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Based on observation, on November 1, 2011 at approximately 7:30am onward, automatic flush bolts are not functioning for top section of delivery suite doors located on the second floor - located near room 232.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the travel distance to existing smoke barriers exceeds limitation allowance for a facility not equipped with sprinklers in all spaces. The travel distance is limited to one hundred and fifty feet for facilities not fully sprinklered. Smoke barrier doors serving special delivery suite floor are greater than one hundred and fifty feet from most remote room in delivery suite.

Based on observation, on November 1, 2011 at approximately 7:30am onward, hyperbaric unit is not separated by minimum one hour fire resistive construction. Fire door to room is not equipped with self-closing hardware; and one door to area is rated for less than forty-five minute fire resistive rating.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the facility is utilizing varied incomplete installations of special locking arrangements. The facility is not equipped throughout with a complete automatic sprinkler system or detection system. Specific noncompliance with special locking arrangement minimum requirements are as follows:

1. Delayed egress locks, as installed, did not release during activation of the facility fire alarm system by activation of corridor smoke detectors - located on second floor near stairway exits, and labor/delivery unit.

2. Delayed egress locks, as installed, would automatically relock without manual intervention once thirty second time delay had expired and door had released and returned to closed position.

3. Door signage is incorrect - signs state that when fire alarm sounds, lock will release in thirty seconds. Signs must state: Push alarm will sound, lock will release in thirty seconds

4. There is no on/off keyed switch within three feet of exit door near fourth floor Delta Center - lock release depends on electronic card swipe adjacent to exit door.

5. Master release switch in third floor CCU is not an on/off switch. The switch is a momentary contact switch. The switch is not labeled for staff identification.

6. On/off switch within three feet of exit access door is greater than forty-eight inches above finish floor level - located in third floor CCU unit.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the means of egress is incomplete due to the following:

1. positive latching hardware is mounted greater than forty-eight inches above finished floor - door to Hyperbaric unit located on fourth floor.

2. positive latching hardware to storage room OB207 is mounted greater than forty-eight inches above finished floor.

3. positive latching hardware for exit access door from recovery suite requires greater than a single hand motion to exit area - locate on first floor.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the special locking arrangements did not release during activation of the facility fire alarm by the smoke detection system.

Note: The doors did release with inadequate switching arrangements as provided on date of survey.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the facility is not equipped with a complete automatic sprinkler system due to the following:

1. electrical equipment rooms do not meet all exceptions required by NFPA 13 for sprinkler coverage. The rooms are not equipped with two hour fire resistive enclosures.

2. the operating room suite is not covered by sprinklers.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the partially installed sprinkler system is noncompliant due to the following:

1. Based upon sprinkler inspection report dated 12/8/2010, the dry-pipe sprinkler system inspectors test appeared to be clogged when fully opened; contractor record states that no water or air flowed from test orifice. There was no documentation available to verify corrective action for dry-pipe sprinkler system.

2. Staff could not verify location of inspectors test valve for system serving the MRI area.

3. The alarm line valves are not electrically supervised for the dry-pipe sprinkler systems.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the means of egress is obstructed due to the following:

1. inward and outward swinging patient room doors do not swing one hundred and eighty degrees to the corridor wall during outward swing path - in the ninety degree position, doors obstruct half of required corridor width. Maximum door protrusion into corridor width is seven inches in the fully open position.

2. tables, and furniture in corridor area beyond delivery suite doors - located near OB218.

3. Electronic bug light protrudes greater than three and a half inches into corridor width within six feet and eight inch headroom clearance area - located near physical therapy on first floor.

Based on observation, on November 1, 2011 at approximately 7:30am onward, audible and visual alarms did not function on panel in the first floor rehabilitation area with activation of panel test switch.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the facility is noncompliant with the National Electrical Code due to the following:

1. multioutlet surge suppressors, not listed for health care facilities, mounted to walls in the first floor recovery area.

2. receptacle outlet installed in valve pit, near water storage tank, is not GFI protected and connected to the essential electrical system in accordance with NFPA 70; Article 517.

3. circuit directories, panelboard near CCU, are incomplete; all electrical breakers are not identified.

4. circuit directory, panelboard 3LA, is incomplete; all electrical breakers are not identified.

5. low fuel level alarm, for three hour capacity, could not be verified by staff for the emergency power system.

