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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. A series of doors to the Second Floor Surgical Department Inpatient Holding Room were observed that are not positive latching as required by 19.3.6.3.2. Locations observed include:

1. East pair of doors.

2. West pair of doors.

3. North pair of doors.

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. During an interview held in the Facilities Conference Room on the morning of September 29, 2009, the provider's Director of Facilities and Safety stated that Stair C constitutes a convenience stair. However, exit signs were observed which direct occupants to Stair C on all building stories. It could thus not be determined whether Stair C is an exit stair or a convenience stair. Should Stair C constitute an exit stair, the following deficiencies exist:
1. The Stair is not provided with an egress path to a a public way, as required by 7.7.1., because there is no identified level of exit discharge.

2. Corrected 05/26/10.

Update 05/26/10: Based upon review of the Life Safety Master Plan it appears that the designated stair Exit "C" on all building stories which discharges on the Ground Floor level utilizes an Exit Passageway. This exit passageway has communicating openings such as Elevators ( No. 2E and No. 1E) that are being opened into this exit enclosure that do not meet requirements of NFPA 101 2000 Section 7.1.3.2.2.

B. Corrected 05/26/10.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. An exit sign was observed, in the Sixth Floor Administrative Suite (immediately north of Exit Stair B), which directs occupants through a door which can be secured against passage in the indicated direction of egress as prohibited by 7.10.

Based on staff interview and random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a series of interviews held throughout the survey, provider representatives were not able to clarify whether portions of the building constitute suites as defined by 19.2.5., or whether these areas constitute a series of rooms served by exit access corridors. The surveyor notes that all of the areas listed below were shown on the provider's Life Safety Master Plans as rooms served by corridors. Portions of the Hospital for which suite limits are not indicated include:
1. Fourth Floor:

a. North Intensive Care Unit. Not all Patient Sleeping Rooms on this Unit are provided with positive latching doors as required by 19.3.6.3.2.; the unit was surveyed as a suite and no deficiencies were cited.
b. South Intensive Care Unit. Not all Patient Sleeping Rooms on this Unit are provided with positive latching doors as required by 19.3.6.3.2.; the unit was surveyed as a suite and no deficiencies were cited.

2. Second Floor:
a. Surgical Department Inpatient Holding Room. This room, which is used directly for patient treatment, was identified on the Life Safety Master Plans as a Corridor as prohibited by 19.3.6.1. For deficiencies cited at this room, refer to K-018.

b. Post Acute Care Unit (PACU). This apparent suite, which includes several open Recovery Bays, was identified on the Life Safety Master Plans as constituting a Corridor as prohibited by 19.3.6.1.

1) During an interview held at the site on the afternoon of September 29, 2009, the Director of Facilities and Safety was not able to identify the limits of the apparent suite.

2) Surveyor 14290 notes that the pair of doors between the PACU and the Same Day Surgery Unit to the north were observed to not be positive latching; it could not be determined from the information provided whether these doors require positive latching hardware for compliance with 18.3.6.3.2.

c. Same Day Surgery Unit. This apparent suite, which includes 2 open Treatment Bays, was identified on the Life Safety Master Plans as constituting a Corridor as prohibited by 19.3.6.1. During an interview held at the site on the afternoon of September 29, 2009, the Director of Facilities and Safety was not able to identify the limits of the apparent suite.

3. First Floor:
a. Nuclear Medicine Unit. During an interview held at the site on the morning of September 30, 2009, the provider's Director of Facilities and Safety was not able to clarify whether the unit constitutes a suite as defined by 19.2.5. Should the Unit constitute a series of rooms served by Corridors as described on the Life Safety Master Plans, the following deficiencies exist.
1) Four Patient Treatment Bays were observed to be open to the Corridor as prohibited by 19.3.6.1.

2) Corrected 05/26/10.

b. Cardiac Catheterization Procedure Unit. Not all Patient Treatment Rooms on this Unit are provided with positive latching doors as required by 19.3.6.3.2.; the unit was surveyed as a suite and no deficiencies were cited.

4. Mezzanine:

a. Emergency Department. Nuclear Medicine Unit. During an interview held at the site on the morning of September 30, 2009, the provider's Director of Facilities and Safety was not able to clarify whether the Unit constitutes a suite as defined by 19.2.5. Should the Unit constitute a series of rooms served by Corridors as described on the Life Safety Master Plans, the following deficiencies exist.
1) The door to the former Seclusion Room, now used as a Patient Treatment Room, was observed to not be positive latching as required by 19.3.6.3.2.

