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Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. On the mooring of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the spaces between guard rail elements at C Wing Exit Stair E were observed to be far enough apart that a 4" sphere could pass through them as prohibited by 7.2.2.4.6(3). Throughout the course of the survey, this condition was also observed to exist at:
1. AB Wing Exit Stair A. Completed 12/10/14

2. AB Wing Exit Stair B. Completed 12/10/14

3. AB Wing Exit Stair C.

4. C Wing Exit Stair D.

B. On the mooring of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the guard rails at all Exit Stairs cited in Item A. above were also observed to be less than 42" high as required by 7.2.2.4.6(2).

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk through the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. The building was equipped with enough transfer switches for each branch of emergency power, but several of the panels served from the branch transfer switches were serving mixed loads and some of the transfer switches were serving panels from more than one branch as shown by some of the following examples:

1. The surveyor observed on the morning of 6/25/14 that critical panel 3CL1 on the 3rd floor, and panel BCL1 in the basement served elevator cab lighting which is required by Section 517-32 of NFPA-70 to be served from the life safety branch of emergency power.

2. The surveyor observed on the afternoon of 6/24/14 that panel EMPP in the elevator equipment room served a mixture of life safety, critical and equipment loads that are required by the 1999 edition of NFPA-70, Sections 517-30 through 517-35 to be separated into three separate branches.

3. The hospital staff was unable to locate life safety panels serving the loads required by NFPA-70, Section 517-32. They were not able to verify from the one-line diagram that there was a separate life safety transfer switch serving only life safety loads.

Based on random observation during the survey walk through the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70.

Findings include:

A. On the afternoon of 6/24/14 the surveyor observed that the cab lighting for the all elevators was not served from the life safety panel as required by NFPA-70, Section 517-32, and there was not a disconnect switch for cab lighting and controls within the elevator equipment room as required by NFPA-70, Section 620-22. This could affect any occupant of the building using the elevator during a power outage.

B. On the morning of 6/25/14, the surveyor observed that the C-section room was not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

C. Panel identification and panel schedules are not accurate or have not been updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13.

D. On the morning of 6/25/14, the surveyor observed that the critical outlets in the C-section room and the Angio room were not labeled and identified in accordance with NFPA-70, Section 517-19.

Based on random observation during the survey walk through the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

A. The surveyor observed on the afternoon of 6/24/14 that the elevator machine room in the 1961 portion of the building did not have a heat detector within 2' of each sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

B. The elevators machine rooms were not equipped with smoke detectors to initiate elevator recall in accordance with ANSI A17.1/A17.3.