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Based on document review during the survey, not all designated smoke compartments are constructed or maintained in accordance with requirements. This deficiency could affect any patients, staff, or visitors in the building by limiting the ability for occupants to reach an area of safety in an adjacent smoke compartment during a fire/smoke event.

Finding include:

On October 3, 2016 at 10:55am while in the company of the ESD, DFM & MS during review of the facility's Life Safety Reference Plans, it was observed that the 1999, 2006 & 2012 1st floor building area is designated as a single smoke compartment of 24,800 sf, thereby in excess of the 22,500 sf permitted by 18.3.7.1(3).

Based upon observation during the survey walk-thru, not all exit access corridors are arranged and constructed in accordance with Code requirements. Failure to maintain exit access corridors can result in mis-direction or confusion when exiting.

Findings include:

On October 3, 2016 at 1:20pm while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that the 2nd floor North/South corridor leading to the Pre-op Teaching Minor Procedure room area does not comply with 19.2.5.9, is greater than 30' in length, and ends at a double egress cross corridor door which is locked and is not marked as a means of egress. The door was not provided with "NO exit" signage to make it clear that means of egress was not available through this door.

Based on observations during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect patients, staff and visitors in this area of the facility by preventing those occupants from reaching an exit from the building.

Findings include:

On October 3, 2016 at 2:05pm while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that the access controlled egress door lock located at the 2nd floor mobile MRI dock exterior door failed to consistantly release the magnetic lock either by sensor or by manual release in accordance with 7.2.1.6.2. The lock released properly upon initial approach but when relocked, it did not release. Staff using the door at the time indicated that the door frequently "sticks" locked to prevent egress.

Based on observations during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect patients, staff and visitors in this area of the facility by preventing those occupants from reaching an exit from the building.

Findings include:

On October 3, 2016 at 2:45pm while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that the delayed egress locks on the doors of the OB unit were not provided with signage in accordance with 7.2.1.6.1(d). The locks become active when initiated by the infant abduction system tag and release upon initiation of the delayed egress function. The locking system does not otherwise comply with the releasing requirements of NFPA 101, 2012 Edition, 18.2.2.2.5.2 where locks without delayed egress are permitted.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure of the fire alarm system compromises occupant safety during a fire emergency.

Findings include:

On October 3, 2016 while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that smoke detectors were not located at the deck or on the wall between 4" and 12" down from the ceiling/deck above to the top of the detector to comply with NFPA 72-1999, 2-3.4.3.1. Locations observed include:

A. At 2:40pm at the Electric room of the 2nd floor OB unit.

B. At 3:20pm at the Electric room of the 1st floor Emergency Dept.

C. At 3:21pm at the IT Equipment room of the 1st floor Emergency Dept.

Based on observation during the survey walk-through, not all medical gas storage locations comply with Code requirements. This deficient practice could affect patients, staff and visitors if medical gases are stored that can create undue hazardous conditions for building occupants.

Findings include:

On October 3, 2016 at 3:05 pm while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that combustible plastic shelving/bins were mounted above and within 5' of the oxygen tank storage location at the 1st floor Clean Supply room in the ED and not in compliance with NFPA 99-1999, 8-3.1.11.2(c)2.

Based on observation during the survey walk-through, not all portions of the building piped medical gas system are installed in accordance with Code requirements. Failure to install medical gas systems in accordance with requirements can result in failure of the system to perform without hazard to the occupants.

Findings include:

On October 3, 2016 it was observed while in the company of the ESD, DFM & MS during the survey walk-thru that the copper medical gas piping systems are not supported by hangers of like finish to comply with NFPA 99-1999, 4-3.1.2.9. The copper lines are not provided with a means of separation between the dissimilar metal iron/steel hangers. Location observed include:

A. At 3:35pm Medical Air lines at the 1st floor 1952 building Mechanical Equipment room were observed to be supported by steel stirrup hangers.

B. At 2:20pm Medical Gas lines above the ceiling at the 2nd floor 1992 building corridor near the 2-hour building separation/smoke barrier doors between the 1992 and 2006 addition were observed to be supported by steel unistrut trapeze hangers.

Based on observation, the Essential Electrical System is not installed in accordance with Code requirements. Failure to install and maintain the Essential Electrical System can result in harm to patients, staff & visitors that rely upon the electrical system for life support and life safety systems.

Findings include:

A. On October 3, 2016 at 2:15pm it was observed during the survey walk-thru while in the company of the ESD, DFM, MS & an Electrician, that the CAT 2 emergency generator is located in an exterior enclosure which is not equipped to be maintained at a minimum temperature not less than 32 degrees F or otherwise provided with a starting battery heater to maintain battery temperature at a minimum 50 degrees F and automatically shuts off when battery temperature reaches 90 degrees F (and when prime mover is running) to comply with NFPA 110-1999, 3-3.1.

B. On October 3, 2016 at 2:15pm it was observed during the survey walk-thru while in the company of the ESD, DFM, MS & an Electrician, that the CAT 2 emergency generator emergency stop switch (located on the exterior building wall less than 10' from the generator equipped with a belly fuel tank) was not located sufficiently remote from the generator to comply with NFPA 110-1999, 3-5.5.6 if the generator and/or fuel supply were on fire.

