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Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors attempting to use the egress paths because the paths could become restricted.

Findings include:

A. In the afternoon of 11/18/2014, the following conditions were observed at the Fifth Floor Center "angled" wall adjacent to the Center Elevator and the Center West Exit Stair:

1. The clear width of the Corridor on both sides of the angled wall was observed to be reduced, as compared to corridor widths at either end of the wall. The angled wall is thus not arranged to avoid an obstruction to the convenient removal of building occupants to comply with 19.2.3.3.

2. The door in the angled wall, when in the open (90 degree) position was observed to reduce the Corridor to less than half its required width which does not comply with 7.2.1.4.4.



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During the survey walk-through, accompanied by facility staff, it was observed that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

B.Corrected 04/15/2015

C. In the morning of 11/19/2014, in the basement Pharmacy, the exit access doors from the Pharmacy were observed to be equipped with multiple locks and latches, thus requiring more than one than one operation to open the doors. 7.2.1.5.4

During the survey walk-through, accompanied by facility staff, it was observed that the facility failed to provide suites that comply with 19.2.5 concerning travel distance to exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Findings include:

A. In the morning of 11/19/2014, on the fourth floor at the O.R. Suite identified on Life Safety drawings dated 10/1/2013 it was observed that egress from the most remote point of the med room located within the PACU area requires travel through two intervening rooms and has a travel distance to an exit access door exceeding the 50 feet permitted by 19.2.5.8. As measured on the 10/1/2013 Life Safety drawing the travel distance is approximately 85 feet.

During the survey walk-through, accompanied by facility staff, it was observed that paths of egress are not identified by exit signage in accordance with 19.2.10.1 and 7.10. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying
the path of egress.

Findings include:

A. In the afternoon of 11/18/2014, on the fifth floor, conflicting signage reading " Stairs " , " Not An Exit " , and " Emergency Exit " were observed on the door of the North B Wing stair. Facility staff removed the " Not An Exit " signage during the survey walk through. 19.2.10.1, 7.10

B. In the afternoon of 11/18/2014 and morning of 11/19/2014, on the fifth, fourth, and second floors of the Pavilion Wing, the door to the northwest stair was observed to be provided with signage reading " Stairs " and " Not An Exit. " This stair is identified as an exit stair on the Life Safety drawings, dated 10/1/2013, and is provided with an exit passageway to the exit discharge on the first floor. During staff interview it could not be determined whether this stair is a required exit or not.

C. In the morning of 11/19/2014, in the basement of the Pavilion Wing, it was observed that the exit access corridor door at the Boiler Room is not provided with exit signage. 19.2.10.1, 7.10

Based on random observation during the survey walk through on the morning of 11/19/2014, while accompanied by the electrical technician, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:


A. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

B. The fire pump was not equipped with a transfer switch at the fire pump location and was not served from the emergency generator to comply with NFPA-20, Section 6.2.

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.

Based on random observation during the survey walk-through, while accompanied by the electrical technician, the surveyor observed the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. On the afternoon of 11/19/2014, the surveyor observed that the emergency power panels are not properly separated into the life safety, the critical and the equipment branches as required by NFPA-70, Section 517-31 thru 35. The system one line diagram was not up to date and it did not show all emergency panels or what branch each transfer switch served, and most panels were not labeled with the branch of emergency power they served. Examples include:

1. On the morning of 11/19/2014, the surveyor observed that panel E5PH is serving a mixture of all three branches, life safety, critical and equipment.

2. On the morning of 11/19/2014, the surveyor observed that panel ETS01-5 serves a mixture of life safety and critical, including room receptacles (critical) Section 517-33, and elevator cab lighting that shall be served from life safety in accordance with section 517-32.

3. On the morning of 11/19/2014, the surveyor observed that panels CP2 and CP3 are new critical panels in the remodeled northeast wings on the second and third floors, and they are serving med gas alarms and emergency lighting which shall be served by the life safety panel to comply with Section 517-32.

4. On the morning of 11/19/2014, the surveyor observed that panel E2PA did not have enough detail in the circuit description to determine if it was life safety or critical.

5. On the morning of 11/19/2014, the surveyor observed that panel EBPA serves a mixture of life safety and equipment.

6. On the morning of 11/19/2014, the surveyor observed that two panels in the tunnel off of mechanical room B, EBPN and EBPO were labeled as critical panels , but served mostly equipment loads.

Based on random observation during the survey walk-through while accompanied by the electrical technician the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. On the morning of 11/19/2014, the surveyor observed that normal power receptacles were not provided in operating rooms on the fourth floor as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. On the morning of 11/19/2014, the surveyor observed that bonding of the piping for the gas system could not be located by staff as required by NFPA-70, Section 250-104(b). This could cause a potential difference between gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

C. On the morning of 11/19/2014, the surveyor observed that patient bed location on the third floor in wing A were not equipped with emergency receptacles as required by NFPA-70, Section 517-18. This could effect any patient in this wing in the event of a power outage.

D. Corrected 04/15/2015

Based on random observation during the survey walk-through on the morning of 11/19/2014, while accompanied by the electrical technician the surveyor found that portions of the elevator control system are not installed in accordance with NFPA-70, and ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. On the morning of 11/19/2014, the surveyor observed that each elevator was not equipped with a single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

B. On the morning of 11/19/2014, the surveyor observed that the disconnect for the emergency lighting and controls for each elevator was not fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).