HospitalInspections.org

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

Findings include:

A. The Basement Waiting area near Nuclear Med is open to the corridor. Only a single smoke detector is provided and not located near the actual seating area. Adequate coverage of the waiting space is not deemed to be met to comply with 19.3.6.1 Exception No. 2.

B. The 4th floor Waiting area space at the Elevator lobby is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2.

C. The 6th floor Waiting area space at the Elevator Lobby and the Information Office Station for Oncology is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2.

D. The Data Equipment rooms in the Olin-Sang building located at the south end of the west corridors on the 4th, 5th, 6th and possibly other floors were equipped with transfer grilles through the corridor walls in non-compliance with 19.3.6.4. The openings were equipped with fire dampers, but no protection was provided for the transfer of smoke.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. A cast iron drain line located in the 7th floor Pre-action sprinkler system room for the Data Room was observed to be unsealed in accordance with a tested design.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. The 13th floor Equipment room was observed with three ducts through the floor. Fire dampers were not observed to be installed. Although this equipment was indicated to be abandoned in-place and not operating, it was not able to be confirmed what areas were served by the equipment relative to the ducts penetrating more than one floor.

B. The 12th floor Equipment room contained multiple ducts through the floor. One was observed with a fire damper #7239 but it was not installed within the floor thinkness. Other ducts did not have fire dampers. It was not clear that the Equipment room was intended to be considered the top of the shafts because two access doors at the corridor wall were observed that were either not fire rated or not self-closing.

C. The 12th floor room identified as a future conference room was observed to have two ducts exiting a shaft without fire dampers.

D. The 12the floor office below the Elevator Penthouse was observed to have a non-fire resistance rated steel floor plate assembly at the equipment hoisting penetration.

E. The 11th floor Data/Electrical room adjacent the smoke barrier doors was observed to have two unsealed conduit penetrations.

F. Unsealed conduit was observed at the 3rd floor room F333.

G. Electric Vault #2 at the Basement level was observed to have an opening in the base of the wall which appeared to be the bottom of a shaft in which air movement was into the shaft. A sheetmetal cover was not installed and did not maintain the required fire rating of the shaft wall.

H. Ducts observed in the Basement penetrating the floor adjacent the north stair were not confirmed to have functional fire dampers. These dampers were not tagged as being on the damper inventory. One duct appeared to have the damper shutter assemble removed.

I. The Frankel building contains multiple access doors along the corridor walls which access chases (where only piping or conduit is sealed at the floor levels) or shafts (where the ducts extend through the floors). A clear delineation between those functioning as shafts from those functioning as chases was not apparent. The original installed access doors contained "Fire Door" labels without an hourly rating identified.

J. The 18" square fire rated access door on the 8th floor west of L-833 is not self-closing.

.

Based on random observation during the survey walk-through on September 29, 2011, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the floor of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the corridors or other occupied areas.

Findings include:

A. The Basement Old Dark Room OS8 utilized as a storage room is not provided with a self-closing door.

B. The Basement Storage room OS10 is not provided with a self-closing door.

C. The 7th floor Storage room #737 is equipped with an electric strike. The electric strike is non-functional and does not provide latchign for the door.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the floor of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the occupied areas.

Findings include:

A. The 12th floor Engineering Offices storage/equipment room was not separated from the bove ceiling space of the adjacent areas. The door to this sprinklered room was not self-closing.

B. The 12th floor Engineering office storage room located at the west end of the floor which had a 1/2 glass door was observed to not have a self-closing door. Ceiling tile was also observed to be missing in this room which compromises the effective activation of the sprinkler system.

C. The Basement Electrical Vault #1 is not provided with sprinkler protection. The corridor door is not 1 1/2-hour rated to comply with the exception allowed under NFPA 13, 1999, 5-13.11.

.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. 11:07 AM September 27, 2011: An open conduit and a junction box, which do not directly serve the exit stair, were observed at the First Floor landing of Exit Stair 14 as prohibited by 7.1.3.2.1(e). This deficiency could affect all occupants of th Kurtzon Building using Exit Stair 14 for egress because the unrelated utilities could compromise the integrity of the fire rated enclosure during an emergency condition.

.

Based on random observation during the survey walk-through on September 27, 2011, not all exit access is arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients expected to utilize the exit access and/or exit, as well as any staff and visitors present, by preventing those occupants from reaching an exit and/or the exterior of the building.

Findings include:

A. The 1st floor ER waiting area and the north elevator lobby area cross corridor doors are equipped with magnetic locking devices without delayed egress in non-compliance with 19.2.2.2.4 and 7.2.1.6.1.

B. The 7th floor Data Room Storage room has two doors to access the room from adjacent rooms. Both doors lock to prevent egress from inside the room.

C. The 7th floor door #739 which accesses the top of the shaft is equipped with only a dead bolt lock without a thumbturn on the inside. The dead bolt lock only is not self-latching to comply with rated door assembly requirments of 8.2.3.2.1 to enclose the shaft.

.

Based on random observation during the survey walk-through on the afternoon of September 26 and on September 27, 2011, not all exit access is arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients expected to utilize the exit access and/or exit, as well as any staff and visitors present, by preventing those occupants from reaching an exit and/or the exterior of the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets. Where the dead bolt locks are operable from the egress side, the dead bolt lock constitutes a second releasing operation to operate the door when used in combination with a latchset in noncompliance with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. The 12th floor Engineering office steel corridor door has both a dead bolt and a latchset.

2. The 5th floor Trash room L-517 is equipped with a dead bolt lock operable from the outside only. Operation of the lock from the egress side is not possible.

3. The 3rd floor room F330 is equipped with both a dead bolt lock and a latchset.

B. The Basement level of the west stair contains an electrical panel in non-compliance with 7.1.3.2.1(e).

.

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. Doors equipped with delayed egress functions were observed to lack identifying signage required by 7.2.1.6.1(d). During an interview held in a Fourth Floor Conference Room at 11:57 AM on September 27, 2011, the Nurse Manager for the Mother/Baby Unit confirmed this observation. These deficiencies could affect all occupants of the Fourth Floor of the Crown Building because they may become confused when the doors do not release to permit egress under emergency conditions. Locations observed include (all Fourth Floor Mother/Baby Unit):
1. Exit Stair 1.
2. Exit Stair 2.