Based on document review during the survey, not all designated smoke compartments are constructed or maintained in accordance with requirements. This deficiency could affect any patients, staff, or visitors in the building by limiting the ability for occupants to reach an area of safety in an adjacent smoke compartment during a fire/smoke event.

Finding include:

On October 3, 2016 at 10:55am while in the company of the ESD, DFM & MS during review of the facility's Life Safety Reference Plans, it was observed that the 1999, 2006 & 2012 1st floor building area is designated as a single smoke compartment of 24,800 sf, thereby in excess of the 22,500 sf permitted by 18.3.7.1(3).

Based upon observation during the survey walk-thru, not all exit access corridors are arranged and constructed in accordance with Code requirements. Failure to maintain exit access corridors can result in mis-direction or confusion when exiting.

Findings include:

On October 3, 2016 at 1:20pm while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that the 2nd floor North/South corridor leading to the Pre-op Teaching Minor Procedure room area does not comply with 19.2.5.9, is greater than 30' in length, and ends at a double egress cross corridor door which is locked and is not marked as a means of egress. The door was not provided with "NO exit" signage to make it clear that means of egress was not available through this door.

Based on observations during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect patients, staff and visitors in this area of the facility by preventing those occupants from reaching an exit from the building.

Findings include:

On October 3, 2016 at 2:05pm while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that the access controlled egress door lock located at the 2nd floor mobile MRI dock exterior door failed to consistantly release the magnetic lock either by sensor or by manual release in accordance with 7.2.1.6.2. The lock released properly upon initial approach but when relocked, it did not release. Staff using the door at the time indicated that the door frequently "sticks" locked to prevent egress.

Based on observations during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect patients, staff and visitors in this area of the facility by preventing those occupants from reaching an exit from the building.

Findings include:

On October 3, 2016 at 2:45pm while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that the delayed egress locks on the doors of the OB unit were not provided with signage in accordance with 7.2.1.6.1(d). The locks become active when initiated by the infant abduction system tag and release upon initiation of the delayed egress function. The locking system does not otherwise comply with the releasing requirements of NFPA 101, 2012 Edition, 18.2.2.2.5.2 where locks without delayed egress are permitted.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure of the fire alarm system compromises occupant safety during a fire emergency.

Findings include:

On October 3, 2016 while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that smoke detectors were not located at the deck or on the wall between 4" and 12" down from the ceiling/deck above to the top of the detector to comply with NFPA 72-1999, 2-3.4.3.1. Locations observed include:

A. At 2:40pm at the Electric room of the 2nd floor OB unit.

B. At 3:20pm at the Electric room of the 1st floor Emergency Dept.

C. At 3:21pm at the IT Equipment room of the 1st floor Emergency Dept.

Based on observation during the survey walk-through, not all medical gas storage locations comply with Code requirements. This deficient practice could affect patients, staff and visitors if medical gases are stored that can create undue hazardous conditions for building occupants.

Findings include:

On October 3, 2016 at 3:05 pm while in the company of the ESD, DFM & MS during the survey walk-thru, it was observed that combustible plastic shelving/bins were mounted above and within 5' of the oxygen tank storage location at the 1st floor Clean Supply room in the ED and not in compliance with NFPA 99-1999, 8-3.1.11.2(c)2.

Based on observation during the survey walk-through, not all portions of the building piped medical gas system are installed in accordance with Code requirements. Failure to install medical gas systems in accordance with requirements can result in failure of the system to perform without hazard to the occupants.

Findings include:

On October 3, 2016 it was observed while in the company of the ESD, DFM & MS during the survey walk-thru that the copper medical gas piping systems are not supported by hangers of like finish to comply with NFPA 99-1999, 4-3.1.2.9. The copper lines are not provided with a means of separation between the dissimilar metal iron/steel hangers. Location observed include:

A. At 3:35pm Medical Air lines at the 1st floor 1952 building Mechanical Equipment room were observed to be supported by steel stirrup hangers.

B. At 2:20pm Medical Gas lines above the ceiling at the 2nd floor 1992 building corridor near the 2-hour building separation/smoke barrier doors between the 1992 and 2006 addition were observed to be supported by steel unistrut trapeze hangers.

Based on observation, the Essential Electrical System is not installed in accordance with Code requirements. Failure to install and maintain the Essential Electrical System can result in harm to patients, staff & visitors that rely upon the electrical system for life support and life safety systems.

Findings include:

A. On October 3, 2016 at 2:15pm it was observed during the survey walk-thru while in the company of the ESD, DFM, MS & an Electrician, that the CAT 2 emergency generator is located in an exterior enclosure which is not equipped to be maintained at a minimum temperature not less than 32 degrees F or otherwise provided with a starting battery heater to maintain battery temperature at a minimum 50 degrees F and automatically shuts off when battery temperature reaches 90 degrees F (and when prime mover is running) to comply with NFPA 110-1999, 3-3.1.

B. On October 3, 2016 at 2:15pm it was observed during the survey walk-thru while in the company of the ESD, DFM, MS & an Electrician, that the CAT 2 emergency generator emergency stop switch (located on the exterior building wall less than 10' from the generator equipped with a belly fuel tank) was not located sufficiently remote from the generator to comply with NFPA 110-1999, 3-5.5.6 if the generator and/or fuel supply were on fire.