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Based on observations and confirmed by staff, patient treatment areas are not separated as required.

THE FINDINGS INCLUDE:

- During the morning hours of 5/26/10 while touring the Radiology area, it was observed that treatment areas are open to the corridor. A total of eight (8) patients are capable of receiving treatment in these areas as combination oxygen/vacuum outlets are provided. The following locations were noted as being open to the corridor:

1) Outside of the Special Procedures Room
2) Outside the Fluoro Room
3) Outside the General Holding across from the Radiology.

These were each acknowledged by the Director of Facilities during the tour.

Based on observations and confirmed by staff, the facility failed to assure that maximum travel distances to exit egress locations are not exceeded. Section 19.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 100 ft (30 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 150 ft (45 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.

THE FINDINGS INCLUDE:

- During the morning of May 25, 2010 while touring the facility, it was noted that the travel distances on both the 2nd & 3rd floors are excessive. Upon measuring the actual distances with a measuring wheel, the following locations were noted as being deficient:

1) Third Floor: The travel distance between the horizontal exit door and stair #5 is 358'. There are numerous patient rooms located within section 3-6 which have distances exceeding 200' from the room door to the exit door.

2) Second Floor: The travel distance between the horizontal exit door and stair #5 is 401'. There are numerous patient rooms located within section 2-3 which have distances exceeding 200' from the room door to the exit door.

These were each acknowledged by the Director of Facilities.

NOTE: These items meet the FSES and do not require correction.

Based on observations and confirmed by staff, it was noted that smoke detectors are not installed properly. NFPA 72, section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

While touring the Hospital on 5/25/10 and 5/26/10 it was noted that numerous smoke detectors were located within three (3') feet of air supply diffusers. This was noted throughout the entire hospital, including patient bedrooms, corridors, common spaces and all habitable spaces.

These were each acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure that all sprinkler valves are protected and maintained as required.

THE FINDINGS INCLUDE:

Vernon Hill Building

- The two (2) Post Indicator Valves (P.I.V.) located on the supply side of the automatic sprinkler system are not electrically supervised to the fire alarm system.
Note: The two valves are currently locked in the open position.

These were acknowledged by the Director of Facilities.

Based on observations and confirmed by staff, the facility failed to assure compliance with NFPA #90A. Section 3.3.1.1 states that approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 2.3.4.1 states service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 states service openings shall be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within.

THE FINDINGS INCLUDE:

- While inspecting the two hour fire rated walls on 5/25/10, 5/26/10, and 5/27/10, which separate the Hospital occupancy from the business occupancy, it was noted that not all air handling ducts penetrating the the fire wall are equipped with the required fire dampers. Air handling ducts with out the required fire dampers were found in following but not limited to locations:
1) 2nd floor GI suite above the fire barrier door has a two foot by two foot air handling duct penetrating the 2 hour fire rated wall without the required fire damper.
2) Labor and Delivery area 1-3 has numerous air handling ducts that penetrating the 2 hour fire rated wall, and do not have the required fire dampers.

Note: In addition, the report conducted by an independent HVAC company did not indicate that the ducts listed above were equipped with the proper fire dampers.

These were acknowledged by the Director of Facilities.