3. Exit Stair 3.

4. Pair of cross-corridor doors east of Olin-Sang Elevator Lobby.

B. The floor levels at 4 exterior exit doors, all in the immediate area of the First Floor exit discharge for exit Stair 3, were observed to not be level, as required by 7.1.7.2., because there is a step immediately outside each of the 4 doors. This deficiency could affect all building occupants exiting the building at this point, as the condition forms a tripping hazard which may prevent safe egress away from the building.
.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect all occupants of the listed building stories of the Kurtzon Building because their ability to successfully exit the building under fire conditions could be compromised.

Findings include:

A. Dead-end corridors of excessive length (in fire compartments classified as existing health care occupancies) were observed as prohibited by 19.2.5.10. Locations observed include:

1. 1:48 PM September 26, 2011: Eighth Floor East Corridor.

2. 2:05 PM September 26, 2011: Seventh Floor Bridge between Frankel and Kurtzon Buildings. Surveyor 14290 notes that the dead-end corridor exists because the door to the Kurtzon Building at the south end of the Bridge is secured against passage to the south.

3. Sixth Floor:
a. 2:17 PM September 26, 2011: Bridge between Frankel and Kurtzon Buildings. Surveyor 14290 notes that the dead-end corridor exists because the door to the Kurtzon Building at the south end of the Bridge is secured against passage to the south.
b. 2:18 PM September 26, 2011: East Corridor.
B. Dead-end corridors in excess of 50'-0" in length (in fire compartments classified as existing business occupancies) were observed as prohibited by 39.2.5.2. Locations observed include:

1. 2:45 PM September 26, 2011: Fifth Floor, south leg of West Corridor.

2. 2:53 PM September 26, 2011: Fourth Floor, south leg of West Corridor.

3. 9:20 AM September 27, 2011: Third Floor, south leg of West Corridor.

C. 9:48 AM September 27, 2011: A pair of cross corridor doors were observed, immediately south of the Second Floor landing for Exit Stair 8, that are equipped with throw bolts, thus requiring more than 1 door releasing operation as prohibited by 7.2.1.5.4.

.

Based on random observation during the survey walk-through on September 27, 2011, not all building separations are constructed and maintained in accordance with 8.2.3.2.3. These deficiencies could affect all patients on either sid eof the fire barrier as well as any staff and visitors present, by preventing allowing the fire barrier to be breeched.

Findings include:

A. The coordination of both sets of doors at the entrance to the 2nd floor Surgery area from the Olin-Sang Elevator Lobby failed to operate properly to allow the doors to close and latch in correct sequence.

.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. 1:59 PM September 27, 2011: The north leaf of a pair of cross-corridor doors, located in the west 2 hour fire rated wall at a "Chicago Vestibule" immediately east of First Floor Sinai Central, was observed to not release to close under fire alarm conditions as required by 7.2.4.3.4. and 8.2.3.2.3.1(1). This deficiency could affect all occupants of the First Floor of the Crown and Olin-Sang Buildings because the unreleased door could permit fire and smoke to pass between fire compartments.

.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. 9:46 AM September 27, 2011: A pair of cross-corridor doors, located in a designated 2 hour fire barrier wall immediately west of the Second Floor landing for Exit Stair 8, were observed to be damaged to a point at which they no longer carry a minimum 1-1/2 hour fire resistance rating as required by 7.2.4.3.4. and 8.2.3.2.3.1(1). This deficiency could affect all occupants of the Kurtzon Building Second Floor because the damaged doors could permit fire and smoke to pass between fire compartments.

.

Based on random observation during the survey walk-through on the afternoon of September 26 and on September 27, 2011, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. The Frankel building exit discharges could not be confirmed to be provided with instantaneous-on type lighting. Lamp type provided was either not observable, unknown by available staff, or of the HID type that required a warm-up period. Where only a single fixture was provided, it could not be confirmed that the fixture was equipped with more than one lamp of the instantaneous-on type. Locations observed include:

1. The southwest exit from the Basement which discharges to an areaway.

2. The north and west 1st floor exits which discharge to the exterior.

.

Based on random observation during the survey walk-through on the afternoon of September 27, 2011, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. The Olin-Sang building exit discharges could not be confirmed to be provided with instantaneous-on type lighting. Lamp type provided was either not observable, unknown by available staff, or of the HID type that required a warm-up period. Where only a single fixture was provided, it could not be confirmed that the fixture was equipped with more than one lamp of the instantaneous-on type. Locations observed include:

1. The lighting at the exterior discharge areaway of the stair from the Linear Accelarator area could not be confirmed to comply.

2. The lighting at the 1st floor ER north exit exterior discharge could not be confirmed to comply.

.

Based on random observation during the survey walk-through on September 27, 2011, exit signs did not identify available paths of egress in all cases in accordance with 19.2.5.9, 19.2.10.1. and 7.10. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the smoke compartment or building.

Findings include:

A. The west corridor in the Basement was not provided with fully visible exit signage from all points in the corridor. The sign at the south end of the corridor was partially obscured by the change in ceiling heights.

B. The Basement Waiting area open to the corridor near Nuclear Med has only one designated exit path identified. The cross corridor doors to the north block visibility of the second exit path when the doors are closed.

C. The Basement newly renovated Cath Lab Waiting area/Elevator Lobby open to the corridor constitutes a dead end greater than 30' in non-compliance with 18.2.5.10.

D. The Basement "L" shaped corridor leading to public toilets and Switchgear room OS40 could be confused as a corridor path of exit. A means of identifying this corridor as not an exit is not provided.

E. Exit signage is not provided in the Basement west north/south corridor to identify the two available exit paths.

F. The exit sign at the Basement horizontal exit to the Crown Building is positioned over the inactive leaf of the pair of doors rather than the door available for egress.

G. The door at the south end of the 2nd floor west corridor is not marked as an exit path from the unit to the elevator lobby and constitutes a dead end of 38'+/-. It appears to be equipped with only a portion of the features required by 7.2.1.6.2 as an access controlled egress locking device to control movement into the unit. Egress from the last patient room adjacent the door does not activate the door lock release. A manual release is not provided.

H. The door at the south end of the 3rd floor west corridor is not marked as an exit path from the unit to the elevator lobby and constitutes a dead end of 38'+/-. The door is locked with a magnetic locking device without delayed egress or access controlled egress hardware. Staff indicated that the door only releases under fire alarm activation. Adequate signage is not otherwise provided to define the available exit paths or make it clear that this door is not part of the required means of egress.

