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Based on observation, the facility failed to ensure all corridor doors latched properly in accordance with NFPA 101, 2000 Edition, Section 19.3.6.3.2¹. The deficiency could affect the occupants in one of thirteen smoke compartments.

Findings include:

The first floor Medical Records office was observed at 2:12 p.m. on 10/6/14. The exit corridor door stayed open when released from the magnetic hold device due to the air differential. The corridor door failed to latch.

¹NFPA 101 Life Safety Code, 2000 Edition, Section 19.3.6.3.2, Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

Based on observations, the facility failed to ensure all exit signs were maintained in accordance with NFPA 101, 2000 Edition, Section 7.10.5.2.¹ The deficiency had the potential to affect the patients and the staff one of thirteen smoke compartments.

Findings include:

The first floor Operating Room (OR) was observed at 11:15 a.m. on 10/7/14. The exit sign just outside OR6 had only one operational light bulb. The exit sign just outside OR1 had none of its light bulbs in good operating condition.

¹NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.5.2 Continuous Illumination.
Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception*: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

Based on observation, the facility failed to prevent use of enclosed exit stairways for storage purposes per NFPA 101, 2000 Edition, Sections 7.1.3.2.3¹ and 7.2.2.5.3². This deficiency had potential to affect all staff accessing the penthouse.

Findings include:

The Medical Office Building 4 (MOB4) penthouse stairway was observed at 9:20 a.m. on 10/7/14. The window washing supplies were stored on the top floor landing just outside the penthouse entrance in the stairway enclosure.

¹NFPA 101 Life Safety Code, 2000 Edition, Section 7.1.3.2.3, An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)

²NFPA 101, 2000 Edition, Section 7.2.2.5.3 Usable Space, There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.) Annex A.7.2.2.5.3 An example of a use with the potential to interfere with egress is storage.

Based on observation, the facility failed to ensure the automatic sprinkler system was maintained per NFPA 13, 1999 Edition, Section 5-1.1 and NFPA 25, 1998 Edition, 2-2.7. This deficiency could affect 11 of 25 smoke compartments.

Findings include:

1. The main dining room was observed at 12:55 p.m. on 10/6/14; the escutcheon ring for one of the automatic sprinkler heads was loose creating an annular space between the sprinkler head and the ceiling tile.¹

2. The education hall closets were observed at 12:57 p.m. on 10/6/14. The escutcheon ring was missing from the sprinkler head in the first closet and lose dangling below the ceiling surface in the second closet.¹

3. The physician's dining room was observed at 1:54 p.m. on 10/6/14. The escutcheon ring was missing from a sprinkler head.¹

4. The Materials was observed at 2:05 p.m. on 10/6/14. The escutcheon ring was missing from the sprinkler head on the east side of the room.¹

5. The walk-in cooler and the freezer were observed at 2:27 p.m. on 10/6/14 in the kitchen. The lone sprinkler head in the walk-in cooler lacked an escutcheon ring. The lone sprinkler head in the freezer had an escutcheon ring below the ceiling surface.¹

6. The main steam/boiler room was observed at 2:43 p.m. on 10/6/14. Four of the six hydraulic calculation plates for the automatic sprinkler risers were not completely legible.²

7. The ICU dictation room was observed at 3:19 p.m. on 10/6/14. The escutcheon ring was missing from the sprinkler head.¹

8. The MRI control room was observed at 4:13 p.m. on 10/6/14. Two of the fire rated ceiling tiles had missing corners.¹

9. The MRI equipment room was observed at 4:15 p.m. on 10/6/14. Several of the ceiling tiles were missing and some were off the tracks.¹

10. The Radiology was observed at 10:17 a.m. on 10/7/14. The ceiling tile in CT2 had a round penetration measuring approximately 1.5 inch in diameter.¹

11. The dirty room in OR was observed at 11:15 a.m. on 10/7/14. The escutcheon ring was missing from the sprinkler head.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1, The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

² NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Section 2-2.7 Hydraulic Nameplate, The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

Based on observation and interview, the facility failed to maintain exit access free of all obstructions or impediments to full instant use in case of fire or other emergency in accordance with NFPA 101, 2000 Edition, Section 7.1.10.¹ The deficiency affected staff in 1 of 25 smoke compartments.

Findings include:

The Engineering hall was observed on 10/6/14 and on 10/7/14. At 8:22 a.m. on 10/7/14 the same patient bed was still parked in the exit corridor.

An interview was conducted with staff member B, engineering manager, on 10/6/14 and on 10/7/14. He stated the bed was being repaired; however, the service contractor must have failed to remove the bed from the corridor.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.1.10, Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition, Articles 110-22, 110-26, and 110-27. These deficiencies could affect 6 of 25 smoke compartments.

