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Based upon observation, corridor access doors from patient care rooms/areas are not maintained to provide required egress. Failure to provide an efficient means of egress can compromise the safe removal of patients and staff during a fire smoke event.

The finding is:

On 5/17/2022 at 12:55pm while accompanied by the DPO, corridor doors to patient care rooms were observed with separate dead bolts requiring a key from both sides. This configuration requires two motions to egress, further, this configuration does not comply with 19.2.2.2.2, 19.2.2.2.4., 19.2.2.2.5.2(security needs). Locations observed:

1. 5th floor Patient Quiet room
2. 5th floor Patient Restraint room

Based on observation vertical enclosures are not protected from other parts of the building. This deficient practice compromises the use of a stair as an exit and could affect all visitors, staff and patients when evacuating a floor or building during a fire smoke event.

Findings include:

A. On 5/17/2022 at 2:19pm while accompanied by the DPO, Exit Stair which serves 1st through 5th floor and roof contains windows (full height of the stair) located approximately 24" from the adjacent nonrated exterior building wall. The exit stair also contains an exterior door (not an exit) which contains ½ glass. The adjacent nonrated exterior building wall also contains patient room windows less than 30" from adjacent exterior stair wall. The angle of exposure is less than 180 degrees therefore protection of either the stair or the adjacent wall is to comply with 7.2.2.5.2.1 and 7.2.2.5.2.2 for a minimum 10'-0". Location observed: exit stair which discharges interior 1st floor at the Emergency Department.

B. On 5/17/2022 at 12:57pm while accompanied by the DPO, an exit stair door contains a non ligature knob for hardware which does not comply with NFPA 80 2010 7.4.3.1.1 and 8.3.3.1. for labeled fire door hardware. Location observed: 5th floor Center wing exit stair door.


Based on observation vertical exit enclosures do not provide adequate identification and direction to the level of exit discharge. This deficient practice compromises the use of a stair as an exit and could affect all visitors, staff and patients when evacuating a floor or building during a fire smoke event.

Findings include:

C. On 5/17/2022 while accompanied by the DPO, Exit stairs which basement level to 5th floor and roof lack directional signage within the exit stair to comply with 7.2.2.5.4.1 (A) - (M). Example locations observed:

1. At 12:40pm 5th floor A wing
2. At 12:45 pm 5th floor B wing

D. On 5/17/2022 at 2:20pm while accompanied by the DPO, the interior discharge exit stair adjacent to the Emergency Department does not comply with 7.2.2.5.4.2 for the upward directional signage required from the Basement level.

Based on observation and document review, components of smoke/fire barriers are not arranged to provide separation and compartmentation. Failure to provide proper smoke/fire compartments can compromise occupant safety by not providing protected areas of refuge.

The finding is:

On 5/17/2022 at 2:40pm while in the company of the DPO , it was observed that the smoke/fire barrier at a pair of cross corridor doors does not comply with 19.2.2.2.7. These doors are held open by maglocks however, upon activation of a fire alarm, the opening of the discharge door for the adjacent exit stair will prevent with the closing of these doors. The exit stair door contains an oversized closer, when opened at 90 degrees blocks the closing of the cross corridor doors which does not comply with 19.3.7, 7.5.1.1.1. Location observed: 1st floor east/west corridor in Emergency Department

Based upon observation, corridor widths are not maintained to provide minimum clearance for egress. Failure to provide a minimum means of egress width can compromise the convenient removal of patients staff and visitors from one compartment to an adjacent.

The finding is:

On 5/17/2022 at 1:40pm while accompanied by the DPO it was observed that the interior discharging stair at the first floor adjacent to the emergency department opens at 90 degrees into the means of egress corridor. This condition leaves less than one half the required means of egress corridor unobstructed which does not comply with 19.2.3.5, 7.2.1.4.3.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect patients, staff, and visitors by preventing those occupants from readily identifying the path to an available exit from the building during an emergency.

Finding is:

On 5/17/2022at 12:35pm while accompanied by the DPO the 5th floor, Center corridor, west end of the corridor lacked an exit sign to comply with 7.8.1.2 and 19.2.8.

Based on observation, 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:

A. On 5/17/2022, at 12:26pm while accompanied by the D.F.O., observation determined that doors to hazardous areas are not self closing to comply with 19.3.2.1.3. Location observed: 5th floor door to Patient Belongings Storage contains a broken overhead closer.

B. On 5/17/2022, at 1:35pm while accompanied by the D.F.O., observation determined that doors to unoccupied building wings contain deadbolt locks (keyed both sides) which require the use of a key to access an exit stair. This configuration does not comply with 19.2.2.2.4. Unnocupied areas are considered as hazardous locations by the AHJ, these areas require free egress without the use of a tool or key. Example location observed: 4th floor B wing.

Portable fire extinguishers are not being maintained in accordance with Code requirements. Failure to inspect portable extinguishers can result failure to control a fire event in its initial stages and cause occupant injury if they were to fail to operate as intended during such a fire event.

The finding is:

On 5/17/2022 at 1:10pm while in the company of the DPO it was observed that a portable fire extinguisher cabinet lacked a fire extinguisher.

Based upon observation, corridor doors are not positive latching. Failure to provide positive latching corridor doors can compromise the effectiveness of the door to remain closed to prevent the passage of smoke from one side of the corridor wall to the other.

The finding is:

On 5/17/2022 at 12:50pm while accompanied by the DPO, it was observed that corridor doors were equipped with an additional lockset on the egress side This does not comply with 19.3.6.3.5 for a corridor door which is required to have a means for keeping the door in the closed position (latched not locked). Closing and latching the door requires several operations rather than one motion which does not comply with 7.2.1.5.3 and 7.2.1.5.10.2.
Locations observed: 5th floor Center Staff restroom

Based on observation, not all portions of the building's medical gas system are installed as required. This deficient practice could affect any patients, staff, and visitors in the building if emergency conditions warranted shut-off of portions of the medical gas system and proper identification of the valves controlling affected areas could not be readily identified.

Findings include:

On 5/17/2022 at 1:20pm while in the company of the DPO it was observed that the medical gas shutoff valves near the G.I. rooms #1 and #2 were labeled as serving "Procedure Rooms #1 and #2 and not identified per room signage. The valve labeling does not match the room labeling to comply with 19.3.2.4 and NFPA 99-2012, 5.1.11.2.1(2).