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Based on observation, means of egress doors are locked in noncompliance with code provisions. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit from the building if there is a fire/smoke event.

The findings include:

A. On 06/09/20212 at 10:10am while in the company of the RDF a releasing mechanism (latch, lock etc) shall open the door having not more than one releasing operation to comply with 7.2.1.5.10.2. Location observed: Basement floor Sterile Processing door leading to Sterile Receiving contains a deadbolt located separate from the door's latchset thus requiring two motions to exit.

B. On 06/09/2021 at 11:05am while in the company of the RDF it was observed that the delayed egress locking devices installed at the cross corridor doors lack signage to comply with 7.2.1.6.1.1 (4). Example location observed: Pair of cross corridor doors (1-20SD) leading from the south end of the ED suite to corridor # T1164.


Based on observation doors do not open in the direction of egress. Failure to provide and maintain the direction of egress in full compliance with all requirements can result in building occupants unable to exit from the building during a fire/smoke event.

The finding is:

C. On 06/09/2021 at 3:10pm while in the company of the RDF it was observed that a required intervening gate within an exit stair opened onto the level of exit discharge such that it blocked the means of egress to the exterior due to the following:

1. The gate does not open in the direction of egress to comply with 7.2.1.4.2(2).

2. The gate encroaches on the minimum required width of the means of egress when opened which does not comply with 7.2.1.4.3.1.
Location observed: First floor Exit Stair C gate to Basement level.

Based on observation, not all stairs or smokeproof enclosures are constructed and utilized as required to maintain the integrity of the stair enclosure. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. On 06/09/2021 at 2:12pm while in the company of the RDF, an exit stair was observed being utilized as other than an exit which does not comply with 7.1.3.2.1(10). A stair is being used as the only means of access to a pathology dumbwaiter. Access to the dumbwaiter is through an entrance door off of the stair landing. The location observed: Exit Stair L, second floor. The same condition exists on the third floor.

B. On 06/09/2021 at 11:45am while in the company of the RDF, an exit stair was observed being utilized as other than an exit which does not comply with 7.1.3.2.1(10). A stair is being used as the only means of access to IT circuitry. The IT circuitry is located within a shaft containing vertical duct runs. The stair landing is used to gain access into the shaft for the IT circuitry. The location observed: Exit Stair C, third floor. The same condition exists on the fourth floor.

Based on observation, 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 06/09/2021 at 9:45am while accompanied by the RDF, surveyor observed that the egress path toward the north from the east end of Corridor T1207, is not identified by exit signage to comply with 7.10.1.1. Location observed: First floor near elevators #1-#3.

B. On 06/09/2021 at 11:01am while accompanied by the RDF, surveyor observed that the egress path toward the north end of the Emergency Department leading into the CT/MRI suite is a designated means of egress due to the exit sign above a door. However, the door contains signage which reads "This is NOT an authorized Exit, please go to the nurse station".

C. On 06/09/2021 at 11:11am while accompanied by the RDF, surveyor observed that the egress path toward the south end of the Emergency Department leading to Corridor #T1124 which is a designated means of egress due to the exit sign above a doors. However, the doors contains signage which reads "This is NOT an authorized Exit, please go to the nurse station".

Based on observation the facility failed to maintain compartment separations between floors/areas. This deficient practice could affect patients, staff and visitors to safely reach an exit on a floor level during a fire event on a separate level.

The finding is:

On 06/09/2021 at 10:50am while in the company of the RDF a multi-story shaft was observed that is not enclosed in fire rated construction to comply with 19.3.1.1, and/or NFPA 90A. Location observed: First floor shaft in corridor #T1253 adjacent to corridor entry to Nuclear Med. The shaft's access panel is bent and damaged. The condition does not appear to maintain the fire rating of the shaft.

Based on observation, the facility failed to provide separation between hazardous rooms from surrounding areas. This deficient practice could affect patients, staff and visitors if a fire spread without proper fire separation.

The finding is:

At 06/09/2021 at 10:05am while accompanied by the RFD doors lack positive latching hardware. Location observed: door located between Sterile Processing (#TB074) and Sterile Recieving (#TB075). Sterile processing is deemed as as a hazardous area, therefore the doors are to be self closing and latching to comply with 19.3.6.3.5.

Based on observation the facility failed to document inspection of the kitchen hood fire suppression system. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 06/09/21 at 11:48am in the company of the MEHS, the inspection tag for the grease hood's fire protection system, was observed to lack a record of the date and initials of the person completing the monthly inspection to comply with NFPA, 17, 2009, 11.2.4 / NFPA 17A, 2009, 7.2.5.