Findings include:

1. The Administration was observed at 12:46 p.m. on 10/6/14; the electrical panel marked LIC was blocked by a bookcase and several 3-ring binders stored on the floor in the accounts payable clerk's cubicle.¹

2. The electrical panel ELL1 was observed in the boiler room alcove on the main floor across from the Facility Services. Three breaker covers were missing.²

3. The Laboratory services were observed at the first level of MOB4 building. Four electrical panels were blocked by storage bins and a large trash can.¹

4. The first electrical room on second floor hospital main corridor was observed at 10:08 a.m. on 10/7/14. Several of the circuit breakers were not identified on the panel marked at L2B's directory.³

5. The second electrical room on the second floor of the hospital main corridor was observed at 10:12 a.m. on 10/7/14. The breaker circuit #30 was in on position, however, the panel directory was blank.³

6. The Endoscopy electrical room was observed at 10:41 a.m. on 10/7/14. The circuit breakers 10 through 42 housed in panel ECH2A were in off positions and not marked as spares on the panel directory. The panel directory was blank corresponding to these circuit breakers.³

¹ NFPA 70 National Electric Code, 1999 Edition, Article 110-26, 110-26. Spaces About Electrical Equipment, Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Exception No. 1: Working space shall not be required in back or sides of assemblies, such as dead-front switchboards or motor control centers, where there are no renewable or adjustable parts, such as fuses or switches, on the back or sides and where all connections are accessible from locations other than the back or sides. Where rear access is required to work on de-energized parts on the back of enclosed equipment, a minimum working space of 30 in. (762 mm) horizontally shall be provided.
Exception No. 2: By special permission, smaller spaces shall be permitted where all uninsulated parts are at a voltage no greater than 30 volts rms, 42 volts peak, or 60 volts dc.
Exception No. 3: In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.
Table 110-26(a). Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 31/2 4

Notes:
1. For SI units, 1 ft = 0.3048 m.
2. Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
(c) Access and Entrance to Working Space. At least one entrance of sufficient area shall be provided to give access to the working space about electric equipment.
For equipment rated 1200 amperes or more and over 6 ft (1.83 m) wide that contains overcurrent devices, switching devices, or control devices, there shall be one entrance not less than 24 in. (610 mm) wide and 6½ ft (1.98 m) high at each end of the working space.
Exception No. 1: Where the location permits a continuous and unobstructed way of exit travel, one means of access shall be permitted.
Exception No. 2: Where the work space required by Section 110-26(a) is doubled, only one entrance to the working space is required. It shall be located so the edge of the entrance nearest the equipment is the minimum clear distance given in Table 110-26(a) away from such equipment.
(d) Illumination. Illumination shall be provided for all working spaces about service equipment, switchboards, panelboards, or motor control centers installed indoors. Additional lighting fixtures shall not be required where the work space is illuminated by an adjacent light source. In electrical equipment rooms, the illumination shall not be controlled by automatic means only.
(e) Headroom. The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 6½ ft (1.98 m). Where the electrical equipment exceeds 6½ ft (1.98 m) in height, the minimum headroom shall not be less than the height of the equipment.
Exception: Service equipment or panelboards, in existing dwelling units, that do not exceed 200 amperes.
(f) Dedicated Equipment Space. Equipment within the scope of Article 384, and motor control centers, shall be located in dedicated spaces and protected from damage as covered in (1) and (2).
Exception: Control equipment that by its very nature or because of other rules of the Code must be adjacent to or within sight of its operating machinery shall be permitted in those locations.
(1) Indoor. For indoor installations, the dedicated space shall comply with the following.
a. Dedicated Electrical Space. The space equal to the width and depth of the equipment and extending from the floor to a height of 6 ft (1.83 m) above the equipment or to the structural ceiling, whichever is lower, shall be dedicated to the electrical installation. No piping, ducts, or equipment foreign to the electrical installation shall be located in this zone.
Exception: Equipment that is isolated from the foreign equipment by height or physical enclosures or covers that will afford adequate mechanical protection from vehicular traffic or accidental contact by unauthorized personnel or that complies with b., shall be permitted in areas that do not have the dedicated space described in this rule.
b. Foreign Systems. The space equal to the width and depth of the equipment shall be kept clear of foreign systems unless protection is provided to avoid damage from condensation, leaks, or breaks in such foreign systems. This zone shall extend from the top of the electrical equipment to the structural ceiling.
c. Sprinkler Protection. Sprinkler protection shall be permitted for the dedicated space where the piping complies with this section.
d. Suspended Ceilings. A dropped, suspended, or similar ceiling that does not add strength to the building structure shall not be considered a structural ceiling.
(2) Outdoor. Outdoor electrical equipment shall be installed in suitable enclosures and shall be protected from accidental contact by unauthorized personnel, or by vehicular traffic, or by accidental spillage or leakage from piping systems. The working clearance space shall include the zone described in Section 110-26(a). No architectural appurtenance or other equipment shall be located in this zone.

² NFPA 70, 1999 Edition, Article 110-27, (a) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electric equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means.
1. By location in a room, vault, or similar enclosure that is accessible only to qualified persons.
2. By suitable permanent, substantial partitions or screens arranged so that only qualified persons will have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them.
3. By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons.
4. By elevation of 8 ft (2.44 m) or more above the floor or other working surface.
(b) Prevent Physical Damage. In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.
(c) Warning Signs. Entrances to rooms and other guarded locations that contain exposed live parts shall be marked with conspicuous warning signs forbidding unqualified persons to enter.

³ NFPA 70, 1999 Edition, Article 110-22, Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.