1. This similar condition also exist on the 4th floor south end of the west corridor.

2. This similar condition also exist on the 5th floor south end of the west corridor.

3. This similar condition also exist on the 6th floor south end of the west corridor.

I. The 3rd floor north end corridor/waiting area lacks exit signage to identify the two required exit paths.

J. The 5th floor north end corridor/waiting area lacks exit signage to identify the two required exit paths.

K. The 6th floor north end corridor/waiting area lacks exit signage to identify the two required exit paths.

.

Based on random observation during the survey walk-through on the afternoon of September 26 and on September 27, 2011, exit signs did not identify available paths of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the smoke compartment or building.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. The 7th floor Exit/Stairway sign at the west Stair is located beyond the stair door where it could be confused as directing the exit path into a dead end corridor.

2. The Basement corridor serving room L41 identifies an exit path in one direction only. The exit sign provided is not fully visible due to ceiling height obstruction.

3. The Basement corridor leading to the north stair has a dead end corridor greater than 30' beyond the stair door. Signage at the door at the end of this corridor is not provided to clearly identify that these doors are not an exit.

.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. On the afternoon of September 26, 2011, a heat detector located at the 14th floor Air Handler room was observed to be located 3' above the floor rather than at the ceiling in accordance with NFPA 72, 1999, 2-2.2. This deficiency could affect all persons in the building, because the lack of proper placement of the detector could result in a delayed notification of a fire condition in the space.

B. On the morning of September 27, 2011, the fire alarm manual station at the Basement southwest exit door was observed to be more than 5' from the exit in noncompliance with NFPA 72, 1999, 2-8.2.2. This deficiency could effect all persons in the building because the placement of the manual station could be overlooked when exiting in an emergency causing delay in activation of the alarm.

.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. 9:40 AM September 27, 2011: The west end of the Second Floor of the Kurtzon Building (that portion of the building west of the designated 2 hour fire barrier immediately west of Exit Stair 8) was observed to lack those fire alarm components required by 19.3.4. and 9.6. as listed below:
1. Manual fire alarm pull stations required by 9.6.2.1(1). This deficiency could affect any occupants of the Kurtzon Building because the identification of a fire condition within the fire compartment could be delayed.
2. Occupant notification devices required by 9.6.3.2. This deficiency could affect any occupants of the fire compartment because the identification of a fire elsewhere within the building could be delayed.
.

Based on random observation during the survey walk-through on September 27, 2011, not all portions of the facility's fire alarm system are installed in accordance with NFPA 72 1999.

Findings include:

A. During the walk-through of the basement the intersection between the Crown and Olin Sang Buildings was observed with a smoke detector installed within 3' of a supply diffuser and not in accordance with 2-3.5.1.

This deficiency could cause injury to patients and staff due to delay of sensing smoke.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, not all portions of the facility's wet sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

A. The 12th floor Engineering office electric/transformer room provided with by-passing doors was not provided with sprinkler protection.

B. Areas of the building were observed to be missing ceiling tile. The open ceilings compromise the effectiveness of the sprinkler head installations by allowing heat to escape into the above ceiling cavity prior to activating the heads. Locations observed include but may not necessarily be limited to the following:

1. The 11th floor old Lab at the east end of the building was observed to be missing ceiling tile.

2. The 8th floor corridor adjacent L-842 was observed to be missing ceiling tile.

.

Based on random observation during the survey walk-through on the afternoon of September 27, 2011, not all portions of the facility's wet sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

A. The Basement old Cath Lab equipment room was observed to be missing ceiling tile. The open ceilings compromise the effectiveness of the sprinkler head installations by allowing heat to escape into the above ceiling cavity prior to activating the heads

B. The Basement Linear Accelarator Waiting space which is provided with a skylite to the exterior above. The sprinkler protection for this space is mounted at the ceiling level of the Basement and not at the peak of the skylite 12' to 15' above the ceiling level. Compliance with NFPA 13-1999, 5-6.4.1.3 is not met.

.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. 10:00 AM September 27, 2011: The following conditions were observed at the Kurtzon Second Floor. These deficiencies could affect all occupants of the Kurtzon Second Floor, as well as those occupants in adjacent fire compartments, because the activation of sprinkler heads could be delayed.

1. Standard pendant or upright spray sprinkler heads were observed, in the Southeast Corridor, that are more than 12" below the ceiling as prohibited by NFPA 13 1999 5-6.4.1.1.

2. Ceiling tiles were observed to be missing in the East Corridor, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-7.4.1.1.

3. The ceiling assembly was incomplete between the East and Southeast Corridors, thus the ceiling cavity above the entire east Corridor was open, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-7.4.1.1.

.


26665


Based on random observation during the survey walk-through on September 27, 2011, not all portions of the facility's fire sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

B. During the afternoon walk-through of the transportation break room voice and data cables were observed to be supported by the fire sprinkler piping and not in accordance with 6-1.1.5.

This deficiency could result in injury to staff and patients due to electrical shorts.

.

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. September 26, 2011, varying times throughout the afternoon, and September 27, 2011, varying times throughout the morning: The conditions listed below were observed at a centrally located shaft within the Kurtzon Building (example location: at the Ninth Floor immediately southeast of the intersection between the East-West Corridor and the South Corridor). The shaft connects at least the Eleventh through Fourth Floors. These deficiencies could affect any occupants of the Kurtzon Building because fire and smoke could pass between building stories. Conditions observed include:

1. No evidence of fire dampers, required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.4. was found on any building story in which ductwork was observed in the shaft.
2. No access panels for any fire dampers, required by NFPA 90A 1999 2-3.4.1., were found on any building story in which ductwork was observed in the shaft.
3. The shaft, which connects at least 8 building stories, was observed to not carry a minimum 2 hour fire rating as required by NFPA 90A 1999 3-3.4.1., because multiple unsealed penetrations and openings (see 8.2.2. and 8.2.3.2.4.2.) were observed in the shaft on all building stories observed.

.

Based on random observation during the survey walk-through, not all portions of the facility's heating and air conditioning system are in accordance with NFPA 90A 1999.

Findings include:

A. During the survey of the sixth floor equipment room AHU #1 was observed to have heavily soiled and loose fitting pre-filters allowing air bypass. Staff interview at the site reveled the filters had not been changed in six months.

.

Based on random observation during the walk-through and staff interview in the afternoon of September 26, 2011, not all portions of the facility's heating, air conditioning and ventilation system are installed in accordance with NFPA 90A 1999.

Findings include:

A. During the afternoon walk-through the seventh floor equipment room numerous supply ducts were observed to conditioned fresh air to the perimeter units on second through sixth floors without dampers where they penetrated the 2 hour floor in accordance with 3-3.2.

