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Based on observation, not all means of egress components enable exiting. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from one location into the exit access corridor during a fire emergency.

The finding is:

On 11/19/2020 at 9:45 am while accompanied by the LSC, corridor egress doors were observed having a separate manual hold open (foot peg) which was engaged. This condition does not comply with 7.2.1.5.10.2.

Example locations observed:

1. CT Room
2. Men's Locker room
3. Former Office (now used for Storage) adjacent to Registration area

Egress doors are observed to be locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

The finding is:

A. While in the company of the LSC, the building was determined to be only partially sprinkler protected thereby not meeting the requirements of 7.2.1.6.1.1(1) the building is to be "protected throughout by an approved, supervised automatic fire detection system or an approved supervised automatic sprinkler system". It was observed at numerous locations that Delayed egress locking systems had been installed. This condition does not comply with 19.2.2.2.4 and 7.2.1.6.1.

Example locations include the following:

1. On 11/17/2020 at 2:45 pm second floor West LDR overflow contains cross corridor doors and exit stair doors with delayed egress.

2. On 11/18/2020 at 9:30 am Door D-1-46 contains a 15 second delay.

3. On 11/17/2020 at 1:15 pm third floor West exit stair #8


Based on observation, not all means of egress components enable exiting. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from one location into the exit access corridor during a fire emergency.

The finding is:

B. On 11/18/2020 at 11:45 am while accompanied by the LSC, corridor egress doors were observed having a separate deadbolt, thumb turn and a manual throw. This condition does not comply with 7.2.1.5.10.2, 19.3.6.5 and 19.3.6.3.10
Example location observed:

1. First floor all O.R. doors

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

Findings include:

A. While accompanied by the LSC exit stairs were observed with guardrails at landings that do not comply with 19.2.2 and 7.2.2.4.5.3 for intermediate railing spacing.

Example locations observed:

1. On 11/17/2020 at 1:10 am Stair # 00
2. On 11/17/2020 at 1:15 am Stair #2
3. On 11/17/2020 at 2:20 am Stair # 11
4. On 11/18/2020 at 9:45am Stair #7

B. On 11/17/2020 at 2:20 pm while in the company of the LSC a switchback exit stair contains the open side of stair runs greater than 11 inches apart which does not comply with 7.2.2.4.5.3(1). Location observed: 5th floor Exit Stair # 21.

C. On 11/18/2020 at 9:20am while accompanied by the LSC an exit stair was observed containing stored equipment. Location observed Stair #5 from the Emergency Department.

Based on observation, the facility failed to provide exit paths that are maintained as a continuously protected path to a public way. This deficient practice could affect staff and patients during egress due to a fire emergency evacuation from the building.

Findings include:

A. On 11/18/2020 at 10:30am while in the company of the LSC an exterior means of egress was observed in which the path is nonreliable. Location observed: Exit Stair 9 exterior stair landing is obstructed and filled with leaves. This condition does not comply with 19.2.7 and 7..1.6.2 and 7.1.6.3.

B. On 11/18/2020 at 10:26 am accompanied by the LSC, Exit Stair 9 discharge door and exit stair #10 discharge door were both difficult to operate and did not open easily to comply with 7.2.1.4.5.

C. On 11/18/2020 while accompanied by the LSC, exit paths to the discharge are blocked by signage reading "This entrance temporarily CLOSED. Please use Emergency Dept entrance". The sign reads as if it should be placed outside, however, it is in front of an exit discharge which does not comply 7.1.10. Locations observed:

1. At 9:35 am Pair of exterior discharge doors at end of first floor corridor (signage in front of door reads EP/Cardiac Cath Lab and Cardiac Testing Rooms 1-3).
2. At 9:40 am First floor Horizontal sliding door #21

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the lighting provided. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

The finding is:

On 11/18/2020 accompanied by the LSC, numerous exit discharge lights were observed which the facility could not confirm to be of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Not all exit discharge locations were provided with multiple fixtures (or confirmed to be fixtures with multiple lamps) to comply with 7.8.1.4.
Example locations observed:

1. At 2:10pm Exterior discharge Stair # 5

2. At 2:17pm Exterior discharge Stair # 11

3. At 2:40pm Exterior discharg Stair # 10

Based on observation, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The finding is:

On 11/18/2020 at 9:50 am while accompanied by the LSC it was determined that battery-powered emergency lights are not provided in all critical care areas to comply with NFPA 99-2012, 6.3.2.2.11.4 and NFPA 70-2011, 517-63A.
Example location observed: Cath Lab

Based on observation, not all portions of the building's Life Safety System is installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The finding is:

On 11/19/2020 at 9:50 am while accompanied by the LSC it was determined that battery-powered emergency lights are not functional to comply with NFPA 70-2011, and 7.9.2.3.
Example location observed: Men's and Women's Toilet rooms.

