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Based upon direct observation during the survey walk-thru, proper 2-hour separation of the Clinic building Business occupancy is not maintained from the Hospital building. Failure to maintain the required separation can compromise the safety of Hospital patients, staff and visitors if a fire condition originating in the Business occupancy were to spread to the Hospital.

Findings include:

On 7/16/19 at 9:30am while in the company of the FM it was observed above the sink in the Clinic building Vending room that an unprotected hole approximately 6" square was cut in the 2-hour barrier between the Hospital building and the Clinic building. This condition does not comply with 19.1.3.3, 19.1.3.5 and 8.3.

Based upon observation during the survey walk-thru, not all corridors are maintained free of obstructions. Failure to maintain corridors free of material obstructions can compromise occupant safety by preventing access to avaialble exits.

Findings include:

On 7/15/19 at 12:10pm while in the company of the FM it was observed that the Basement corridor leading to the exit availble at the loading dock was used to store fork/pallet trucks which obstructed the width of the corridor in non-compliance with 39.3.2.1 and 7.5.1.6.

Based on observation, means of egress doors are locked without full compliance with Code allowance provisions. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit from the building if there is a fire/smoke event.

Findings include:

A. On 7/15/19 while in the company of the FM, it was observed that door locking systems were installed that did not fully comply with Code requirements. Conditions observed include:

a. At 3:15pm it was observed at the 1st floor patient sleeping room wing that multiple doors marked with exit signs have magnetic locking systems which become locked upon sensing the presentce of a patient tag system. The installed Delayed Egress locks are permitted by 19.2.2.2.4 but lack the signage required by 7.2.1.6.1(4).

1. The west end of the corridor.
2. Stair #3 door.

b. At 3:30pm it was observed at the 1st floor patient sleeping room wing that room 110 was provided with a dead bolt lock operated by manual key only from both sides in non-compliance with 19.2.2.2.2.

Based on observation, means of egress doors are locked without full compliance with Code allowance provisions. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit from the building if there is a fire/smoke event.

Findings include:

On 7/16/19 at 8:05am while in the company of the FM, it was observed that the door leading from the out-patient surgery reception/waiting room into and thru the Prep/recovery room was marked as an exit and locked against egress in non-compliance with 18.2.2.2.4. Surveyor notes that the waiting room is currently identified as part of a suite requiring two exit access doors from the suite.

Based on observation, means of egress doors are locked without full compliance with Code allowance provisions. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit from the building if there is a fire/smoke event.

Findings include:

On 7/16/19 at 9:10am while in the company of the FM, it was observed that the door leading to the connecting corridor to the hospital is an identified exit path which is provided with magnetic locking hardware operated only by card reader and fire alarm activation. A Delayed Egress system in full compliance with 7.2.1.6.1.1 as permitted by 38.2.2.2.5 is not provided.

Based upon observation, hazardous areas designed with self-closing door assemblies are not maintained to separated them from the remainder of the occupancy. Failure to properly separate Hazardous Areas from the remainder of the occupancy can compromise the safety of occupants if a fire were to originate within the Hazardous Area.

Findings include:

On 7/15/19 at 11:40am while in the company of the FM, it was observed that the sprinklered Kitchen storage room door was being held open by non-approved hold-open devices (material propping door and wire tie) in non-compliance with 39.3.2.1, 8.7.1, 8.4.3 and 7.2.1.8.2.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate areas identified as Storage rooms used for the 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.

Findings include:

On 7/16/19 at 9:05am while in the company of the FM it was observed that the sprinklered "Storage" room near the Mechanical room lacked a self-closing door to comply with 38.3.2.1, 8.7.1.1 and 8.4.3.5.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the 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.

Findings include:

On 7/15/19 at 3:35pm while in the company of the FM it was observed that sprinklered patient room 116 was being used for storage of equipment & supplies and lacked a self-closing door to comply with 19.3.2.1.3.

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 7/15/19 at 11:50am while in the company of the FM, it was observed at the basement level Fan Room that electrical panel EN had a circuit supplying power to the Fire Alarm system.

a. This circuit was not being fed from a Life Safety Branch panel to comply with NFPA 99-2012, 6.4.2.2.3.2(7).

b. This circuit lacked a mechanical lock-on device to comply with NFPA 72-2010, 10.5.5.3.

Based on observation during the survey walk through the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

On 7/15/19 at 12:07pm accompanied by the FM in the Basement, it was observed that sprinkler installed within the Housekeeping Closet was obstructed by ventilation duct work not allowing for complete coverage of the room. (NFPA 13, 2010, 8.6.5)

Based on observation during the survey walk through the facility lacks complete electronic supervision of sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

On 7/15/19 at 11:55am accompanied by the FM in the Basement, it was observed that sprinkler system control valve for the Purchasing Storeroom is not provided with supervisory attachments for monitoring and signaling at a constant attended location. This is in non-compliance with NFPA 101, 2012, 9.7.2.

Fire Drills are not adequately documented to demonstrate that staff are being trained to respond to fire conditions. Failure to train and document staff knowledge of required responses to fire conditions can compromise patient, staff and visitor safety during a fire.

Findings include:

On 7/15/19 at 2:00pm while in the company of the FM and SM it was observed that not all fire drills are recorded with response documentation to judge staff response to alarm activation in accordance with 19.7.1 & 19.7.2. Only actual alarm activations had response documentation. Unannounced drills had no response documentation other than to identify the time and date recorded for the drills.

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. Failure to provide GFCI protection can result in electrical shock hazards to occupants.

Findings include:

On 7/16/19 at 8:35am while in the company of the FM, it was observed that receptacles within 6'-0" of sink fixtures were not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(6) at the Emergency Dept. south Nurse Station sink.

Based upon observation, not all Critical Care bed locations are provided with power from both the Essential Electrical System and the Normal power electrical system. Failure to provide both Critical power and Normal power at the bed locations can result in no power being available.

Findings include:

On 7/16/19 at 8:20am while in the company of the FM it was observed that no normal power receptacles were available at the Emergency Department rooms 1 & 2, both bed locations to comply with NFPA 99-2012, 6.3.2.2.1.2.