B. During the walk-through of the sixth floor mother/baby unit a painted duct was observed supplying fresh air to the perimeter ventilation unit without an enclosure in accordance with 3-3.4.1.
During an interview held in room 620 on the afternoon of September 26, 2011 with the Vice President of Facilities it was confirmed room 620 was typical installation of ductwork to perimeter units on second through sixth floors of the building.

C. During the survey of the seventh floor equipment room AGS1 and AGS2 were observed to have heavily soiled and loose fitting pre-filters allowing air bypass. Staff interview at the site revieled the filters had not been changed in six months.

The 3 deficiencies above could result in patient and staff injury due to a lack of building fire separation and clean air.

.

Based on random observation during the survey walk-through on September 28, 2011, at 9:00 am, not all portions of the facility's commercial cooking system are installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. The two class "K" fire extinguishers in the main food preparation area was not provided with a placard to identify their use only after the automatic extinguisher had discharged in accordance with 7-2.1.1.

B. The main food preparation area exhaust hood suppression system was observed without protective caps on the discharge nozzles in accordance with NFPA 17A 1998 2-3.1.4.

Deficiency A could result in staff injury and prolonged burning of the fire.

Deficiency B could result in staff injury due to a plugged nozzle not discharging.

.

Based on random observation during the survey walk-through and staff interview, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. 2:25 PM September 27, 2011: A gurney was observed, in the Second Floor Surgical Department East-West Corridor, that obstructs egress as prohibited by 19.2.3.3. and 7.1.10.2.1. During an interview held at that time, the provider's Surgical Nurse manager stated that gurneys are typically placed in that Corridor while patients undergo procedures. This deficiency could affect all occupants within the Surgical Department because their ability to reach an exit from the building story could be compromised under emergency conditions.

.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. 1:42 PM September 26, 2011: Carts and equipment were observed in the Corridor within the Sixth Floor MICU/CCU that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. This deficiency could affect all occupants within the MICU/CCU because their ability to reach an exit from the building story could be compromised under emergency conditions.

.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. 9:29 AM September 27, 2011: Medical gas tanks were observed being stored, in Third Floor Room K313A, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the Third Floor of the Kurtzon Building because the medical gas tanks could contribute to any combustion which might occur within the stored materials.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, not all medical gas systems comply with with NFPA 99, 1999, Chapter 4. These deficiencies could affect all persons in the facility required to utilize the systems by preventing the safe and proper abandonment of the portions of the systems no longer in use.

Findings include:

A. The 11th floor Lab areas (at the east end of the floor) were abandoned in-place. The medical gas systems consisted of natural gas, air, and vacuum. The gas and air were not functional at the outlets. The vacuum system was still operational. It was unknown where the system shut-off valves were located for any of the systems. It was not known how much of the system(s) was active and how much was inactive throughout the building.

.

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed and maintained in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the facility grounds the Emergency Oxygen fill location was observed to be without a sign identifying it as the "Emergency Low Pressure Gaseous Oxygen Inlet" in accordance with 4-3.1.1.8 (h).

B. The medical air 1 and 2 receiver was observed without a source valve at the receiver in accordance with 4-3.1.2.3 (a).

C. The medical air 1 and 2 receiver was observed without an automatic drain in accordance with 4-3.1.1.9 (f).

These deficiencies could result in patient injury due to system failure.

.

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the basement level electrical switchgear room OS39 had 3 copper lines crossing the ceiling identified as medical gas lines. During an interview held with the Operation Manager at the location it was revieled they might be abandoned but it was not confirmed at the time of the survey.

This deficiency could injury patients or staff due to increased fire hazard.

.

Based on random observation during the survey walk-through, not all plumbing is installed and maintained in accordance with State and National Sanitation Standards. This deficiency can effect all persons exposed to the improper accummulation of and disposal of waste water.

Findings include:

A. The drain path for the Janitor sink located in the Basement L-28 Janitor closet was through an open cleanout located in the adjacent room. Waste water was being discharged through the open cleanout rather than draining down the pipe into the underfloor piping. Waste was allowed to traverse across the floor to reach a floor drain. The condition did not provide for proper sealing and venting of the piping system.

.



14290


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:

B. 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 building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. Emergency loads were not separated into life safety, critical and equipment branches which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. Emergency panels throughout the building were serving both life safety and critical loads which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. The critical rather than life safety panels on each floor were serving med gas alarms, exit signs, and emergency lighting which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. The critical rather than life safety panels on each floor were serving med gas alarms, exit signs, and emergency lighting which does not meet the requirements of NFPA-70, Section 517-31 thru 35. Examples include panel 5CR1 and 4CR2 which were serving med gas alarms and corridor emergency lighting.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through on the morning of September 26 and on September 27, 2011, not all portions of the facility's electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. The panel cover on panel LBEM2 (LBSB2 old) located in the Basement Electrical Vault #1 was observed to be removed. Although work had been indicated to be taking place, no work was being performed at the time of observation.

B. An electrical box cover at the 5th floor west Janitor closet was observed to not be installed.

.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in C-section rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, the operating rooms could be left with no power.

.

Based on random observation during the survey walk-through on September 27, 2011, not all elevator equipment spaces are maintained in accordance with 19.5.3, 9.4.3.2 and ASME/ANSI A17.3. These deficiencies could affect all patients expected to utilize the elevators, as well as any staff and visitors present, by exposing the elevator equipment to conditions not permitted by the Code(s).

Findings include:

A. The 7th floor elevator machine room was also utilized as an office space and storage area in non-compliance with ASME/ANSI A17.3, 2.2.1.

.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

Findings include:

A. The Basement Waiting area near Nuclear Med is open to the corridor. Only a single smoke detector is provided and not located near the actual seating area. Adequate coverage of the waiting space is not deemed to be met to comply with 19.3.6.1 Exception No. 2.

B. The 4th floor Waiting area space at the Elevator lobby is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2.

C. The 6th floor Waiting area space at the Elevator Lobby and the Information Office Station for Oncology is not provided with smoke detection to comply with 19.3.6.1 Exception No. 2.

