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Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 18.2.1 and Chapter 7. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On the morning of 3/4/14, it was observed that magnetic locks were employed at the 2nd floor Endoscopy area which prevented egress through routes marked with exit signage. The second required exit route from the main elevator core area is directed through the Endoscopy area corridors. Two entries into the procedure room corridor from the prep/recovery area corridor have delayed egress locks; one is marked with exit signage to enter the procedure room corridor from the prep/recovery room corridor and the other is marked with exit signage from the procedure room corridor to the prep/recovery corridor. The doors between the procedure room corridor and the Scope Cleaning area corridor have magnetic locks equipped with access-controlled egress door hardware which allows free movement toward the available exit stair beyond. However, the reverse direction of exiting from the Scope Cleaning room area through the Endoscopy procedure room corridor and then through the prep/recovery room corridor which is marked with exit signage has locked doors without delayed egress or access controlled egress door hardware to comply with 7.1.10, 7.2.1.5, 7.2.1.6.

1. The Scope Cleaning room area corridor is provided with exit signage which directs one exit access to lockable doors which prevent entry into the Endoscopy procedure room area corridor. The Scope Cleaning room corridor was also observed to contain multiple supply carts, a C-arm, and monitor carts in non-compliance with 7.1.10.

2. The Endoscopy procedure room area corridor is provided with exit signage which directs exiting to doors with delayed egress locks on the opposite side of the doors but does not allow egress from the Endoscopy procedure room area corridor side because functional access-controlled egress hardware was not provided on the procedure room area corridor side of the door.

3. The corridor providing access to the exit stair outside the Scope Cleaning area was observed not to be provided with access to two exits to comply with 18.2.5.9.

B. On the morning of 3/4/14, the 1st floor Stair #6 exit door (near the ER ambulance entrance) was observed to have a magnetic lock activated by a 'wander guard' system. The door is not locked unless the 'wander guard' activator is present. The system incorporates a delayed egress function when activated by the 'wander guard' system but lacks signage in accordance with 7.2.1.6.1(d) to identify the exit procedures when the door is locked.

Based on record review and staff interview it was determined that the facility did not conduct fire drills at least quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required.

Findings include:

A. No drill documentation was available for review for the 2013 2nd quarter, first shift. The Director of Building Services acknowledged that this drill period had been missed due to schedule conflicts.

Based on an observation and an interview, the facility failed to have all sprinklers installed to meet the requirements of NFPA 101, 2000 Edition, Section 18.3.5; NFPA 13, 1999 Edition. This deficient practice would affect an indeterminable number of staff and visitors in the emergency waiting room, if the sprinklers provided failed to provide complete coverage in the event of a fire.

Findings include: On 3/4/14 at 11:05 AM, while accompanied by the Director of Construction, an observation and an interview determined that the emergency waiting room area contained three areas with 14 " -16 " deep, recessed ceilings containing cove lighting and various lengths of fabric suspended from the recessed ceiling tiles.

1. Main waiting room recess was approximately 9 ' x 16 ' oval containing a recessed ceiling and cove lighting. The recess contained five rows of green fabric circling the perimeter which surround a sprinkler and a smoke detector located on the recessed ceiling. The location of the sprinkler on the recessed ceiling is not centered within the oval and one head may not provide protection of the entire fabric enclosed space (NFPA 13, 5-5.5.1).

2. Children ' s area recess was approximately 5 ' x 8 ' oval containing a recessed ceiling and cove lighting. The recess contained five rows of gray fabric circling the perimeter which surrounding a smoke detector located on the recessed ceiling. The current recessed area does not meet with NFPA 13 (1999), 5-6.4.1.1 for unobstructed construction (due to fabric) where the distance between the sprinkler deflector and the lower ceiling was greater than the maximum of 12 inches.

3. Corridor intersection recess was approximately 5 ' x 8 ' oval containing a recessed ceiling and cove lighting. The recess contained five rows of red fabric circling the perimeter, no sprinkler or smoke detection was provided in the recessed area. The current recessed area does not meet with NFPA 13 (1999), 5-6.4.1.1 for unobstructed construction (due to fabric) where the distance between the sprinkler deflector and the lower ceiling was greater than the maximum of 12 inches.

4. No information was provided on the fabric as to the flammability or its fire retardant properties to confirm compliance with NFPA 101-2000, 18.7.5.1 and 10.3.1.

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

Findings include:

A. On the morning of 3/4/14, the conduit and junction box for the thermostat located in the Electrical closet adjacent the 2nd floor Surgery Soiled Cart Storage room was observed not to be securely mounted in accordance with NFPA 70 standards. The box and conduit appeared to have been temporarily relocated and zip-tied to overhead supports.

