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Based on observation during the survey walk-through, not all portions of the building structure are constructed and maintained in a manner consistent with the designated building construction classification. This deficiency could affect any patients, staff, or visitors in the building because portions of the building structure could fail under fire conditions.

The finding is:

On August 9, 2017 at 9:30 AM, while accompanied by DSER, MSFO and ME on the 18th floor at the cross corridor (18C31) doors by IDF 18355U an exposed unistrut penetrates the designated 2 hour rated wall. The wall is not sealed at the penetration. Documentation could not be provided for the designated U. L. listed design for the penetration in a 2 hour barrier to comply with 19.1.6.1 and 8.3.1.

Based on 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. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The findings are:

A. On August 9, 2017 at 9:45 AM, while accompanied by DSER, MSFO and ME on the 18th floor in review of the patient infusion rooms. The drawings provided indicated all rooms are located off of "hallways". The hallways contain an excessive amount of stored equipment which reduces the required width of the means of egress. The areas are not designated as "suites" nor do they comply with 19.2.5.6 and 7.5.1.


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B. On August 9, 2017 at 10:10 AM while accompanied by the SD and MR, means of egress corridors were observed containing multiple pieces of equipment being charged while plugged into electrical wall outlets. Materials block part of the egress path including patient step on scales which form tripping hazards. This condition does not comply with 19.2.3.4. (4). Example locations observed:

1. 7th Floor Prep holding area corridor adjacent to All-Gender Restroom # 07-189T
2. 7th Floor Prep holding area corridor adjacent to Room # 7202 (life safety floor plan)

C. On August 9, 2017 while accompanied by the SD and MR, egress paths located within rooms were observed containing multiple pieces of equipment and materials being stored. These storage locations reduce the required width for the means of egress which does not comply with 19.2.3.4 (1).
Locations observed:

1. At 2:10 PM 11th Floor Kitchen
2. At 11:20 AM 9th Floor Central Sterile Processing

Based upon observation, Exit signs do not provide clear identification of exit access. Failure to identify available means of egress can result in occupant confusion or inability to reach an exit during a fire/smoke event.

The finding is:

On August 9 at 1:25 PM while in the company of the ME and MR exit signage was observed to be covered by long red rectangular signage which does not comply with 7.10.1.2.1. Example locations:

1. Floor 6 Corridor north of Surgery
2. Floor 7 Corridor north of Surgery
3. Floor 8 Corridor adjacent to Core Lab

Based on observations during the survey walk-through, not all egress paths are identified by exit signs as required. These deficiencies could affect patients, staff, and visitors if egress paths are not properly identified during and emergency evacuation.

The finding is:

On August 9, 2017, while accompanied by the SBM, it was determined that on the 7th floor the following egress paths were not provided with proper "EXIT" signage as required by 7.10.1.1.

1. 2:10 PM, directional 'EXIT' sign was not provide at the corridor intersection adjacent to room 7311.
2. 2:20 PM, directional 'EXIT' sign was not provide at the corridor intersection adjacent to room 7104.

Based upon direct observation and document review, sprinklered hazardous areas are not separated by a minimum of smoke resisting construction. The facility failed to provide proper separation between hazardous areas used for storage and the surrounding areas. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur. This deficient practice could affect patients, staff and visitors if a fire would spread without proper separation.

Findings include:

A. On August 9, 2017 at 1:05 PM, while accompanied by DSER and MFT on the 14th floor at corridor 14C16, located in a back area of NICU. The space connects staff hallways. It is a corridor which connects several areas. The corridor contains bassinets / isolets and miscellaneous equipment storage. This does not comply with 19.1.1.4.2 or 19.3.2.4. The amount of storage within this corridor deems it as a hazardous area.

B. On August 9, 2017 at 1:30 PM, while accompanied by DSER and MFT on the 14th floor at corridor 14C34, located in a back area of NICU. It is a corridor which connects several areas which is being used as storage. The area contains bassinets/ isolets and miscellaneous equipment storage. The amount of storage within this corridor deems it as a hazardous area. This does not comply with 19.1.1.4.2 or 19.3.2.4.