D. The Data Equipment rooms in the Olin-Sang building located at the south end of the west corridors on the 4th, 5th, 6th and possibly other floors were equipped with transfer grilles through the corridor walls in non-compliance with 19.3.6.4. The openings were equipped with fire dampers, but no protection was provided for the transfer of smoke.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. A cast iron drain line located in the 7th floor Pre-action sprinkler system room for the Data Room was observed to be unsealed in accordance with a tested design.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. The 13th floor Equipment room was observed with three ducts through the floor. Fire dampers were not observed to be installed. Although this equipment was indicated to be abandoned in-place and not operating, it was not able to be confirmed what areas were served by the equipment relative to the ducts penetrating more than one floor.

B. The 12th floor Equipment room contained multiple ducts through the floor. One was observed with a fire damper #7239 but it was not installed within the floor thinkness. Other ducts did not have fire dampers. It was not clear that the Equipment room was intended to be considered the top of the shafts because two access doors at the corridor wall were observed that were either not fire rated or not self-closing.

C. The 12th floor room identified as a future conference room was observed to have two ducts exiting a shaft without fire dampers.

D. The 12the floor office below the Elevator Penthouse was observed to have a non-fire resistance rated steel floor plate assembly at the equipment hoisting penetration.

E. The 11th floor Data/Electrical room adjacent the smoke barrier doors was observed to have two unsealed conduit penetrations.

F. Unsealed conduit was observed at the 3rd floor room F333.

G. Electric Vault #2 at the Basement level was observed to have an opening in the base of the wall which appeared to be the bottom of a shaft in which air movement was into the shaft. A sheetmetal cover was not installed and did not maintain the required fire rating of the shaft wall.

H. Ducts observed in the Basement penetrating the floor adjacent the north stair were not confirmed to have functional fire dampers. These dampers were not tagged as being on the damper inventory. One duct appeared to have the damper shutter assemble removed.

I. The Frankel building contains multiple access doors along the corridor walls which access chases (where only piping or conduit is sealed at the floor levels) or shafts (where the ducts extend through the floors). A clear delineation between those functioning as shafts from those functioning as chases was not apparent. The original installed access doors contained "Fire Door" labels without an hourly rating identified.

J. The 18" square fire rated access door on the 8th floor west of L-833 is not self-closing.

.

Based on random observation during the survey walk-through on September 29, 2011, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the floor of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the corridors or other occupied areas.

Findings include:

A. The Basement Old Dark Room OS8 utilized as a storage room is not provided with a self-closing door.

B. The Basement Storage room OS10 is not provided with a self-closing door.

C. The 7th floor Storage room #737 is equipped with an electric strike. The electric strike is non-functional and does not provide latchign for the door.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the floor of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the occupied areas.

Findings include:

A. The 12th floor Engineering Offices storage/equipment room was not separated from the bove ceiling space of the adjacent areas. The door to this sprinklered room was not self-closing.

B. The 12th floor Engineering office storage room located at the west end of the floor which had a 1/2 glass door was observed to not have a self-closing door. Ceiling tile was also observed to be missing in this room which compromises the effective activation of the sprinkler system.

C. The Basement Electrical Vault #1 is not provided with sprinkler protection. The corridor door is not 1 1/2-hour rated to comply with the exception allowed under NFPA 13, 1999, 5-13.11.

.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. 11:07 AM September 27, 2011: An open conduit and a junction box, which do not directly serve the exit stair, were observed at the First Floor landing of Exit Stair 14 as prohibited by 7.1.3.2.1(e). This deficiency could affect all occupants of th Kurtzon Building using Exit Stair 14 for egress because the unrelated utilities could compromise the integrity of the fire rated enclosure during an emergency condition.

.

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 all occupants of the building because their ability to exit the building and reach a public way could be compromised.

Findings include:

A. During document review and staff interview conducted in the Facilities Office at 11:15 AM on September 27, 2011, it was determined that several building stories do not comply with 7.7.2. because less than 50 per cent of the exit stairs serving those building stories discharge directly to the exterior of the building. During the interview listed above, the provider's Vice President for Facilities confirmed the following:
1. The Thirteenth/Twelfth Floors (Elevator/Mechanical Penthouses ) of the Frankel Building are served only by Exit Stair 6, which does not exit directly to the exterior of the building.
2. The Eleventh, Tenth, Ninth, Eighth, and Seventh Floors of the Frankel and Kurtzon Buildings are served by Exit Stairs 6, 7, 8, and 12. Of these, none discharge directly to the exterior of the building.
3. The Sixth Floor of the Olin-Sang, Frankel, and Kurtzon Buildings are served by Exit Stairs 4, 5, 6, 7, 8, and 12. Of these, only Exit Stair 4 discharges exterior to the building.

4. The Sub-Basement of the Olin-Sang Building is served by Exit Stairs 5 and 13. Of these, none discharge directly to the exterior of the building.
B. During document review and staff interview conducted in the Facilities Office at 11:15 AM on September 27, 2011, it was determined that building occupants must exit the fire rated enclosure for Exit Stair 12 at the Third Floor of the Kurtzon Building and cross through the building in a non-fire rated corridor in order to gain access to the fire rated enclosure for Exit Stair 9 to continue egress, which does not comply with 7.2.6.3.

.

Based on random observation during the survey walk-through on September 27, 2011, not all exit access is arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients expected to utilize the exit access and/or exit, as well as any staff and visitors present, by preventing those occupants from reaching an exit and/or the exterior of the building.

Findings include:

A. The 1st floor ER waiting area and the north elevator lobby area cross corridor doors are equipped with magnetic locking devices without delayed egress in non-compliance with 19.2.2.2.4 and 7.2.1.6.1.

B. The 7th floor Data Room Storage room has two doors to access the room from adjacent rooms. Both doors lock to prevent egress from inside the room.

C. The 7th floor door #739 which accesses the top of the shaft is equipped with only a dead bolt lock without a thumbturn on the inside. The dead bolt lock only is not self-latching to comply with rated door assembly requirments of 8.2.3.2.1 to enclose the shaft.

.

Based on random observation during the survey walk-through on the afternoon of September 26 and on September 27, 2011, not all exit access is arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients expected to utilize the exit access and/or exit, as well as any staff and visitors present, by preventing those occupants from reaching an exit and/or the exterior of the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets. Where the dead bolt locks are operable from the egress side, the dead bolt lock constitutes a second releasing operation to operate the door when used in combination with a latchset in noncompliance with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. The 12th floor Engineering office steel corridor door has both a dead bolt and a latchset.

2. The 5th floor Trash room L-517 is equipped with a dead bolt lock operable from the outside only. Operation of the lock from the egress side is not possible.

3. The 3rd floor room F330 is equipped with both a dead bolt lock and a latchset.

B. The Basement level of the west stair contains an electrical panel in non-compliance with 7.1.3.2.1(e).

.