B. On the morning of 3/4/14, an open, unused junction box was observed at the 3rd floor Triage room 3417.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 18.2.1 and Chapter 7. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On the morning of 3/4/14, it was observed that magnetic locks were employed at the 2nd floor Endoscopy area which prevented egress through routes marked with exit signage. The second required exit route from the main elevator core area is directed through the Endoscopy area corridors. Two entries into the procedure room corridor from the prep/recovery area corridor have delayed egress locks; one is marked with exit signage to enter the procedure room corridor from the prep/recovery room corridor and the other is marked with exit signage from the procedure room corridor to the prep/recovery corridor. The doors between the procedure room corridor and the Scope Cleaning area corridor have magnetic locks equipped with access-controlled egress door hardware which allows free movement toward the available exit stair beyond. However, the reverse direction of exiting from the Scope Cleaning room area through the Endoscopy procedure room corridor and then through the prep/recovery room corridor which is marked with exit signage has locked doors without delayed egress or access controlled egress door hardware to comply with 7.1.10, 7.2.1.5, 7.2.1.6.

1. The Scope Cleaning room area corridor is provided with exit signage which directs one exit access to lockable doors which prevent entry into the Endoscopy procedure room area corridor. The Scope Cleaning room corridor was also observed to contain multiple supply carts, a C-arm, and monitor carts in non-compliance with 7.1.10.

2. The Endoscopy procedure room area corridor is provided with exit signage which directs exiting to doors with delayed egress locks on the opposite side of the doors but does not allow egress from the Endoscopy procedure room area corridor side because functional access-controlled egress hardware was not provided on the procedure room area corridor side of the door.

3. The corridor providing access to the exit stair outside the Scope Cleaning area was observed not to be provided with access to two exits to comply with 18.2.5.9.

B. On the morning of 3/4/14, the 1st floor Stair #6 exit door (near the ER ambulance entrance) was observed to have a magnetic lock activated by a 'wander guard' system. The door is not locked unless the 'wander guard' activator is present. The system incorporates a delayed egress function when activated by the 'wander guard' system but lacks signage in accordance with 7.2.1.6.1(d) to identify the exit procedures when the door is locked.

Based on record review and staff interview it was determined that the facility did not conduct fire drills at least quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required.

Findings include:

A. No drill documentation was available for review for the 2013 2nd quarter, first shift. The Director of Building Services acknowledged that this drill period had been missed due to schedule conflicts.

Based on an observation and an interview, the facility failed to have all sprinklers installed to meet the requirements of NFPA 101, 2000 Edition, Section 18.3.5; NFPA 13, 1999 Edition. This deficient practice would affect an indeterminable number of staff and visitors in the emergency waiting room, if the sprinklers provided failed to provide complete coverage in the event of a fire.

Findings include: On 3/4/14 at 11:05 AM, while accompanied by the Director of Construction, an observation and an interview determined that the emergency waiting room area contained three areas with 14 " -16 " deep, recessed ceilings containing cove lighting and various lengths of fabric suspended from the recessed ceiling tiles.

1. Main waiting room recess was approximately 9 ' x 16 ' oval containing a recessed ceiling and cove lighting. The recess contained five rows of green fabric circling the perimeter which surround a sprinkler and a smoke detector located on the recessed ceiling. The location of the sprinkler on the recessed ceiling is not centered within the oval and one head may not provide protection of the entire fabric enclosed space (NFPA 13, 5-5.5.1).

2. Children ' s area recess was approximately 5 ' x 8 ' oval containing a recessed ceiling and cove lighting. The recess contained five rows of gray fabric circling the perimeter which surrounding a smoke detector located on the recessed ceiling. The current recessed area does not meet with NFPA 13 (1999), 5-6.4.1.1 for unobstructed construction (due to fabric) where the distance between the sprinkler deflector and the lower ceiling was greater than the maximum of 12 inches.

3. Corridor intersection recess was approximately 5 ' x 8 ' oval containing a recessed ceiling and cove lighting. The recess contained five rows of red fabric circling the perimeter, no sprinkler or smoke detection was provided in the recessed area. The current recessed area does not meet with NFPA 13 (1999), 5-6.4.1.1 for unobstructed construction (due to fabric) where the distance between the sprinkler deflector and the lower ceiling was greater than the maximum of 12 inches.

4. No information was provided on the fabric as to the flammability or its fire retardant properties to confirm compliance with NFPA 101-2000, 18.7.5.1 and 10.3.1.

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

Findings include:

A. On the morning of 3/4/14, the conduit and junction box for the thermostat located in the Electrical closet adjacent the 2nd floor Surgery Soiled Cart Storage room was observed not to be securely mounted in accordance with NFPA 70 standards. The box and conduit appeared to have been temporarily relocated and zip-tied to overhead supports.

B. On the morning of 3/4/14, an open, unused junction box was observed at the 3rd floor Triage room 3417.