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Based upon observation, building separations between the Hospital and other occupancies are not maintained as 2-hour rated assemblies. Failure to maintain building separations can compromise the healthcare occupancy by allowing fire conditions to spred to the healthcare occupancy.

Findings include:

At 8:45am on 10/22/20 while in the company of the COO, MMOPM, & MC it was observed that the 2-hour rated west wall of the 1st floor Boiler room had a duct passing through the wall which was not protected by a fire damper assembly to comply with 19.1.3.4.1 and NFPA 90A-2012, 5.4.1.1.

Based upon observation, egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

A. On 10/21 & 10/22, 2020 while in the company of the COO, MMOPM & MC it was observed at various locations that Delayed egress locking systems had not been installed in full compliance with 19.2.2.2.4 and 7.2.1.6.1. Locations & conditions observed include the following:

1. At 11:30am on 10/21 the building was determined to be only partially sprinkler protected (as a minimum, the 2nd floor, the North Penthouse and Basement freezer lacked sprinkler protection) thereby not meeting the requirements of 7.2.1.6.1.1(1) which requires the building to be "protected throughout by an approved, supervised automatic fire detection system or an approved supervised automatic sprinkler system".

2. Delayed egress locking devices (magnetic locks) lacked signage to identify the delay feature to comply with 7.2.1.6.1(4) at the following locations:

a. At 3:15 on 10/21/20 at the South Stair door on the 3rd floor had a sign but was not readily visible because the dark red letters did not contrast with the dark brown door color.

b. At 3:50pm on 10/21/20 at the smoke barrier doors on the 2nd floor leading to the west wing lacked signage.

c. At 9:10am on 10/22/20 at the double egress doors at the 1st floor north corridor leading from the Lab/Emergency Lobby entrance to the North-South east corridor lacked signage at the delyed egress door. The other door leaf was provided with an Access controlled egress door locking system.

d. At 9:30am on 10/22/20 at the double egress doors at the 1st floor south corridor leading from the Emergency Dept. to the North-South east corridor lacked signage at the delyed egress door. The other door leaf was provided with an Access controlled egress door locking system.

B. On 10/22/20 at 9:45am while in the company of the COO, MMOPM & MC it was observed that the main Hospital entry 4-panel bifold door assembly was closed for entry but unlocked for egress. The doors were maintained in the manual operation mode during COVID 19 restricted entry conditions. Signage on the door indicating "emergency" operation indicated the "push" point on the door assemble was at the center meeting stiles of the door assembly, but the actual push point is required to be at the hinge point of each bifolding pair. The means of operating the door when in the manual condition for emergency use did not provide for an obvious means of operation to permit opening to comply with 7.2.1.5.3.

Based upon observation, stairs are not constructed in accordance with Code requirements. Failure to construct stairs in accordance with Code requirements can present a hazard to occupants using the stair.

Findings include:

A. At 3:05 on 10/21/20 while in the company of the COO, MMOPM & MC it was observed that the center convenience stairway lacked guards to prevent a 4" sphere from passing through the guard rail (or 6" sphere at the riser/tread triangle) to comply with 19.2.2.3, 7.1.8, 7.2.2.4 and 7.2.2.4.5.3. The convenience stair is considered a means of egress when an occupant is using the stair at the time of a fire/smoke event.

B. At 3:05 on 10/22/20 while in the company of the COO, MMOPM & MC it was observed that the west stair had a fire rated door assembly directly into the stair from a Mechanical room which did not close when fully opened due to contact with the floor holding it open. It was not confirmed that no fuel fired equipment or storage was separated from the area accessing the stair directly. These conditions does not comply with the requirements of 7.1.3.2.1(9).

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the lighting provided. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. On 10/22/20 while in the company of the COO, MMOPM & MC it was observed that exit discharge lighting was not confirmed to be of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Exit discharge locations were provided with multiple fixtures but the lamp type was believed to be HID requiring a restrike period not in compliance with 7.8.1.4. Locations observed:

1. At 9:05am at the 1st floor Lab exterior door.

2. At 9:15am at the Emergency Dept. canopy.

Based upon record document review and staff interview, battery powered emergency lighting is not maintained in accordance with Code requirements. Failure to properly maintain battery powered emergency light can compromise occupant movement during emergency procedures when normal lighting has failed.