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. Doors equipped with delayed egress functions were observed to lack identifying signage required by 7.2.1.6.1(d). During an interview held in a Fourth Floor Conference Room at 11:57 AM on September 27, 2011, the Nurse Manager for the Mother/Baby Unit confirmed this observation. These deficiencies could affect all occupants of the Fourth Floor of the Crown Building because they may become confused when the doors do not release to permit egress under emergency conditions. Locations observed include (all Fourth Floor Mother/Baby Unit):
1. Exit Stair 1.
2. Exit Stair 2.

3. Exit Stair 3.

4. Pair of cross-corridor doors east of Olin-Sang Elevator Lobby.

B. The floor levels at 4 exterior exit doors, all in the immediate area of the First Floor exit discharge for exit Stair 3, were observed to not be level, as required by 7.1.7.2., because there is a step immediately outside each of the 4 doors. This deficiency could affect all building occupants exiting the building at this point, as the condition forms a tripping hazard which may prevent safe egress away from the building.
.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect all occupants of the listed building stories of the Kurtzon Building because their ability to successfully exit the building under fire conditions could be compromised.

Findings include:

A. Dead-end corridors of excessive length (in fire compartments classified as existing health care occupancies) were observed as prohibited by 19.2.5.10. Locations observed include:

1. 1:48 PM September 26, 2011: Eighth Floor East Corridor.

2. 2:05 PM September 26, 2011: Seventh Floor Bridge between Frankel and Kurtzon Buildings. Surveyor 14290 notes that the dead-end corridor exists because the door to the Kurtzon Building at the south end of the Bridge is secured against passage to the south.

3. Sixth Floor:
a. 2:17 PM September 26, 2011: Bridge between Frankel and Kurtzon Buildings. Surveyor 14290 notes that the dead-end corridor exists because the door to the Kurtzon Building at the south end of the Bridge is secured against passage to the south.
b. 2:18 PM September 26, 2011: East Corridor.
B. Dead-end corridors in excess of 50'-0" in length (in fire compartments classified as existing business occupancies) were observed as prohibited by 39.2.5.2. Locations observed include:

1. 2:45 PM September 26, 2011: Fifth Floor, south leg of West Corridor.

2. 2:53 PM September 26, 2011: Fourth Floor, south leg of West Corridor.

3. 9:20 AM September 27, 2011: Third Floor, south leg of West Corridor.

C. 9:48 AM September 27, 2011: A pair of cross corridor doors were observed, immediately south of the Second Floor landing for Exit Stair 8, that are equipped with throw bolts, thus requiring more than 1 door releasing operation as prohibited by 7.2.1.5.4.

.

Based on random observation during the survey walk-through on September 27, 2011, not all building separations are constructed and maintained in accordance with 8.2.3.2.3. These deficiencies could affect all patients on either sid eof the fire barrier as well as any staff and visitors present, by preventing allowing the fire barrier to be breeched.

Findings include:

A. The coordination of both sets of doors at the entrance to the 2nd floor Surgery area from the Olin-Sang Elevator Lobby failed to operate properly to allow the doors to close and latch in correct sequence.

.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. 1:59 PM September 27, 2011: The north leaf of a pair of cross-corridor doors, located in the west 2 hour fire rated wall at a "Chicago Vestibule" immediately east of First Floor Sinai Central, was observed to not release to close under fire alarm conditions as required by 7.2.4.3.4. and 8.2.3.2.3.1(1). This deficiency could affect all occupants of the First Floor of the Crown and Olin-Sang Buildings because the unreleased door could permit fire and smoke to pass between fire compartments.

.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. 9:46 AM September 27, 2011: A pair of cross-corridor doors, located in a designated 2 hour fire barrier wall immediately west of the Second Floor landing for Exit Stair 8, were observed to be damaged to a point at which they no longer carry a minimum 1-1/2 hour fire resistance rating as required by 7.2.4.3.4. and 8.2.3.2.3.1(1). This deficiency could affect all occupants of the Kurtzon Building Second Floor because the damaged doors could permit fire and smoke to pass between fire compartments.

.

Based on random observation during the survey walk-through on the afternoon of September 26 and on September 27, 2011, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. The Frankel building exit discharges could not be confirmed to be provided with instantaneous-on type lighting. Lamp type provided was either not observable, unknown by available staff, or of the HID type that required a warm-up period. Where only a single fixture was provided, it could not be confirmed that the fixture was equipped with more than one lamp of the instantaneous-on type. Locations observed include:

1. The southwest exit from the Basement which discharges to an areaway.

2. The north and west 1st floor exits which discharge to the exterior.

.

Based on random observation during the survey walk-through on the afternoon of September 27, 2011, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. The Olin-Sang building exit discharges could not be confirmed to be provided with instantaneous-on type lighting. Lamp type provided was either not observable, unknown by available staff, or of the HID type that required a warm-up period. Where only a single fixture was provided, it could not be confirmed that the fixture was equipped with more than one lamp of the instantaneous-on type. Locations observed include:

1. The lighting at the exterior discharge areaway of the stair from the Linear Accelarator area could not be confirmed to comply.

2. The lighting at the 1st floor ER north exit exterior discharge could not be confirmed to comply.

.

Based on random observation during the survey walk-through on September 27, 2011, exit signs did not identify available paths of egress in all cases in accordance with 19.2.5.9, 19.2.10.1. and 7.10. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the smoke compartment or building.

Findings include:

A. The west corridor in the Basement was not provided with fully visible exit signage from all points in the corridor. The sign at the south end of the corridor was partially obscured by the change in ceiling heights.

B. The Basement Waiting area open to the corridor near Nuclear Med has only one designated exit path identified. The cross corridor doors to the north block visibility of the second exit path when the doors are closed.

C. The Basement newly renovated Cath Lab Waiting area/Elevator Lobby open to the corridor constitutes a dead end greater than 30' in non-compliance with 18.2.5.10.

D. The Basement "L" shaped corridor leading to public toilets and Switchgear room OS40 could be confused as a corridor path of exit. A means of identifying this corridor as not an exit is not provided.

E. Exit signage is not provided in the Basement west north/south corridor to identify the two available exit paths.

F. The exit sign at the Basement horizontal exit to the Crown Building is positioned over the inactive leaf of the pair of doors rather than the door available for egress.