Based an observations, not all exit doors are installed or maintained to permit egress and provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency.

The finding is:

On 11/18/2020 while accompanied by the LSC it was determined that not all exit components are provided with elements that maintain the fire resistant rating of the enclosure. Exit stair door hardware components did not provide a self closing assembly. This does not comply with the requirements of NFPA 101, 19.3.1. 19.3.6.3.11

Example locations observed:

1. At 9:30 am Exit Stair #4 first floor door D-1-70 did not latch.

2. At 9:10 am Exit Stair #10 door second floor D-1-209 did not latch.

Based on observation hazardous rooms were not maintained as fire rated and smoke proof enclosures. This condition may affect all patients, staff and visitors during an emergency egress condition.

The finding is:

On 11/19/2020 at 9:48 am while accompanied by the LSC egress door from the file room lacks a self closing mechanism due to the removal of the door closer's arm. This condition does not comply with NFPA 80 2010.

On 11/19/2020 at9:40 m while accompanied by the LSC an office is being used as a storage room. The office lacks a self closing fire rated door and fire rated enclosure to comply with 39.3.2.1 and 8.7.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy or from a means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

Finding is:

A. On 11/18/2020 at 11:01am while in the company of the LSC a hazardous area was observed which does not comply with 19.3.2.1 for a minimum 1-hour fire resistant rating. Location observed: Second floor, Sterile Core between each unsprinklered O.R. This space exceeds 100 square feet and contains numerous combustibles. The walls are not rated due to the numerous metal/glass pass throughs to each O.R., therefore, each O.R. constitutes an unsprinklered patient care area open to a hazardous area. This condition does not comply with 19.3.2.3 due to the following:

1. Non self closing pass through doors, 19.3.2.1.3
2. Non fire rated hazardous enclosure, 19.3.2.1.5(7).

B. While accompanied by the LSC hazardous rooms were not maintained as fire rated and smoke proof enclosures to comply with 19.3.2. Locations observed include:

1. On 11/18/2020 at 1:25pm Corridor doors to both the Linen and Trash chute collection rooms are not self closing and do not maintain the latched position to comply with 19.3.2.1.3.


2. On 11/18/2020 at 2:30 pm pair of corridor entry doors to the kitchen (deemed hazardous due to the amount of combustibles and the lack of separation from dry goods storage) do not self close to the latching position, door D-0-815 (19.3.2.1.3).

3. Doors to Storage rooms contain a manual hold open device 19.3.2.1.3 NFPA 80 2010 6.1.4.2.2. Example locations include:
i. 11/18/2020 at 1:15 pm Basement EVS supply room D-0-544
ii. 11/18/2020 at 2:25 pm Basement D450 084, doors to Dialysis storage
iii. 11/18/2020 at 1:20 pm Basement D-0-560
iv. 11/18/2020 at 11:45 am First floor Soiled Holding in PACU
v. On 11/18/2020 at 1:30pm, Both pairs of linen and trash room corridor doors contain manual flush bolts which do not maintain the doors in the closed position.

Based on observation the facility failed to correctly install and inspect kitchen ventilation equipment. This deficient practice could result in the uncontrolled spread of fire and products of combustion during kitchen cooking operations, which may affect patients, staff and visitors.

The finding is:

A. On 11/18/20 at 2:15pm accompanied by the LSC, in the ground level kitchen, it was observed that the grease hood filter segments were separated allowing grease laden vapor to bypass the filters. (NFPA 101,2012, 19.3.2.5 / NFPA 96, 2011, 6.2.3.3)


Based on observation the facility failed to construct and maintain a compliant grease duct system. This deficient practice could result in the uncontrolled spread of fire and products of combustion during a kitchen hood and duct fire event, which may affect patients, staff and visitors.

The findings are:

B. On 11/18/20 at 2:25pm accompanied by the LSC in the ground level mechanical room containing the kitchen hood's exhaust fan, connections between the kitchen grease ducts and the exhaust fans were observed to be made using flexible canvas connectors which does not comply with NFPA 96, 2011, 8.1.3.4 & 8.1.3.5.

C. On 11/18/20 at 2:25pm accompanied by the LSC in the ground level mechanical room containing the kitchen hoods exhaust fan a non-compliant connection of a round stainless steel duct was observed apparently serving an abandoned capture hood located in the kitchen.
1. This duct penetrates the 2-hour fire rated enclosure without a fire stop appliance.
2. The duct attachment is made to the fan plenum at a screw attached galvanized panel not of welded steel construction. (NFPA 96, 2011, 10.2.7.1)

D. On 11/18/20 at 2:25pm accompanied by the LSC in the ground level mechanical room containing the kitchen hoods exhaust fan the installation of a non-compliant access panel was observed for interior fan cleaning and inspection. This access panel does not match the construction of the fan casing. (NFPA 96, 2011, 7.4.3)


Based on observation the facility failed to regularly inspect fire extinguishing devises. This deficient practice could affect patients, staff and visitors.