Findings include:

A. On 10/21/20 at 1:30pm while in the company of the MMOPM & MC it could not be confirmed that testing of the battery powered emergency lighting systems were conducted in accordance with 7.9.3.1.1 and NFPA 99-2012, 6.3.2.2.11.5 because:

1. Documentation did not indicate the procedure followed to define the duration of the monthly and annual testing. It could not be confirmed the duration lasted 30 seconds monthly and 90 minutes annually (for means of egress lighting) and 30 minutes annually (for anesthetizing locations).

2. Documentation did not indicate the date during the month that testing was performed.

3. Documentation did not identify by name or initials the person responsible for the testing.

Based upon observation, exit signs are not provided to identify access to two remote exits from the building. Failure to provide exit signs to correctly identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition.

Findings include:

A. On 10/21/20 & 10/20/20 while in the company of the COO, MMOPM & MC it was observed that corridors (and passages within designated suites) lacked proper exit signs to clearly identify access to at least two remote means of egress from the building to comply with 19.2.4.3, 19.2.10 and 7.10. Locations and conditions include:

1. At 4:00pm on 10/21/20 at the 2nd floor north wing smoke barrier doors a directional exit sign is provided where a directional exit sign is not appropriate to identify movement through the smoke barrier.

2. At 9:20am on 10/22 at the 1st floor Radiology suite north door a directional exit sign was observed where it should not be a directional sign as the directional change occurs beyond the doors to the suite.

3. At 10:20am on 10/22/20 at the Basement (indicated to be the "Ground floor") the exit sign at the north end of the corridor was not visible from the bulk of the corridor due to the sign being located beyond the bend in the corridor.

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:

A. On 10/21/20 at 3:50pm while in the company of the COO, MMOPM & MC it was observed that the old non-sprinklered OB delivery room on the 2nd floor was being used as a storage location. The door was not rated and not self-closing to comply with 19.3.2.1 and 19.3.2.1.3.

B. On 10/22/20 at 10:15am while in the company of the COO, MMOPM & MC it was observed that the Dirty Linen room in the Basement was not self-closing within 30 seconds (as required by 7.2.1.9.2 for power operated doors). The door took approximately 150 seconds to close from a fully open position.

C. On 10/22/20 at 10:20am while in the company of the COO, MMOPM & MC it was observed that the northern corridor door at the Basement Materials Management storage room did not close to a latched condition and the inactive door manual flush bolts were not maintained in the latched condition to provide positive latching for the active leaf to comply with 19.3.2.1, 8.7.1.1 & 19.3.6.3.5.

Based upon observation, the facility failed to provide documentation of monthly inspections for Kitchen hood suppression systems. Failure to perform and document monthly inspections can result in failure to observe deficiencies during periodic inspections of the system that could prevent proper operation of the system when needed.

Findings include:

On 10/22/20 at 10:00am while in the company of the COO, MMOPM & MC it was observed that inspection tags for the Basement Kitchen hood Ansul fire suppression systems were not filled out to indicate the date and initials of the inspector to indicate monthly inspections to comply with NFPA 17-2009, 11.2.1 & 11.2.4 (Dry Chemical systems) or NFPA 17A-2009, 7.2.1 & 7.2.5 (Wet Chemical systems).

Based upon observation, the fire alarm system is not installed in accordance with Code requirements. Failure to properly install the fire alarm system can result in failure of the system to operate.

Findings include:

On 10/22/20 while in the company of the COO, MMOPM & MC , it was observed that several circuits in the LGA Life Safety electrical panel in the basement were not provided with red markings and mechanical lock-on devices in accordance with NFPA 72-2010, 10.5.5.2.3 and 10.5.5.3 to prevent accidentally turning off the power to the fire alarm system.

Based upon observation, sprinkler systems are not installed in accoradance with Code requirements. Failure to properly install and maintain the sprinkler system can result in failure of the system to function to control a fire condition.