G. The door at the south end of the 2nd floor west corridor is not marked as an exit path from the unit to the elevator lobby and constitutes a dead end of 38'+/-. It appears to be equipped with only a portion of the features required by 7.2.1.6.2 as an access controlled egress locking device to control movement into the unit. Egress from the last patient room adjacent the door does not activate the door lock release. A manual release is not provided.

H. The door at the south end of the 3rd floor west corridor is not marked as an exit path from the unit to the elevator lobby and constitutes a dead end of 38'+/-. The door is locked with a magnetic locking device without delayed egress or access controlled egress hardware. Staff indicated that the door only releases under fire alarm activation. Adequate signage is not otherwise provided to define the available exit paths or make it clear that this door is not part of the required means of egress.

1. This similar condition also exist on the 4th floor south end of the west corridor.

2. This similar condition also exist on the 5th floor south end of the west corridor.

3. This similar condition also exist on the 6th floor south end of the west corridor.

I. The 3rd floor north end corridor/waiting area lacks exit signage to identify the two required exit paths.

J. The 5th floor north end corridor/waiting area lacks exit signage to identify the two required exit paths.

K. The 6th floor north end corridor/waiting area lacks exit signage to identify the two required exit paths.

.

Based on random observation during the survey walk-through on the afternoon of September 26 and on September 27, 2011, exit signs did not identify available paths of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the smoke compartment or building.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. The 7th floor Exit/Stairway sign at the west Stair is located beyond the stair door where it could be confused as directing the exit path into a dead end corridor.

2. The Basement corridor serving room L41 identifies an exit path in one direction only. The exit sign provided is not fully visible due to ceiling height obstruction.

3. The Basement corridor leading to the north stair has a dead end corridor greater than 30' beyond the stair door. Signage at the door at the end of this corridor is not provided to clearly identify that these doors are not an exit.

.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. On the afternoon of September 26, 2011, a heat detector located at the 14th floor Air Handler room was observed to be located 3' above the floor rather than at the ceiling in accordance with NFPA 72, 1999, 2-2.2. This deficiency could affect all persons in the building, because the lack of proper placement of the detector could result in a delayed notification of a fire condition in the space.

B. On the morning of September 27, 2011, the fire alarm manual station at the Basement southwest exit door was observed to be more than 5' from the exit in noncompliance with NFPA 72, 1999, 2-8.2.2. This deficiency could effect all persons in the building because the placement of the manual station could be overlooked when exiting in an emergency causing delay in activation of the alarm.

.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. 9:40 AM September 27, 2011: The west end of the Second Floor of the Kurtzon Building (that portion of the building west of the designated 2 hour fire barrier immediately west of Exit Stair 8) was observed to lack those fire alarm components required by 19.3.4. and 9.6. as listed below:
1. Manual fire alarm pull stations required by 9.6.2.1(1). This deficiency could affect any occupants of the Kurtzon Building because the identification of a fire condition within the fire compartment could be delayed.
2. Occupant notification devices required by 9.6.3.2. This deficiency could affect any occupants of the fire compartment because the identification of a fire elsewhere within the building could be delayed.
.

Based on random observation during the survey walk-through on September 27, 2011, not all portions of the facility's fire alarm system are installed in accordance with NFPA 72 1999.

Findings include:

A. During the walk-through of the basement the intersection between the Crown and Olin Sang Buildings was observed with a smoke detector installed within 3' of a supply diffuser and not in accordance with 2-3.5.1.

This deficiency could cause injury to patients and staff due to delay of sensing smoke.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, not all portions of the facility's wet sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

A. The 12th floor Engineering office electric/transformer room provided with by-passing doors was not provided with sprinkler protection.

B. Areas of the building were observed to be missing ceiling tile. The open ceilings compromise the effectiveness of the sprinkler head installations by allowing heat to escape into the above ceiling cavity prior to activating the heads. Locations observed include but may not necessarily be limited to the following:

1. The 11th floor old Lab at the east end of the building was observed to be missing ceiling tile.

2. The 8th floor corridor adjacent L-842 was observed to be missing ceiling tile.

.

Based on random observation during the survey walk-through on the afternoon of September 27, 2011, not all portions of the facility's wet sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

A. The Basement old Cath Lab equipment room was observed to be missing ceiling tile. The open ceilings compromise the effectiveness of the sprinkler head installations by allowing heat to escape into the above ceiling cavity prior to activating the heads

B. The Basement Linear Accelarator Waiting space which is provided with a skylite to the exterior above. The sprinkler protection for this space is mounted at the ceiling level of the Basement and not at the peak of the skylite 12' to 15' above the ceiling level. Compliance with NFPA 13-1999, 5-6.4.1.3 is not met.

.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.

Findings include:

A. 10:00 AM September 27, 2011: The following conditions were observed at the Kurtzon Second Floor. These deficiencies could affect all occupants of the Kurtzon Second Floor, as well as those occupants in adjacent fire compartments, because the activation of sprinkler heads could be delayed.

1. Standard pendant or upright spray sprinkler heads were observed, in the Southeast Corridor, that are more than 12" below the ceiling as prohibited by NFPA 13 1999 5-6.4.1.1.

2. Ceiling tiles were observed to be missing in the East Corridor, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-7.4.1.1.

3. The ceiling assembly was incomplete between the East and Southeast Corridors, thus the ceiling cavity above the entire east Corridor was open, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-7.4.1.1.

.


26665


Based on random observation during the survey walk-through on September 27, 2011, not all portions of the facility's fire sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

B. During the afternoon walk-through of the transportation break room voice and data cables were observed to be supported by the fire sprinkler piping and not in accordance with 6-1.1.5.

This deficiency could result in injury to staff and patients due to electrical shorts.

.

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. September 26, 2011, varying times throughout the afternoon, and September 27, 2011, varying times throughout the morning: The conditions listed below were observed at a centrally located shaft within the Kurtzon Building (example location: at the Ninth Floor immediately southeast of the intersection between the East-West Corridor and the South Corridor). The shaft connects at least the Eleventh through Fourth Floors. These deficiencies could affect any occupants of the Kurtzon Building because fire and smoke could pass between building stories. Conditions observed include:

1. No evidence of fire dampers, required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.4. was found on any building story in which ductwork was observed in the shaft.
2. No access panels for any fire dampers, required by NFPA 90A 1999 2-3.4.1., were found on any building story in which ductwork was observed in the shaft.
3. The shaft, which connects at least 8 building stories, was observed to not carry a minimum 2 hour fire rating as required by NFPA 90A 1999 3-3.4.1., because multiple unsealed penetrations and openings (see 8.2.2. and 8.2.3.2.4.2.) were observed in the shaft on all building stories observed.

