observed to be in excess of 4" which does not comply with 19.2.2.3, 7.2.2.4.5.3.
Location observed: Exit Stair # S-1 landing

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. On 7/17/18 at 2:45pm while in the company of the CPE & MS, it was observed that the 3rd floor corridor in the East Tower serving patient rooms E3068, E3069, E3071 & E3072 identified only a single path of egress rather than two in order to comply with 19.2.5.4, 7.5.1.1.1.

B. On 7/18/18 at 9:25am while in the company of the CPE & MS, it was observed that the 1st floor semi-restricted surgery corridor in the East Tower was not provided with an exit sign at the NE corner intersection as viewed from the west.

C. On 7/18/18 at 9:30am while in the company of the CPE & MS, it was observed that the 1st floor semi-restricted surgery corridor in the East Tower was not provided with an exit sign at the SW corner intersection as viewed from the north.


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D. On 07/18/2018 at 11:45 AM, while accompanied by the FSO and the MS, only one path of egress was observed to be identified by exit signage. Location observed: First Floor, OB Unit, by the Nurse Exit access corridor near Toilet E100.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

The finding is:

On 07/18/2018 at 10:45 AM, while accompanied by the FSO, the DBH and the MS, only one path of exit access was observed to be identified by exit signage. The means of egress from the suite to the exit access corridor does not comply with 19.2.10.1 and 7.10.

Location observed: Girls Unit Suite, Second Floor of the Mental Health Department.

Based upon observation, vertical openings between floor levels are not maintained as fire resistant assemblies in accordance with the Code. Failure to maintain fire rated assemblies between floor levels can allow fire/smoke to pass from one floor to another.

The finding is:

On 7/17/18 at 2:00pm while in the company of the CPE & MS, it was observed that the perimeter fire safing near the SE & SW corners of the East Tower building at the 3rd floor interstitial level (level between the 3rd & 5th floors) was damaged and lacked the intumescent spray coating over the mineral wool backing to comply with the tested design assembly requirements required by 19.3.1 and 8.3.6.7.

Based upon observation, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area.

Findings include:

A. While in the company of facility staff, it was observed that Hazardous Areas are not protected in accordance with 19.3.2.1.

Locations and conditions observed include:

1. On 7/18/18 at 9:15am while in the company of the CPE & MS, it was observed that the labeled door at the 1st floor East Tower Surgery semi-restricted corridor EVS room E164 containing a housekeeping cart with trash bin capacity greater than 32 gal. was not self-closing to a latched condition to comply with 19.3.2.1 and NFPA 80-2010, 6.1.4.

2. On 7/18/18 at 9:17am while in the company of the CPE & MS, it was observed that the labeled door at the 1st floor East Tower Surgery semi-restricted corridor Clean Equipment Storage room E165 was provided with a closer which took over 100 seconds to close and latch the door. This extended closure time does not comply with 7.2.1.8 & 7.2.1.9 which limits the hold-open period to 30 seconds.

3. On 7/18/18 at 9:46am while in the company of the CPE & MS, it was observed that the labeled door at the 1st floor East Tower Surgery semi-restricted corridor Clean Equipment Storage room E170 was provided with a closer which took over 60 seconds to close and latch the door. This extended closure time does not comply with 7.2.1.8 & 7.2.1.9 which limits the hold-open period to 30 seconds.

4. On 7/18/18 at 9:45am while in the company of the CPE & MS, it was observed that the labeled door at the 1st floor East Tower Surgery semi-restricted center core room door to OR 176 was not self-closing to a latched condition to comply with 19.3.2.1 and NFPA 80-2010, 6.1.4.

5. On 7/18/18 at 10:30am while in the company of the CPE & MS, it was observed that the 45-minute labeled door at the Basement level East Tower corridor door at the SPD Break room was not self-closing to a latched condition to comply with 19.3.2.1 and NFPA 80-2010, 6.1.4.

6. On 7/18/18 at 11:00am while in the company of the CPE & MS, it was observed that the Maintenance Shop in the Basement level of the 350 Building corridor door was equipped with an electric strike which did not provide positive latching for the door to comply with 19.3.2.1, NFPA 80-2010, 6.1.4 and 19.3.6.3.5.

7. On 7/18/18 at 11:05am while in the company of the CPE & MS, it was observed that the Storage room door just west of the Maintenance Shop in the Basement level of the 350 Building located in a designated 2-hour barrier was not self-closing to a latched condition to comply with 19.3.2.1, NFPA 80-2010, 6.1.4 and 19.3.6.3.5.

8. On 7/18/18 at 11:20am while in the company of the CPE & MS, it was observed that the two D077 Medical Gas storage room doors in the Basement level of the 350 Building were not self-closing due to contact with the floor to comply with 19.3.2.1, NFPA 99-2012, 5.1.3.3.2, and NFPA 80-2010, 6.1.4.

