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Based upon record document review, testing of the battery powered emergency lighting systems was not completed. Failure to properly performing maintenance activities can result in failure of the lighting systems due to lack of periodic inspection and maintenance affecting all occupants during an emergency event.

Findings include:

On April 18, 2022, at 10:15 am while in the company of the DOF & MS, it was observed that the documentation for annual 90-minutes tests for the Battery-Operated Emergency Lights in accordance with NFPA 101 2012 Edition, Section 7.9.3, is not available for review.

Based upon observation during the survey walk-through, exit signs are not placed appropriately to identify available exit paths. Failure to correctly identify exit paths can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.

Findings include:

On April 18, 2022, while in the company of the DOF & MS, it was observed that EXIT signage is not provided as required to identify the means of egress:

A. At 11:28 am at the 4th floor 1979 building fire door near Duplex Elevator Lobby, it was observed that exit signage was not provided to comply with NFPA 101 2012 Edition, Section 19.2.10.1 and 7.10.

B. At 11:37 am at the 4th floor 1979 building Mechanical Room, it was observed that exit signage was not provided to comply with NFPA 101 2012 Edition, Section 19.2.10.1 and 7.10.

Based upon observation during the survey walk-through, not all smoke detectors are installed and maintained as required. Smoke detectors should not be installed within 36 inches horizontally of a supply and return register, and outside the direct air flow to and from a register. The air flow to and from a register that is too close to a smoke detector will disturb the natural upward flow of smoke to the detector and slow its response time.

Findings include:

On April 18, 2022, at 11:25 am while in the company of the DOF & MS, a Smoke Detector was observed near supply/return register at the 4th floor 1954 building IT Closet that is not in compliance with NFPA 72 2010 Edition, Section 29.8.3.4(6).

Based upon document review, sprinkler systems are not being inspected, tested and maintained in accordance with Code requirements. Failure to inspect, test and maintain the sprinkler system can result in failure of the system to operate as required when needed to control a fire event.

Findings include:

On April 18, 2022, while in the company of the DOF & MS, it was observed that the following documentation are not available for review:

A. At 10:25 am, the documentation for weekly Sprinkler System Control Valves Inspection in accordance with NFPA 25 2011 Edition, Section 13.3.3 and Table 13.1.1.2. is not available for review.

B. At 10:30 am, the documentation for monthly Sprinkler System Pressure Gauges Inspection for condition/water pressure in accordance with NFPA 25 2011 Edition, Section 5.2.4.1, is not available for review.

C. At 10:35 am, the documentation for 5 - Year FDC Hydrostatic Piping Test in accordance with NFPA 25 2011 Edition, Section 6.3.2.1 and Table 13.8.1, is not available for review.

Based upon document review, fire and smoke doors are not being inspected, tested and maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency.

Findings include:

On April 18, 2022, at 10:40 am while in the company of the DOF & MS, it was observed that the documentation for Annual Fire and Smoke Door Inspections in accordance with NFPA 101 2012 Edition, Section 19.7.6, 8.3.3.1, 7.2.1.15, and NFPA 80 2010 Edition, Section 5.2.4.2, is not available for review.

Based on observation the facility lacks complete electrical bonding of the medical gas piping system. Failure to install and maintain this installation could potentially result in the piping system becoming electrically energized. This deficient practice could affect patients, staff and visitors.

Findings include:

On April 18, 2022, at 1:45 pm while in the company of the DOF & MS, it could not be confirmed through direct observation that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70 2011 Edition, Section 250.104 (B).

Based upon observation during the survey walk-through, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

Findings include:

On April 18, 2022, while in the company of the DOF & MS, it was observed that some electrical receptacles are not installed and maintained as required:

A. At 11:23 am, it was observed that electrical receptacles at the 4th floor 1954 building Auxiliary Office is within 6'-0" of sink fixture and is not provided with GFCI protection to prevent shock injuries and electrical burns in accordance with 2011 NFPA 70, 210.8(B)(5).

B. At 11:59 am, it was observed that 3rd floor 2011 building C-Section Operating Room lacked electrical receptacles served by normal power system as required by NFPA 70-2011, 517-19(A). It could not otherwise be determined that the red receptacles in the room were served by two separate transfer switches in accordance with Exception No. 2.

C. At 12:15 pm, it was observed that 2nd floor 2003 building Operating Rooms #3, #4, #5, #6 & #7 lacked electrical receptacles served by normal power system as required by NFPA 70-2011, 517-19(A). It could not otherwise be determined that the red receptacles in the room were served by two separate transfer switches in accordance with Exception No. 2.