The finding is:

E. On 11/18/20 at 2:10pm accompanied by the LSC, in the ground level kitchen, it was observed that the wet chemical grease hood fire suppression system was not inspected on a monthly basis, (NFPA 17A 2009, 7.2)

Based on observation the facility failed to provide protection for the fire alarm components. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 11/18/20pm at 2:30 pm accompanied by the LSC, at electrical panel LP EM 2, it was observed that the circuit breakers for the fire alarm panel were not mechanically protected. (NFPA 72, 2010, 10.5.5.3)

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

The finding is:

On 11/18/2020 while in the company of the LSC, it was observed that Waiting Area for the Fast Track emergency department is open to the corridor and lacks a supervisory station which is able to observe all locations or smoke detection devices to comply with 19.3.6.1(2). The only 24 hour supervisory station is the main entry reception which does not contain a full view of the waiting area.

Based on observation the facility failed to install required elevator controls electrical disconnects. Failure to install a single means to disconnect as required, could leave the elevator car without power for the services required. This deficient practice could affect patients, staff and visitors.

The finding is:

On 9/17/20 at 1:15 pm accompanied by the LSC, it was observed that a lockable disconnecting means is not provided in the machine room for the car lights, receptacles and ventilation for Elevators #5, #6 and #9. (NFPA 101, 2012, 19.5.3 / NFPA 70, 2011, 620.53)

Based on observation during the survey walk through the facility failed to identify and correctly install components of the Category 1 medical gas systems. This deficient practice could affect patients during treatment while using these systems.

The findings are:

A. On 11/18/20pm at 1:45pm accompanied by the LSC, in the ground level medical records file room, identified on the life safety drawings as a mechanical room, it was observed the installed medical gas pipe system was not separated from dissimilar metals. (NFPA 99, 2012, 5.1.10.11.4

B. On 11/18/20pm at 2:30pm accompanied by the LSC, in the ground level medical records file room, it was observed the installed medical gas pipe system was not labeled once in every room and every 20 feet. (NFPA 99, 2012, 5.1.11.1.2

Based on observation, the facility failed to install and maintain its piped-in medical gas system in the manner required. This deficient practice could affect patients, staff, and visitors in the building because the medical gas piping system could fail to operate when needed if not properly installed and maintained.

The findings are:

A. On 11/18/2020 while accompanied by the LSC, observation determined that medical gas station outlets are located in which there is not a complete wall between the outlets and the shut off valve suppling them. This condition does not comply with NFPA 99 2012, 5.1.4.8(3). Locations observed:

1. At 9:45am Emergency Department exam bays 10 and 11.

2. At 10:19 am Endoscopy Prep/Recovery bays

B. On 11/18/2020 at 10:20 am while in the company of the LSC observation determined that med gas shut off valves are not labeled to coordinate with the outlets served. This condition does not comply with NFPA 99, 2012. Location observed: first floor Endo suite. Questioning staff, they did not know which "rooms" listed on the valves referenced the recovery bays.

C. On 11/18/2020 at 11:00 am while in the company of the LSC observation determined that the medical gas shut off for the Special Procedures Room reads for a Cardiac Cath Lab. Location observed: First floor corridor to Nuclear Medicine.

Based on observation, the facility failed to install a compliant emergency electrical system. Failure to install and maintain these systems could result in delayed response. This deficient practice could affect patients, staff and visitors during a utility power outage.

The finding are:

A. On 11/18/20pm at 1:20pm accompanied by the LSC, it was observed the Kohler Emergency Generator did not have an installed starting battery warmer. (NFPA 110, 2010, 5.3.1)

B. On 11/18/20pm at 1:25pm accompanied by the LSC, it was observed the emergency stop station for the interior installed Caterpillar Generator was installed as required (NFPA 99, 2012, 5.6.5.6) in an adjoining room, however the door to that room could not be opened.


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Based upon observation, electrical systems are not maintained in conformance with Code requirements. Failure to maintain the electrical system can lead to confusion when selected components require shut-down for maintenance and power circuits cannot be accurately identified.

The findings are:

C. On 11/18/2020 while in the company of the LSC, critical care patient rooms/areas contain electrical outlets serving patient care locations which did not identify the electrical panel which served them. This condition was observed within all critical care patient areas as follows:

1. It is not indicated which outlets are under normal power and which are under the critical branch of the emergency power system.

2. It is not known which isolation panel serves which isolation outlet.

These conditions do not comply with NFPA 70-2011, 408.4. Example locations observed: PACU, Operating Rooms, C-Section and Cath Labs.

D. On 11/18/2020 at 11:20 while in the company of the LSC, critical care patient rooms did not contain electrical outlets served by normal power to comply with NFPA 70 2011 517-19(A). Location observed Cath Labs.