9. On 7/18/18 at 1:25pm while in the company of the DSBE, SPM & MS, it was observed that the Basement level Respiratory Therapy Storage room door to the adjacent office area was not self-closing due to the use of a wooden wedge not in compliance with 7.2.1.8.1.

Based upon observation, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area.

The finding is:

A. On 7/19/18 at 9:15am while in the company of the DSBE and the IDPOM, it was observed that the Ambulance Bay/Drive-thru Canopy is used to store supplies. During an interview with staff, it was discovered that certain staff use the Canopy for parking regardless of the posted signs, spaces are still available. This constitutes a hazardous area that is not spearated from the means of egress directed through this space to comply with 19.3.2.1 and 7.5.2.1

Based on an observation and staff interview, the facility failed to properly install all required initiating devices to provide a functioning fire alarm system. This deficient practice could affect patients, staff and visitors if the system should fail to operate as intended and delay safe egress.

Findings include:

A. On 7/18/18 at 11:45am while in the company of the DSBE, SPM & MS, it was observed that two detectors were not secured to their junction boxes to comply with NFPA 72-2010, 29.8.1.3.

Location observed:
Elevator machine room for elevators 6 & 7 in the basement of the 350 Building


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B. On 07/18/2018 at 11:00am, while accompanied by FSO and MS, several smoke detectors were observed located improperly which does not comply with 9.6, and NFPA 72 2010, 17.7.6.3.2.

Location observed: First Floor, Med / Surge Unit, Nutrition Room A109 less than 3-feet from a mechanical supply vent.


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C. On 07/17/2018 at 2:25pm while accompanied by the DSBE, fire alarm manual pull stations were not provided within 5' of a designated exit which does not comply with NFPA 72-2010, 17.14.6.

Locations observed:
1. 4th floor Exit Stair #S-4
2. 4th floor Horizontal Exit from Med/Surg wing to the "Interconnect Hallway"

Based upon observation and staff interview, fire alarm system components are not installed in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended and delay proper repairs when necessary.

The finding is:

On 7/18/18 at 2:15pm while in the company of the DSBE, SPM & MS, it was observed that the electrical panel DPL-1 circuit #1 serving the Fire Alarm Control Panel (FACP) was not provided with red markings along with a lock-on device to comply with NFPA 72-2010, 10.5.5.2.3 and 10.5.5.3.

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 07/18/2018, at 10:40 am while accompanied by FSO and MS, the placement of several smoke detectors were observed located within skylights which do not comply with 9.6, and NFPA 72 2010 17.7.3.3.

Location observed: Second Floor, Girls Unit (Mental Health), exit access corridor by the Staff Area.


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B On 07/18/2018 at 2:25pm while accompanied by the DSBE, fire alarm manual pull stations were observed to not be provided within 5' of a designated exit which does not comply with NFPA 72-2010, 17.14.6.

Location observed: 3rd floor Horizontal Exit from the "Interconnect Hallway" to the 400 Building.

Based on observation during the survey walk through the facility failed to install complete sprinkler protection. Failure to install and maintain complete protection 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 7/17/18 at 1:50 PM in the company of the FSO and MS, while touring the 5th floor of the East Tower, it was observed a recently buildout patient rooms with the ceiling mounted fire sprinkler heads installed more than 7' 6" from the back wall of the patient wardrobes. This is not in compliance with NFPA 101, 2012, 18.3.5.10 and NFPA 13, 2010, 8.5.3.2.


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B. On 07/18/18 at 9:40 AM, while accompanied by the FSO, DBH and MS, it was observed that exit Stair #S-5, Fifth Floor landing of the Building 350 lacked sprinkler protection to comply with NFPA 101 19.3.5.3 and NFPA 13.


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C. On 07/18/2018 at 3:15PM while in the company of the DSBE, it was observed the 1st floor level for exit Stair #S-4 extends to an area below the 2nd floor landing (this area contains an access door to the tunnels). This area is not provided with sprinkler protection to comply with NFPA 13 2010 8.1.

D. On 07/17/2018 at 2:55pm, while in the company of the DSBE, it was observed the 5th floor level Dietary Elevator machine room adjacent to exit Stair #S-1 lacks a means to automatically disconnect the main power supply to elevators prior to the application of water due to activation of a sprinkler system. This application does not comply with NFPA 13, 2010, NFPA-72, 2010 21.4, and ASME A17.1 for sprinkler protection, heat detector, tied to a shunt trip.

Based on observation during the survey walk through the facility failed to install required sprinkler protection. Protection is not provided which would maintain the construction type limitations of the building. Failure to install and maintain complete protection could result in delayed fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 07/18/2018 at 10:10am while accompanied by the DSBE, the 1st Floor Emergency Department was observed to have two exit paths that are directed with exit signs into the Ambulance Bay/Drive-thru Canopy area. The Ambulance Bay/Drive-thru Canopy is structurally attached to the Hospital and is used as required exiting from the building. It does not comply with 19.1.6.2 for a compliant building construction type and NFPA 13, 2010 8.15 without full sprinkler protection.