2) Carts and equipment were observed which obstruct most Corridors within the Department as prohibited by 19.2.3.3. and 7.1.10.2.1.

b. ED Fast Track Unit. Nuclear Medicine Unit. During an interview held at the site on the morning of September 30, 2009, the provider's Director of Facilities and Safety was not able to clarify whether the Unit constitutes a suite as defined by 19.2.5. Should the Unit constitute a series of rooms served by Corridors as described on the Life Safety Master Plans, then carts and equipment were observed which obstruct most Corridors within the Department as prohibited by 19.2.3.3. and 7.1.10.2.1.

Updates 05/26/10:
A. Based on review of the facility's Life Safety Plans, it was determined that the information shown are inaccurate due to indicating stair enclosures and shafts on the CADD generated Life Safety Plans (as 1 hour fire wall-designated color purple on the Life Safety Legend).

B. According to the Updated Life Safety Plans- Ex. Fifth Floor Life Safety Plan: No apparent means of egress to adjacent smoke compartment (North of compartment with Exit B Stair) is being identified.
The identified travel distance of 173 feet from a Patient Room across the Dumb Waiter No. 3 leads to the smoke compartment door near the Patient Room 50 which has no designation of exit to lead occupants into an adjacent compartment. Section 19.2.4.3 indicates that egress shall be permitted through an adjacent compartment(s) but shall not require return through the compartment of origin. Note that this appears to be present on every floor.

C. Based on review of the facility's updated Life Safety Plan documents, it was detemined that:

1. Fifth Floor Life Safety Plan: Corridor 500CJ has less than two approved exits to comply with 19.2.5.9 and in accordance with Sections 7.4. and 7.5. It appears to be present on every floor Ex. Sixth Floor, Fourth Floor, Third Floor and Second Floor.

2. First Floor Life Safety Plan: With the removal of exit signs by the two sets of double doors leading to the Radiology Suite has created an excessive dead end corridor to comply with 19.2.5.10.

3. Identify designated exits, exit discharges, exit passageway and horizontal exits on the Life Safety Plan. Horizontal Exits if any are not identified on the facility's updated Life Safety Plans. Designated horizontal exits shall comply with 19.2.2.5 and 7.2.4.

4. Fourth Floor Life Safety Plan: Exit sign located on Corridor 400CW appears to direct occupants into the designated MED/ICU Patient Suite which is not allowed by Section 19.2.5.9.

Based on random observation during the survey walk-through, staff interview, and document review, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. A series of perimeter ventilation shafts were observed which connect the Sixth through Third Floors between pairs of Patient Sleeping Rooms in the "Main Building." During an interview held in the Facilities Conference Room on the afternoon of September 28, 2009, based on the provider's Life Safety Master Plans, it was determined that there appear to be 21 such ventilation shafts, all serving below-window induction units in Patient Sleeping Rooms. The following deficiencies were observed relative to these ventilation shafts:

1. During an interview held in a Sixth Floor Patient Sleeping Room, the provider's Director of Facilities and Safety was not able to verify that the shaft enclosures carry a minimum 2 hour fire resistance rating required by 19.3.1.1., 8.2.5.4(1), and NFPA 90A 1999 3-3.4.1.

2. Penetrations of the ventilation shafts by ductwork were observed to lack fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.1.1. During an interview held in a Sixth Floor Patient Sleeping Room on the afternoon of September 28, 2009, the provider's Director of Facilities and Safety acknowledged that the cited condition was typical for these shaft enclosures.

3. Access panels were observed in the ventilation shafts that do not carry a minimum 1-1/2 hour fire resistance rating as required by 19.3.1.1., 8.2.5.4(1), and 8.2.3.2.3.1(1). During an interview held in a Sixth Floor Patient Sleeping Room on the afternoon of September 28, 2009, the provider's Director of Facilities and Safety acknowledged that the cited condition was typical for these shaft enclosures.

B. A series of toilet exhaust shafts were observed which connect the Sixth through Third Floors between Patient Sleeping Rooms in the "Main Building." During an interview held in the Facilities Conference Room on the afternoon of September 28, 2009, based on the provider's Life Safety Master Plans, it was determined that there appear to be 18 such toilet exhaust shafts. Penetrations of the toilet exhaust shafts by ductwork were observed to lack fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.1.1. During an interview held in a Sixth Floor Patient Sleeping Room on the afternoon of September 28, 2009, the provider's Director of Facilities and Safety acknowledged that the cited condition was typical for these shaft enclosures.



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C. 1. Corrected 05/26/10.

2. Corrected 05/26/10.

3. Corrected 05/26/10.

D. Corrected 05/26/10.

E. 1. Corrected 05/26/10.

2. Corrected 05/26/10.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.