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Based on observation, not all exit access corridors are being maintained as required. Failure to maintain means of egress for patients, staff, and visitors in the building can impede their egress under emergency conditions if corridors are not properly maintained clear of stored materials.

Findings include:

On October 29, 2019 at 10:00 AM, while in the company of the T, it was observed that the corridor leading from the lower level Dining room to the Exit Stair contained stacked excess dining room chairs and a wheeled trash bin not in compliance with 7.1.10.1. The materials determined to be stored, were not separated from the corridor to comply with 19.3.2.1.

Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained.

Findings include:

A. On October 28, 2019 at 1:42 PM, while accompanied by the DFO, observation determined that two doors in the Third Floor BioMed Suite require more than one releasing operation, as prohibited by 7.2.1.5.3, because throw-bolts have been applied to the latching doors.

B. On October 28, 2019 at 2:51 PM, while accompanied by the DFO, observation determined that the exterior gate at the northeast corner of the site, which serves the northeast door from the First Floor Special Procedures Suite, is secured against egress with a padlock as prohibited by 19.2.2.2.5.1.

Based on observation, not all designated suites are separated from each other as required. This deficient practice could affect patients, staff, and visitors in the suites because smoke or fire could pass between them if they are not properly separated.

Findings include:

On October 28, 2019 at 2:37 PM, while accompanied by the DFO, observation determined that the door between the First Floor Special Procedures Suite and the First Floor High Acuity Unit is not positive latching as required by 19.2.5.7.1.2 and 19.3.6.3.5.

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not 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.

Findings include:

On October 29, 2019 at 9:55 AM, while in the company of the T, it was observed that the lower level 'B' Wing Exit Stair 'E' exterior discharge lacks lighting to comply with 19.2.8, 19.2.9 and 7.8 & 7.9 because no lighting fixtures were present at the door or provided to illuminate the walk leading away from the building.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

A. On October 29, 2019 at 8:30 AM, while in the company of the COO, it was observed on the 2nd floor 'B' Wing where construction activities are currently taking place, that identification of exits is not being maintained in accordance with 43.6.2.1 and 43.1.2.1(1). Not all available Exits for construction personal are identified with exit signs during construction and not all available marked Exits are provided with special signage identifying special procedures necessary to gain access to the dust protected doorways.

B. On October 29, 2019 at 9:55 AM, while in the company of the T, it was observed that the 2nd exit access from the lower level corridor outside the Staff Dining room was not identified with an exit sign to comply with 7.5.1.1.2 and 7.10.1.5.1.

C. On October 29. 2019 at 11:06 AM, while in the company of the T and FD, it was observed that the 2nd exit access from the lower level corridor serving the General Storage room and the EVS Storage area lacked proper installation of the exit sign located at the cross corridor doors leading to the elevators to comply with 7.5.1.1.2 and 7.10.1.5.1 because the sign appeared to be facing the wrong way.

Based on observation, not all vertical openings and exit stairs are constructed as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass between building stories if all vertical openings are not properly protected, and the stairs could be difficult to use under emergency conditions if they are not properly constructed.

Findings include:

A. On October 28, 2019, while accompanied by the DFO, observation determined that exit stairs exist at which intermediate rails at (top of stair) landing guardrails permit a sphere larger than 4 inches in diameter to pass as prohibited by 7.2.2.4.5.3. Locations observed include:

1. 1:00 PM: Fifth Floor North Exit Stair landing guardrail.

2. 1:10 PM: Fifth Floor South Exit Stair landing guardrail.

3. 1:59 PM: Second Floor East Exit Stair landing guardrail.

Based on observation, not all hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:

A. On October 29, 2019 at 10:15 AM, while in the company of the T, it was observed that the lower level Paint shop corridor door was being held open by a non-approved hold-open device consisting of a 'wet paint' warning cone not in compliance with 19.3.2.1, 8.7.1.2, 8.4.3.5 and 7.2.1.8.

B. On October 29, 2019 at 10:30 AM, while in the company of the T, it was observed that the lower level Kitchen Dry Storage room door was being held open due to it rubbing on the floor which prevented it from self-closing to comply with 19.3.2.1, 8.7.1.2, 8.4.3.5 and 7.2.1.8.

C. On October 29, 2019 at 11:15 AM, while in the company of the T, it was observed that the lower level Linen Storage room corridor door was being held open by a wood wedge not in compliance with 19.3.2.1, 8.7.1.2, 8.4.3.5 and 7.2.1.8.

Based upon observation, fire alarm systems are not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in disruption of the system to not function as required.

Findings include:

A. On October 29, 2019 at 10:35 AM while in the company of the T, it was observed at the lower level 'D' Wing Electrical room that electrical panel LS4 had circuits 8 & 10 supplying power to the Fire Alarm system, but lacked mechanical lock-on devices to comply with NFPA 72-2010, 10.5.5.3 and were not identified by red markings to comply with NFPA 72-2010, 5.5.2.3. The fire alarm NAC panel located in this room was not provided with labeling to identify the panel and circuit from which it received its electrical supply to comply with NFPA 72-2010, 10.5.5.2.1.

