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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:

On September 30, 2020 at 2:00pm while in the company of the DEC it was observed at the south end of the Staff Elevator lobby on the 1st floor that a magnetic locking device was being installed (but not actively engaged) which did not comply with the requirements of 19.2.2.2.4 if actively locked to restrict unauthorized access through the required exit access door. The magnetic lock system could not be verified to meet all the requirements of any of the permitted systems allowed by 19.2.2.2.4.

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required. This deficient practice could result in the delayed egress during a fire event, which may affect patients, staff and visitors.

The finding is:

On September 30, 2020 at 1:30pm in the company of the EF the surveyor finds the installation of a fire suppression pre-action system within Stair CS4 at the concourse level in non-compliance with NFPA 101, 2012, 7.1.3.2 / 7.1.3.2.3. Staff indicated this system serves the IT Riser Shaft adjacent to the stair enclosure.

Based on observation, the overall square footage of non sleeping patient care suites exceeds the maximum allowed. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

Findings include:

A. On September 30,2020 at1:25pm while accompanied by the DF it was noted that the Life Safety floor plans indicates non sleeping patient care suites to be in excess of 10,000 s.f. The same floor plans indicate that there is an FSES for the condition, however, any FSES is considered out of date and does not contain current conditions of the physical environment. The suites do not comply with 19.2.5.7.3.3.

Locations observed:

1. Same Day Surgery suite is 11, 030 s.f.

2. Surgery suite is 11, 220 s.f.

Based upon observation, exit signage was not provided, was not fully visible, or incorrectly identified paths of egress. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition. This deficient practice could affect the safety of patients, staff, and visitors.

Findings include:

A. On September 30, 2020 while in the company of the ADHS it was observed that corridors (and passages within designated suites) lacked 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 observed include:

1. 8th Floor Adult Psychiatrc Wing at 10:30am, a directional 'EXIT' sign was not observed to be installed at the end of the south hallway of the 8 East exit corridor, to identify the secondary means of egress.

2. 7th Floor at 10:50am a directional 'EXIT' sign was not observed to be installed at the end of the south corridor, to identify the secondary means of egress.


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B. On September 30, 2020 while in the company of the ADF it was observed that corridors (and passages within designated suites) lacked 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.

Location observed:

1. At 10:45am, Illuminated 'EXIT' signage was observed not to be installed to identify the secondary means of egress from Corridor 2162. The cross-corridor doors in Corridor 2162 remain closed which leaves the illuminated exit signage beyond, not fully visible.


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C. On September 30, 2020 while in the company of the DF, exit signage was observed to be partially obstructed or missing which provides for dead end corridor conditions, and further does not comply with 19.2.5.2, 7.5.1, 7.10.1.2.1 or 7.10.1.5.1. Example locations:

1. At 10:50am Fifth floor, pair of cross corridor doors west of nurse station and north of Sicle Cell Clinic contain a sign reading "exit". However, this is not a designated exit.

2. At 11:15am Sixth floor, Stair #5 corridor contains a facility sign which blocks the view of a designated exit sign. This condition exists on several floors.

3. At 2:40pm Third floor, a public corridor adjacent to the elevators, lacks a designated exit sign at the north end.

4. At 2:45pm Third floor, Surgery suite means of egress adjacent to OR #18 lacks a exit sign indicating exiting is available in both directions.

Based on the observations on multiple floors, the HVAC Ducts penetrating the rated walls are installed with fire dampers not in compliance with the Manufacturers Installation instructions, failing to stop the spread of fire to the other adjoining areas, jeopardizing the life safety of the patients, staff and visitors:

Finding Includes:

A. On September 30, 2020 at 9:45am while accompanied by the ADHS, it was determined that the fire dampers installed in the designated fire walls were found not installed with Manufacturers Installation Instructions, as there was no verification of the retaining angles installed as it was covered with fire caulking, not in compliance with Section 8.3.3.2.

Locations includes:

1. 8th Floor - all locations
2. 7th Floor - all locations
3. 6th: Floor - all locations

Based upon observation, vertical openings beteen floor levels are not protected to maintain separation of floor levels. Failure to maintain separation of floor levels can result in fire/smoke conditions migrating to other floors of the building.