Based on observation, 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 06/09/2021 at 10:20am while accompanied by the RDF, a fire alarm manual pull station was not provided within 5' of a designated exit which does not comply with NFPA 72-2010, 17.14.6.
Location observed: 1st floor exit passageway serving Stair A from Corridor #T1196 at Door #1-90-1134.

B. On 06/09/2021 at 2:45pm while in the company of the RDF Third floor On-Call Sleep room(s) lack a single station smoke alarm notification device to comply with 19.3.4 and NFPA 72 2010 29.5.1.1.

Based on observation, sprinklers are not provided in all spaces to comply as a fully sprinklered building. Failure to install and maintain a fully sprinklered building could compromise the suppression of a fire affecting all occupants of the building in case of fire event.

Findings include:

A. On 06/09/2021 at 9:50am while accompanied by the RDF a room was observed which lacks sprinkler protection to comply with NFPA 13-2010, 4.1. Location observed: First floor Storage room #A128 adjacent to Corridor #T1183.

B.. On 06/09/2021 at 1:20pm while accompanied by the RDF electrical closets #3019 and #3017 were observed which lack sprinkler protection to comply with NFPA 13-2010, 8.8.7. Location observed: Third floor Corridor #T3056

Based on document review and staff interview the facility failed to record required electrical measurements and testing for annual fire pump testing. Failure of the fire pump during a fire event risk safety of patients, staff and visitors.

The findings include:

A. On 06/10/21 at 10:00am in the company of the RDF review of the annual fire pump test finds that the record of the electric motor voltage and current of all lines at all flow conditions is not provided to comply with NFPA 25, 2011, 8.3.3.2 (2) (a)

B. On 06/10/21 at 10:00am in the company of the RDF review of the annual fire pump test finds no record of the pump being tested under emergency power to comply with NFPA 25, 2011, 8.3.3.4

Based upon observation, areas open to the corridor are not provided with supervision or smoke detection system. Failure to provide supervision or smoke detection devices may prevent the building's occupants from being alerted to a fire related emergency. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

On 06/09/2021 at 1:45pm while in the company of the RDF, it was observed that a nurse station, which is not in use, is therefore an area open to the means of egress corridor which lacks smoke detection devices to comply with 19.3.6.1(c). During discussion the surveyor was notified that the 6th and 7th floors remain unoccupied and the nurse stations are therefore unattended.
Locations required: 3rd floor nurse station #T3069, 6th and 7th floors nurse stations

Based on observation, 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:

A. On 06/09/21, at 10:10 am, while accompanied by the DFPO on the Eight floor , the smoke door between Wing 'A' & 'B' did not close completely to resist the transfer of smoke from one compartment to another. This condition does not comply with 19.3.6.3.

B. On 06/09/21, at 10:40 am, while accompanied by the DFPO, on the Seventh floor all of the corridor doors including those to patient rooms did not latch. Each door could be pushed open from the latched position which does not in comply with 19.3.6.3.

C. On 06/09/21, at 1:50 pm, while accompanied by the DFPO on the Fourth floor, the smoke door between Wing 'C' & 'D' (between Room D4411 & D4410) did not close completely to resist the transfer of smoke from one compartment to another. This condition does not comply with 19.3.6.3.


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D. On 06/9/2021 at 2:10pm while accompanied by the RDF, suite entry corridor doors do not latch which does not comply with 19.3.6.3.
Locations observed:
1. 2nd Floor pair of cross corridor doors at south end of Corridor #T2073 from Surgical suite.
2. 2nd Floor corridor door to O.R. #7 (#T2074).

E. On 06/9/2021 at 1:10pm while accompanied by the RDF, corridor doors do not latch which does not comply with 19.3.6.3.
Locations observed: Basement floor corridor entry door to Sterile Receiving #TB075.

Based on observation fire and smoke dampers are not maintained in accordance with Code requirements. Failure to protect the vertical openings between floors can permit fire/smoke conditions to migrate to other floors during an emergency situation.

The finding is:

On 06/09/21, at 10:40 am, while accompanied by the DFPO an access panel installed to provide maintenance and inspection of a damper was observed to be installed beyond human reach, approximately 6 feet from the damper installation. This condition does not comply with NFPA 80, 19.2.3 and NFPA 90A, 2012, 4.3.5.1. Location observed, Seventh floor.

Based on observation the facility failed to protect the bulk oxygen facility from hazards. Failure to protect this installation could affect patients visitors and staff should an accident occur.

The findig is:

On 06/09/21 at 1:25pm while in the company of the MEHS the lack of a means to restrict and control the parking of motor vehicles within 10 feet of the bulk oxygen facility is not provided.