Findings include:

A. On 10/21/20 at 3:15pm while in the company of the COO, MMOPM & MC it was observed that two sprinkler heads were located in the 3rd floor Soiled Utility room (with the clinical sink) that were not a minimum of 6' apart to comply with NFPA 13-2010, 8.6.3.4.1.

B. On 10/22/20 at 9:50am while in the company of the COO, MMOPM & MC it was observed that the Basement Kitchen Storage room Freezer lacked sprinkler protection for a floor level indicated to be fully sprinklered to comply with NFPA 13-2010, 8.1.1.

Based upon observation, smoke barriers are not constructed or maintained in accoradance with Code requirements. Failure to properly construct and maintain smoke barriers can result in migration of fire/smoke between smoke compartments to compromise the usefullness of areas of refuge.

A. On 10/21/20 at 3:35 while in the company of the COO, MMOPM & MC it was observed that the smoke barrier near the 3rd floor communicating stair had unsealed penetrations and lacked a minimum 1/2-hour rating. The stair side vertical portion of the wall above the ceiling and the horizontal portion of the wall only had one layer of drywall on one side. Protection of the framing on the other side was not provided to qualify as 1/2-hour rated construction to comply with 19.3.7.3.

B. On 10/21/20 at 4:05pm while in the company of the COO, MMOPM & MC it was observed that the smoke barrier for the 2nd floor south wing had unsealed penetrations not in compliance with 19.3.7.3.

Based upon record review and staff interview, fire drills are not conducted and documented in accordance with Code requirements. Failure to conduct required fire drills can result in lack of training for staff to respond correctly during a fire/smoke condition.

Findings include:

On 10/21/20 at 1:00pm during record document review of Fire Drill documentation it was determined that drills were not conducted at least once per quarter per shift under varying conditions to comply with 19.7.1.6. A drill was not conducted for the 2nd shift of the 3rd quarter period 2020 and for the 3rd shift of the 4th quarter 2019. Times for conducting the drills did not have substantial variation. The 1st shift drills were conducted early afternoon approximately between 1:00pm and 2:00pm. The 2nd shift drills were conducted late afternoon at approximately 6:00pm. The 3rd shift drills were conducted at approximately between 1:30am and 2:30am.

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 10/21/20 at 4:10pm, while in the company of the COO, MMOPM & MC, it was observed at the 2nd floor Clean Utility room that a receptacle within 6'-0" of the sink fixture was not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(6).

Based on observation, the facility failed to install a compliant emergency electrical system. Failure to install and maintain these systems could result in delayed response for emergency power which could affect patients, staff and visitors during a utility power outage.

Findings include:

On 10/22/20 at 8:35am while in the company of the COO, MMOPM & MC, it was observed that connection of the battery charger for the emergency generators were connected at the battery end of the starting cables and not to the primary side of the starter solenoid (positive) and the EPS frame (negative) to comply with NFPA 110, 2010, 7.12.6.2.

Based upon observation, the essential electrical system receptacles are not installed in accordance with Code requirements. Failure to properly install components of the Essential Electrical System can result in failure to utilize available receptacles during loss of normal power.

Findings include:

On 10/22/20 at 9:05am while in the company of the COO, MMOPM & MC it was observed that some of the red receptacles located in Emergency Dept. Trauma room #4 were not labeled to identify the panel and circuit from which they were fed to comply with NFPA 70-2011, 517.19(A).

Based upon observation, Oxygen storage is not maintained in accordance with Code requirements. Failure to protect oxygen storage can result in accelarated combustion of combustible materials within the same storage location if oxygen leakage occurs.

Findings include:

On 10/21/20 at 3:40pm while in the company of the COO, MMOPM & MC it was observed that the 2nd floor Respiratory Care Storage room contained oxygen tank storage of less than 300 cf (at the time of observation) that was not separated from combustible if more than 300 cf is permitted (no signage limiting the quantity of tanks was observed) and signage to indicate oxygen storage was not provided to comply with NFPA 99-2012. The unsprinklered storage room could not be determined to be separated by 1-hour rated construction including a minimum 3/4-hour self-closing door assembly to comply with 19.3.2.1 and 8.7.1.