B. On October 29, 2019 at 10:40 AM while in the company of the T, it was observed that a fire alarm manual pull-station was not located at the lower level 'D' Wing entry door to the Stair located near the Electrical room housing the LS4 panel. Although a manual pull-station is located within the Stair enclosure near the exterior discharge door, it is not deemed to be "conspicuous" from the corridor side of the stair enclosure as all other such devices are consistantly located to comply with NFPA 72-2010, 17.14.6.

Based on observation, the facility failed to provide a complete automatic sprinkler system where installed. This deficient practice could affect patients, staff, and visitors in the building by delaying response and suppression during a fire event because the automatic sprinkler system does not extinguish a fire if it is not properly installed.

Findings include:

A. On October 28, 2019 at 12:55 PM, while accompanied by the DFO, observation determined that a portion of the drywall ceiling is missing in the Ante Room for Patient Sleeping Room 553, thus compromising the coverage of the room by a standard pendant sprinkler head, as prohibited by NFPA 13 2010 8.6.4.1.1, because the activation of the sprinkler head could be delayed due to heat rising past it.


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B. On October 28, 2019 at 11:25 AM while in the company of the BE, the surveyor observed the lack of fire sprinkler protection for the Emergency Generator Room as required by NFPA 13-2010, 8.1.1

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor if the doors are not properly installed and maintained.

Findings include:

On October 28, 2019 at 2:57 PM, while accompanied by the DFO, observation determined that the hold-open feature of the automatic door operator, at the Corridor door to the First Floor High Acuity Unit, did not release under fire alarm conditions, thus preventing the door from being positive latching as required by 19.3.6.3.5.

Based on observation, not all smoke barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke could pass between adjacent smoke compartments if the smoke barriers are not properly constructed.

Findings include:

On October 28, 2019 at 1:32 PM, while accompanied by the DFO, observation determined that three conduit penetrations, in the Fourth Floor east smoke barrier wall (above the ceiling, above the cross-corridor doors) are not sealed against the passage of smoke as required by 8.5.6.2.

Based on observation and staff interview, components of the elevator recall system are not provided and maintained in accordance with requirements. Failure to maintain the elevator recall system can prevent the system from operating as required during a fire or smoke condition.

Findings include:

On October 29, 2019 at 8:35 AM, while in the company of the COO & T, it was observed that the second floor landing for the elevators lacked smoke detection to activate the elevator recall system in accordance with 19.5.3, 9.4.3.2 and ASME A17.1, 2.27.4.2. It was not clear that current construction activities on the second floor may have removed the required devices without reinstalling them for the area of the second floor which remains occupied.

Based on document review, not all fire door assemblies are inspected, tested, and maintained on an annual basis. This deficient practice could affect patients, staff, and visitors in the building because the doors may fail to operate when needed if they are not periodically inspected, tested, and maintained.

Findings include:

On October 28, 2019 at 2:00 PM, while in the company of the COO & CE, it was determined during document review that fire door assemblies are not inspected and tested annually, as required by NFPA 80 2010 5.2.1, because no records of such inspections were available for review.

Based on observation and staff interview during the survey walk through the facility failed to install a compliant Type 1 medical gas central supply system. Failure to install and maintain these systems could result in delayed response. This deficient practice could affect patients during a system outage.

The finding is;
On October 28, 2019 at 11:20 AM accompanied by the BE it was observed and through staff interview that an emergency oxygen supply connection has not been provided to comply with NFPA 99, 2012, 5.1.3.5.13.

Based on observation during the survey walk through 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 is:

On October 28, 2019 at 11:30 AM, while accompanied by the BE, it was observed that connection of the battery charger for the emergency generators were connected at the battery end of the starting cables and not to the primary side of the starter solenoid (positive) and the EPS frame (negative) to comply with NFPA 110, 2010, 7.12.6.2.

Based on observation and staff interview during the survey walk through the facility failed to install a complete alarm monitoring system for the emergency electrical system. Failure to install and maintain these systems could result in delayed response to electrical system malfunction. This deficient practice could affect patients, staff and visitors during a utility power outage.

The finding is:

On October 29, 2019 at 10:05 AM accompanied by the T it was determined through observation and staff interview that a remote audible alarm is not provide at a work station observable by personnel.

Based on observation, not all medical gas storage locations are protected as required. This deficient practice could affect patients, staff, and visitors in the building because the medical gases could contribute to a fire condition if not properly protected.

Findings include:

On October 29, 2019 at 8:51 AM, while accompanied by the DFO, observation determined that two medical gas tanks, located in the First Floor Imaging Department Medical Gas Storage Room, are not restrained as required by NFPA 99 2012 11.6.2.3(11).