Based upon observation, corridor doors are not maintained with positive latching hardware. Failure to maintain positive latching doors can permit fire/smoke conditions to compromise the use of the corridor as a means of egress and prevent effective containment of a fire/smoke condition to the room of origin.

The finding is:

On 7/17/18 at 2:30pm while in the company of the CPE & MS, it was observed that horizontal sliding corridor doors in the ICU on the 3rd floor of the East Tower (which is not defined as a suite) did not close and latch to comply with 19.3.6.3.1 and 7.2.1.4.1(4)(c)(v). Three of three doors able to be tested without disrupting patients or families failed to latch at ICU rooms #1, #2 & #18.

Based on document review and interview, the facility failed to conduct fire drills at varied times. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

The finding is:

On 07/18/2018 at 2:35pm during document reviews accompanied by FSO and IDPOM, it was determined that the facility's quarterly fire drills do not meet the requirement of varying times for all three shifts throughout the annual cycle. First quarter 2018, second quarter 2018, third quarter of 2018 drills were conducted on the 30th or 31st or the 18th and 20th of the designated month which does not comply with 19.7.1.6.

Based upon observation and staff interview, electrical systems are not installed in accordance with Code requirements. Failure to properly install electrical systems can result in electrical shock to patients or staff in the event of fault condition.

The finding is:

On 7/19/18 at 9:15am while in the company of the FSO, it was observed that GFCI receptacles were not installed at locations within 6'-0" of the sinks at the Staff Lounge and typical treatment bays of the Infusion Center on the 3rd floor of the Pavilion Building to comply with NFPA 99-2012, 6.3.2.5 and NFPA 70-2011, 210.8(B)(6). Not all receptacles above the counter at the Staff Lounge within 6'-0" of the sink were GFCI protected. Receptacles above the counter at the sinks of the treatment stations were GFCI but other wall outlets within 6'-0" of the sinks used for equipment/pumps were not GFCI.

Based upon observation and staff interview, the emergency generator system is not installed in accordance with applicable requirements. Failure to install and maintain the emergency power system can result in failure of the lighting and power systems served to remain operational during a shelter-in-place or emergency condition where normal utility power is lost.

The finding is:

On 7/18/18 at 11:15am while in the company of the CPE & MS, observed that electrical panel "LSN" located in room D079 adjacent the freight elevator in the basement of the 350 Building was determined to be a Life Safety Branch panel and contained loads which were not permitted to be on the Life Safety Branch of the Essential Electrical System to comply with NFPA 99-2012, 6.4.2.2.3. The following circuits were determined not to be Life Safety loads:

1. Circuit 21/23 serving "AC Unit Pharmacy"
2. Circuit 22 serving "Receptacle E003 East Wall Maintenance"
3. Circuit 13 serving "Receptacle in Electrical Room"

Based upon observation, Critical Branch essential electrical system receptacles are not identified in accordance with Code requirements. Failure to identify receptacles can prevent prompt identification of the panel and circuit from which they are fed to perform maintenance or remedy a loss of power condition promptly.

The finding is:

On 7/17/18 at 2:20pm while in the company of the CPE & MS, it was observed that red critical receptacles in ICU room #18 (E18-E3057) on the 3rd floor of the East Tower were not labeled to identify the electrical panel and circuit from which they were fed to comply with NFPA 99-2012, 6.4.2.2.6.2(C) and NFPA 70-2011, 517.19(A).

Based on observation and staff interview, the essential electrical system generator is not maintained in accordance with Code requirements. Failure to maintain the generator can result in failure of the generator to perform as intended when required.

Findings include:

A. On 7/19/18 at 9:30am while in the company of the FSO & MS, it was observed that the exterior mounted emergency generator for the Pavilion Building was not provided with battery warmers to comply with NFPA 110-2010, 5.3.1.

B. On 7/19/18 at 9:30am while in the company of the FSO & MS, it was determined that weekly inspections for the exterior mounted emergency generator for the Pavilion Building are not being performed and documented to comply with NFPA 110-2010, 8.3 & 8.4.

Based upon observation medical gas cylinder storage does not comply with applicable Code requirements. Failure to store medical gas cylinders in compliance can result in increased potential of combustible material to an ignition source.

The finding is:

On 7/18/18 at 9:47am while in the company of the CPE & MS, it was observed that Oxygen storage was placed within 5'-0" of combustible materials on shelving. Nine 'E'-size cylinders in two 12-space racks were observed in the Operating Room core area of the Surgical Department on the 1st floor of the East Tower not in compliance with NFPA 99-2012, 11.3.2.3.