C. On August 9, 2017 at 10:00 AM, while accompanied by DSER, MSFO and ME on the 17th floor there are several office cubicles located along the Southwest side of the building. The cubicles are located off of "hallways" based on the Facility provided Life Safety drawings. Cubicles 17398, 17400, 17402 and 17408 are used as storage and are no longer functioning as offices. Storage from the 21st and 22nd floor construction projects were also located in the hallways adding to the fire load and reducing the required width for a means of egress. This arrangement does not meet with 19.2.5.6 and 7.5.1.


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D. On August 9, 2017 at 2:10 PM while in the company of MR the Kitchen is deemed a hazardous area due to the amount of stored items within the Kitchen as follows:
1. Numerous shelves along the NW wall contain styrofoam cups, plates, trays etc.
2. Numerous cardboard boxes are stacked adjacent to the Dry Goods Storage and along the NW wall.
3. Wooden palettes are stacked next to the entrance to Dry Goods Storage

E. On August 9, 2017 at 10:45 AM while in the company of ME and MR areas were observed being used for the storage of equipment, supply carts, gurneys and bassinets in quantities greater than that for the normal area's function. Example locations:
1. At 9:35 AM 6th Floor P.A.C.U. Approxmately 6 bays (example bays L and M ) are being utilized for storage.
2. At 8:55 AM 5th Floor Prep/Holding bay used for Clean Storage with sliding doors that are not self closing to a latched position to comply with 19.3.2.1, 8.7.1 & 8.4.

Based on observation, the facility failed to provide a complete kitchen hood system. This deficient practice creates a high risk of fire and allows the spread of flames should a fire under the hood occur.

The finding is:

On August 9, 2017 at 2:15 PM while accompanied by the MR on the 11th floor, the kitchen hood installation was observed to lack a complete filter installation due to gaps between filter segments. This condition could allow for a fire condition within the hood to reach the duct above should flames develop from the cooking procedures. This condition does not comply with NFPA 96, 2011, 6.2.4.2 and 6.2.5

Based on direct observation and staff interview the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The finding is:

On August 8, 2017 at 1:45 PM in the company of the DFO the surveyor finds the lack of fire sprinkler protection for all of the facilities elevator machine rooms except for those hydraulically operated. NFPA 13, 2010, 8.1.1

Based on observations during the survey walk-thru and review of the facility's life safety reference drawings, Corridor doors are not properly installed to latch. This deficient practice could affect patients, staff and visitors if failure of the corridor doors and the means of keeping the door closed compromises the means of egress corridor intended to provide a protected path of egress to an exit.

The finding is:

On August 9, 2017 at 9:50 AM while accompanied by the DFO it was determined that on the Second Floor, Emergency Department contained sliding doors into exam rooms that did not latch to the frame when tested. The following doors did not comply with NFPA 101, 19.3.6.3.5.

1. Exam room 14 door
2. Exam room 17 door

Based on document review and staff interview , the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

The finding is:

A. On August 10, 2017 at 9:00 AM during document review with the DSER, the reporting documentation for 1/20/17; 2/10/17 and 5/10/17 contained the following questions and responses:

1. "Were any smoke/fire doors obstructed?" The observer marked "Y" (yes)
2. "Was the pull station obstructed?" The observer marked "Y" (yes)

The reporting documentation for 7/18/17, included the following questions and responses:

1. "Did response Team members follow proper procedures?" The observer marked "N" (no).
2. "Did smoke/fire doors close properly?" The observer marked "N" (no)
3. "Did smoke/fire doors seal tightly"? The observer marked "N" (no)

The forms did not include if/how the remarks above were reviewed. There was no indication of follow through along with how the facility will manage any future contrasting items. The documents failed to comply with 19.7. 1.

B. On August 10, 2017 at 9:20 AM during document review with the DSER, documentation for the past 12 months did not indicate that all floors participated to comply with 19.7.1.