Findings include:

On September 30, 2020 at 11:45am while in the company of the ADHS, it was observed that the 7th floor Oxygen Storage Room had a Pneumatic Tube penetrating the floor above that did not have the annular space fire sealed to resist the transfer of fire/smoke to the floor above to comply with 19.3.1, 8.6, 8.3.4.2.

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 September 30, 2020 at 1:35pm while in the company of the DEC and ARS it was observed that the BioHazard storage room (with elevator) at the Emergency Dept. was not protected to comply with 19.3.2.1, 8.7.1.2 and 8.4.3.5 because a wooden wedge was being used to hold the door open.


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Based upon observation, sprinklered hazardous areas are not separated by a minimum of smoke resisting construction. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

Finding is:

B. On September 30, 2020 at 9:01am while in the company of the DF doors to hazardous areas were observed which do not comply with 19.3.2.1.3 for self closing, smoke tight requirements. Location observed: Third floor, Same Day Surgery Gowned Storage rooms A, B and C (rooms were formerly dressing room having the doors' bottom rails approximately 30 inches above the finished floor).

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:

A. On September 30, 2020 while in the company of the DEN and ARS it was observed that inspection tags for the 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). Locations observed include:

1. The Concourse level main Kitchen hood observed at 10:20am.

2. The 1st floor Servery hoods observed at 2:25pm.

Based on observation, Alcohol Based Hand Rub dispensors are not installed in accordance with Code requirements. Failure to properly install dispensors can create a potential fire hazard, thus jeopardizing the life and safety of the patients, staff and visitors.

Findings include:

On September 30, 2020 at 10:45am while in the company of ADHS an Alcohol Based Hand Rub dispensor near 8100 W on the 8th floor was installed directly above an active electric outlet, not complying with Sections 19.3.2.6(8)(a) and 8.7.3.1.

Based on observation and staff interview the facility lacks a complete identifiable Essential Electrical System (EES). Failure to provide and maintain this system places patients, staff and visitors at risk during a utility failure.

The finding is:

On September 30, 2020 at 1:00pm while in the company of the EF it could not be determined if the 1st floor electrical panel 1LLS was served by the Life Safety Branch of the EES. Panel 1LLS contained the service breaker for the Fire Alarm Panel marked in Red but not provided with a mechanical protective device as required by NFPA 72, 2010, 10.5.5.3. If this panel is part of the Life Safety Branch, the directory indicates connected loads not allowed by NFPA 99, 2012, 6.4.2.2.3.2 such as patient convenient receptacles and lighting.

Based on observation the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The finding is:

On September 30, 2020 at 10:30am while in the company of the EF the surveyor finds the lack of fire sprinkler protection for all the facilities traction elevator machine room (P1004) located on the 10th Floor. NFPA 13, 2010, 8.1.1

Based upon observation, waiting areas open to the corridor are not provided with supervision or smoke detection system. Failure to provide supervision or smoke detection devices may prevent the building's occupants from being alerted to a fire related emergency. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

On September 30, 2020, at 10:00am while in the company of the ADF, it was observed that Waiting Area 2710 is open to the corridor and lacks a supervisory station or smoke detection devices to comply with 19.3.6.1(2).

Based on observation not all exit access corridors are separated from use areas. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. On September 30, 2020 while in the company of the DF corridor walls were observed that do not comply with 19.3.6.2.3 as a barrier to limit the transfer of smoke.

Locations observed:

1. At 9:15am Third floor,West Wing containing Stair #6, corridor wall at the Blood Lab, tube penetration not sealed.

2. At 9:05am above pair of cross corridor doors #737522, conduit penetration not sealed.

Based on observation and staff interview the facility lacks complete Emergency power for the elevator cab controls. Failure to provide and maintain this system can result of unsafe condition for patients, staff and visitors during a utility outage.

The finding is:

On September 30, 2020 at 10:35am while in the company of the EF it could not be determined if the electrical panel 10 CL 1 in the tenth floor Electrical Room (P1004B) providing power to the Elevators' cab car lighting, control, communication and signaling systems is served by the Life Safety Branch of the Essential Electrical System. NFPA 99, 2012, 6.4.2.2.3.2 (5)

Based on observation, the facility failed to provide a means of egress which is dependable during an evacuation of an immediate area or evacuation of a smoke compartment. This deficient practice could affect patients and staff, if due to the lack of meeting properly conducted protocols, the staff failed to promptly respond during an emergency.

