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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.


12/29/2011 - This is re-cited item. See attached waiver/extension request. Building to be 100% sprinklered per NFPA 13 by March 31, 2012.

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 equipped throughout with a complete automatic smoke 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. - Corrected 12/29/2011

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. Corrected 12/29/2011

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 Corrected 12/29/2011

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. Corrected 12/29/2011

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. Corrected 12/29/2011

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. Corrected 12/29/2011

All items listed above have been corrected by follow-up survey 12/29/2011

12/29/2011: At approximately 11;30 AM

7. The Special Locking Arrangements for the exit doors in the Emergency Department were found to be non-compliant.
a. Emergency Override Switches for the Magnetic Locking Devices were found to be momentary switches and not two way (on/off) switches both at the exit doors and the nurses station.

b. The Emergency Override Switches for the Magnetic Locking Devices at the nurses station were not labeled/identified. At time of survey the staff on duty were not aware of location of switches.