Based on observation, on November 1, 2011 at approximately 7:30am onward, automatic flush bolts are not functioning for top section of delivery suite doors located on the second floor - located near room 232.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the travel distance to existing smoke barriers exceeds limitation allowance for a facility not equipped with sprinklers in all spaces. The travel distance is limited to one hundred and fifty feet for facilities not fully sprinklered. Smoke barrier doors serving special delivery suite floor are greater than one hundred and fifty feet from most remote room in delivery suite.

Based on observation, on November 1, 2011 at approximately 7:30am onward, hyperbaric unit is not separated by minimum one hour fire resistive construction. Fire door to room is not equipped with self-closing hardware; and one door to area is rated for less than forty-five minute fire resistive rating.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the facility is utilizing varied incomplete installations of special locking arrangements. The facility is not equipped throughout with a complete automatic sprinkler system or detection system. Specific noncompliance with special locking arrangement minimum requirements are as follows:

1. Delayed egress locks, as installed, did not release during activation of the facility fire alarm system by activation of corridor smoke detectors - located on second floor near stairway exits, and labor/delivery unit.

2. Delayed egress locks, as installed, would automatically relock without manual intervention once thirty second time delay had expired and door had released and returned to closed position.

3. Door signage is incorrect - signs state that when fire alarm sounds, lock will release in thirty seconds. Signs must state: Push alarm will sound, lock will release in thirty seconds

4. There is no on/off keyed switch within three feet of exit door near fourth floor Delta Center - lock release depends on electronic card swipe adjacent to exit door.

5. Master release switch in third floor CCU is not an on/off switch. The switch is a momentary contact switch. The switch is not labeled for staff identification.

6. On/off switch within three feet of exit access door is greater than forty-eight inches above finish floor level - located in third floor CCU unit.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the means of egress is incomplete due to the following:

1. positive latching hardware is mounted greater than forty-eight inches above finished floor - door to Hyperbaric unit located on fourth floor.

2. positive latching hardware to storage room OB207 is mounted greater than forty-eight inches above finished floor.

3. positive latching hardware for exit access door from recovery suite requires greater than a single hand motion to exit area - locate on first floor.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the special locking arrangements did not release during activation of the facility fire alarm by the smoke detection system.

Note: The doors did release with inadequate switching arrangements as provided on date of survey.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the facility is not equipped with a complete automatic sprinkler system due to the following:

1. electrical equipment rooms do not meet all exceptions required by NFPA 13 for sprinkler coverage. The rooms are not equipped with two hour fire resistive enclosures.

2. the operating room suite is not covered by sprinklers.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the partially installed sprinkler system is noncompliant due to the following:

1. Based upon sprinkler inspection report dated 12/8/2010, the dry-pipe sprinkler system inspectors test appeared to be clogged when fully opened; contractor record states that no water or air flowed from test orifice. There was no documentation available to verify corrective action for dry-pipe sprinkler system.

2. Staff could not verify location of inspectors test valve for system serving the MRI area.

3. The alarm line valves are not electrically supervised for the dry-pipe sprinkler systems.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the means of egress is obstructed due to the following:

1. inward and outward swinging patient room doors do not swing one hundred and eighty degrees to the corridor wall during outward swing path - in the ninety degree position, doors obstruct half of required corridor width. Maximum door protrusion into corridor width is seven inches in the fully open position.

2. tables, and furniture in corridor area beyond delivery suite doors - located near OB218.

3. Electronic bug light protrudes greater than three and a half inches into corridor width within six feet and eight inch headroom clearance area - located near physical therapy on first floor.

Based on observation, on November 1, 2011 at approximately 7:30am onward, audible and visual alarms did not function on panel in the first floor rehabilitation area with activation of panel test switch.

Based on observation, on November 1, 2011 at approximately 7:30am onward, the facility is noncompliant with the National Electrical Code due to the following:

1. multioutlet surge suppressors, not listed for health care facilities, mounted to walls in the first floor recovery area.

2. receptacle outlet installed in valve pit, near water storage tank, is not GFI protected and connected to the essential electrical system in accordance with NFPA 70; Article 517.

3. circuit directories, panelboard near CCU, are incomplete; all electrical breakers are not identified.

4. circuit directory, panelboard 3LA, is incomplete; all electrical breakers are not identified.

5. low fuel level alarm, for three hour capacity, could not be verified by staff for the emergency power system.