Findings include:

A. On September 30, 2020 while in the company of the DF, surveyor observed continuously stored equipment, C-arms, C.O.W's, instrument carts, lead aprons gurneys etc. within means of egress. This equipment ran the entire length of the means of egress. The stored equipment within the means of egress does not appear to comply with the proper maintenance of a means of egress in preparation for a prompt evacuation of nonambulatory patients. This condition does not comply with 19.2.3.5, 19.7.1.1, 19.7.2.1.1 and 19.7.3.1. Example conditions as follows:

1. At 1:35pm Surgery suite means of egress adjacent to OR # 16 and OR #17 contains equipment stacked up along a wall. A gurney is located in front of equipment and across from OR # 17. A crib is located across from OR #16, with numerous other equipment. A staff member was observed maneuvering equipment in order to find a location for the crib.

2. At 1:50pm the means of egress from numerous OR's requires a 90 degree turning radius for aided patient transport (gurneys stretchers wheelchairs). The location of parked/stored equipment, along with the proximity to cross corridor doors within the means of egress, appears to provide maneuvering obstacles. Two way traffic (staff aiding others) would be problematic.

Based on observation, the facility failed to install and maintain the piped medical gas system in accordance with Code requirements. Failure to maintain the system could affect patients, staff, and visitors in the area because the medical gas piping system could fail to operate properly and expose occupants to an oxygen-rich environment and increased fire hazard.

Findings include:

A. On September 30, 2020 at 1:30pm while in the company of the DEC and ARS it was observed that the Emergency Dept. treatment room 1763 lacked a door to separate the medical gas outlets from the shut off valve supplying them. This condition does not comply with NFPA 99 2012, 5.1.4.8(3).


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B. On September 30, 2020 at 2:10pm while accompanied by the DF, observation determined that medical gas station outlets are located in which there is not a wall between the outlets and the shut off valve supplying them. This condition does not comply with NFPA 99 2012, 5.1.4.8(3). Location observed: P.A.C.U.

Based on observation a portion of the facility lacks isolation of the medical gas piping systems from dissimilar materials. Failure to install and maintain this installation could result in the piping system failure. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

A. On September 30, 2020 at 10:30am while in the company of the ADF, it was observed above Corridor 2316 near Office 2010 that the medical gas pipe installation is not supported by copper tube hangers and supports in contact with the piping are not plastic-coated. NFPA 99, 2012, 5.1.10.11.4.4


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Based on observation and staff interview the facility lacks complete electrical bonding of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients and staff.

The finding is:

B. On September 30, 2020 at 2:30pm while in the company of the MF, it could not be confirmed through observation and interview at the exit conference with the EF that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B).

Based on observation and staff interview the facility lacks a complete identifiable Category 1 Essential Electrical System (EES). Failure to provide and maintain this system places patients, staff and visitors at risk during a utility failure.

The finding is:

On September 30, 2020 at 1:10pm while in the company of the EF the facility could not confirm that a complete EES was provided with separate and identifiable Life Safety, Critical and Equipment Branches. Surveyor identified during the facility walk through, only one Life Safety Panel which was non-compliant.

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

A. On September 30, 2020 at 2:20pm while accompanied by the DF, observation determined that critical care patient beds lack electrical receptacles served by normal power to comply with NFPA 70 2011 517-19(A). During discussions with the Facility representative it was determined that this condition exists in numerous locations.

Example locations observed:

1. Third floor Operating Room #16

2. Third floor Operating Room #10

3. Third floor P.A.C.U.

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

A. On September 30, 2020 at 2:20pm while in the company of the ADF, it was observed in Staff Toilet 4013 that a receptacle is not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(1).

B. On September 30, 2020 at 10:10am while in the company of the ADF, it was observed in the Nuclear Pharmacy 2519 and Diagnostic Science Laboratory 3153 that a surface mounted raceway with numerous receptacles is within 6'-0" of a sink fixture and is not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).

C. On September 30, 2020 at 11:15am while in the company of the ADF, it was observed in the Diagnostic Science Laboratory 3153 that a surface mounted raceway with numerous receptacles is within 6'-0" of a sink fixture and is not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).