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Based on observation, not all portions of the building constitute structures of complaint construction types. This deficient practice could affect patients, staff, and visitors in the building because fire conditions could cause the building structure to fail prematurely if a compliant construction type is not provided.

Findings include:

On May 22, 2019 at 8:38 AM, while accompanied by the SM, observation determined that required fireproofing materials had been removed from a structural steel column on the east side of the Mechanical Penthouse, which reduces the fire rating required for that steel below what is required by 19.1.6.2 and NFPA 220 2012 Table 4.1.1.

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:

On May 22, 2019 at 9:40 AM, while accompanied by the SM, observation determined that the south cross-corridor door from the First Floor Outpatient Waiting Room is secured against egress as prohibited by 19.2.2.2.5.1 because it is not equipped with a delayed egress locking mechanism.

Based on document review, not all emergency lighting in the building is installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their ability to exit the building under emergency conditions could be impeded if emergency lighting is not properly provided.

Findings include:

On May 22, 2019 at 10:47 AM, while accompanied by the SM, document review determined that battery-powered emergency lights are not tested for at least 90 minutes every year as required by 7.9.3.1.1(3) because no records of any such tests were available.

Based on observation, not all vertical openings in the building are protected as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass between building stories if vertical openings are not protected.

Findings include:

On May 22, 2019 at 9:10 AM, while accompanied by the SM, observation determined that conduit penetrations in the fire rated shaft west enclosure wall in the Second Floor Pharmacy are not sealed against the passage of fire as required by 8.3.5.1.

Based on observation, not all enclosures for 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:

On May 22, 2019 at 9:11 AM, while accompanied by the SM, observation determined that the door to the Second Floor Pharmacy is not self-closing as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

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 because the automatic sprinkler system may fail to extinguish a fire if it is not properly installed.

Findings include:

On May 22, 2019 at 9:55 AM, while accompanied by the SM, observation determined that the rolling files in the First Floor Radiology Film Storage Room are less than 18 inches below standard pendant or upright spray sprinkler heads as prohibited by NFPA 13 2010 8.5.6.1.

Based on observation, the facility failed to install and maintain all elevators as required. This deficient practice could affect patients, staff, and visitors in the hospital because smoke and fire could be permitted to spread throughout the building via the elevator shafts, and the elevators could be unavailable to firefighters when needed, if the recall systems are not properly installed.

Findings include:

On May 22, 2019 at 8:40 AM, while accompanied by the SM, observation determined that a heat detector is not provided within 2 feet of the sprinkler head located above the North Elevator Equipment as required by NFPA 72 2010 21.4.2.

Based on observation, not all components of the building's Essential Electrical System are correctly installed and maintained. This deficient practice could affect patients, staff, and visitors in the building because the Essential Electrical System could fail to operate under emergency conditions if it is not consistent with the level of care being provided to patients.

Findings include:

On May 22, 2019 at 10:30 AM, while accompanied by the SM, observation determined that the remote manual stop station for the emergency generator is not remote from it, as required by NFPA 110 2010 5.6.5.6, because it is mounted directly on the side of the emergency generator enclosure.