.

Based on random observation during the survey walk-through, not all portions of the facility's heating and air conditioning system are in accordance with NFPA 90A 1999.

Findings include:

A. During the survey of the sixth floor equipment room AHU #1 was observed to have heavily soiled and loose fitting pre-filters allowing air bypass. Staff interview at the site reveled the filters had not been changed in six months.

.

Based on random observation during the walk-through and staff interview in the afternoon of September 26, 2011, not all portions of the facility's heating, air conditioning and ventilation system are installed in accordance with NFPA 90A 1999.

Findings include:

A. During the afternoon walk-through the seventh floor equipment room numerous supply ducts were observed to conditioned fresh air to the perimeter units on second through sixth floors without dampers where they penetrated the 2 hour floor in accordance with 3-3.2.

B. During the walk-through of the sixth floor mother/baby unit a painted duct was observed supplying fresh air to the perimeter ventilation unit without an enclosure in accordance with 3-3.4.1.
During an interview held in room 620 on the afternoon of September 26, 2011 with the Vice President of Facilities it was confirmed room 620 was typical installation of ductwork to perimeter units on second through sixth floors of the building.

C. During the survey of the seventh floor equipment room AGS1 and AGS2 were observed to have heavily soiled and loose fitting pre-filters allowing air bypass. Staff interview at the site revieled the filters had not been changed in six months.

The 3 deficiencies above could result in patient and staff injury due to a lack of building fire separation and clean air.

.

Based on random observation during the survey walk-through on September 28, 2011, at 9:00 am, not all portions of the facility's commercial cooking system are installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. The two class "K" fire extinguishers in the main food preparation area was not provided with a placard to identify their use only after the automatic extinguisher had discharged in accordance with 7-2.1.1.

B. The main food preparation area exhaust hood suppression system was observed without protective caps on the discharge nozzles in accordance with NFPA 17A 1998 2-3.1.4.

Deficiency A could result in staff injury and prolonged burning of the fire.

Deficiency B could result in staff injury due to a plugged nozzle not discharging.

.

Based on random observation during the survey walk-through and staff interview, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. 2:25 PM September 27, 2011: A gurney was observed, in the Second Floor Surgical Department East-West Corridor, that obstructs egress as prohibited by 19.2.3.3. and 7.1.10.2.1. During an interview held at that time, the provider's Surgical Nurse manager stated that gurneys are typically placed in that Corridor while patients undergo procedures. This deficiency could affect all occupants within the Surgical Department because their ability to reach an exit from the building story could be compromised under emergency conditions.

.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. 1:42 PM September 26, 2011: Carts and equipment were observed in the Corridor within the Sixth Floor MICU/CCU that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. This deficiency could affect all occupants within the MICU/CCU because their ability to reach an exit from the building story could be compromised under emergency conditions.

.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. 9:29 AM September 27, 2011: Medical gas tanks were observed being stored, in Third Floor Room K313A, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the Third Floor of the Kurtzon Building because the medical gas tanks could contribute to any combustion which might occur within the stored materials.

.

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, not all medical gas systems comply with with NFPA 99, 1999, Chapter 4. These deficiencies could affect all persons in the facility required to utilize the systems by preventing the safe and proper abandonment of the portions of the systems no longer in use.

Findings include:

A. The 11th floor Lab areas (at the east end of the floor) were abandoned in-place. The medical gas systems consisted of natural gas, air, and vacuum. The gas and air were not functional at the outlets. The vacuum system was still operational. It was unknown where the system shut-off valves were located for any of the systems. It was not known how much of the system(s) was active and how much was inactive throughout the building.

.

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed and maintained in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the facility grounds the Emergency Oxygen fill location was observed to be without a sign identifying it as the "Emergency Low Pressure Gaseous Oxygen Inlet" in accordance with 4-3.1.1.8 (h).

B. The medical air 1 and 2 receiver was observed without a source valve at the receiver in accordance with 4-3.1.2.3 (a).

C. The medical air 1 and 2 receiver was observed without an automatic drain in accordance with 4-3.1.1.9 (f).

These deficiencies could result in patient injury due to system failure.

.

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the basement level electrical switchgear room OS39 had 3 copper lines crossing the ceiling identified as medical gas lines. During an interview held with the Operation Manager at the location it was revieled they might be abandoned but it was not confirmed at the time of the survey.

This deficiency could injury patients or staff due to increased fire hazard.

.

Based on random observation during the survey walk-through, not all plumbing is installed and maintained in accordance with State and National Sanitation Standards. This deficiency can effect all persons exposed to the improper accummulation of and disposal of waste water.

Findings include:

A. The drain path for the Janitor sink located in the Basement L-28 Janitor closet was through an open cleanout located in the adjacent room. Waste water was being discharged through the open cleanout rather than draining down the pipe into the underfloor piping. Waste was allowed to traverse across the floor to reach a floor drain. The condition did not provide for proper sealing and venting of the piping system.

.



14290


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:

B. 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, 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 building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. Emergency loads were not separated into life safety, critical and equipment branches which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. Emergency panels throughout the building were serving both life safety and critical loads which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. The critical rather than life safety panels on each floor were serving med gas alarms, exit signs, and emergency lighting which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. The critical rather than life safety panels on each floor were serving med gas alarms, exit signs, and emergency lighting which does not meet the requirements of NFPA-70, Section 517-31 thru 35. Examples include panel 5CR1 and 4CR2 which were serving med gas alarms and corridor emergency lighting.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through on the morning of September 26 and on September 27, 2011, not all portions of the facility's electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. The panel cover on panel LBEM2 (LBSB2 old) located in the Basement Electrical Vault #1 was observed to be removed. Although work had been indicated to be taking place, no work was being performed at the time of observation.

B. An electrical box cover at the 5th floor west Janitor closet was observed to not be installed.

.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in C-section rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, the operating rooms could be left with no power.

.

Based on random observation during the survey walk-through on September 27, 2011, not all elevator equipment spaces are maintained in accordance with 19.5.3, 9.4.3.2 and ASME/ANSI A17.3. These deficiencies could affect all patients expected to utilize the elevators, as well as any staff and visitors present, by exposing the elevator equipment to conditions not permitted by the Code(s).

Findings include:

A. The 7th floor elevator machine room was also utilized as an office space and storage area in non-compliance with ASME/ANSI A17.3, 2.2.1.

.