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Based on observation the facility failed to provide adequate smoke detectors. Surveyor observed between 10:30 and 11:30 am on 8/15/12 that North Tower levels 1, 2 and 3 nursing units had identical areas for nourishment open to corridor with unattended coffee bar. No smoke detection was observed to be present. This does not meet NFPA 101, 18.3.6.1. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5.

Based on observations during the survey walk on the afternoon of 8/15/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to maintain the egress corridor. The egress corridor contained both oxygen outlets at midtower's first floor's 1) imaging corridor and 2) imaging's sub waiting and 3) imaging corridor near the control room . Patient care can not occur in an egress corridor.
Corridors shall be separated from all other areas by partitions complying with 18.3.6.2. through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observation the facility failed to maintain exit signage. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there was the following issue. There was a missing exit sign in the central plant south exit.

Based on observations during the survey walk on the afternoon of 8/15/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to provide an exit sign marking the exit path. This occurred in the egress corridor, near the south tower ' s first floor ' s electrical room and exterior doors leading to the generators. Exit, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Based on observation the facility failed to provide adequate smoke barriers. The inspector observed, while accompanied by the System Engineer, the Safety Officer, the Compliance Coordinator, the Engineering Tech, and the Safety Tech during the hours of the inspection from 1:00 pm to 5:00 pm on 8/14/2012 that there were penetrations in the smoke barriers. They were at the following door locations: 1) FDMT3-007, 2) FDST2-025, 3) ST4-019, 4) ST4-016, 5) FDST4-006, 6) FDST2-006, 7)FDST2-013, 8) FDST2-021, 9) FDNT2-005, 10) FDNT2-015, 11) FDMTI-008, 12) FDMICU-001, 13) FDNUC-001, 14) FDRAD-001, 15) FDCATHREC-006, 16) FDCATH-007, 17) FDDIAL-001, 18) FDRAD-007, 19) FDRAD-011, 20) FDMEDREC-001, 21) FDNTI-017, 22) FDPREOP-001, 23) FDREC-001, and FDREC-007.

Based on observations during the survey walk on the afternoon of 8/15/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to assure the doors in smoke barriers completely shut. This allowed a gap and prevented a smoke tight seal at the meeting edges of the doors when closed a the second floor ' s corridor connection between midtower and south tower.

Based on observations during the survey walk on the afternoon of 8/14/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to assure the doors in rated barriers had the required smoke control amenities. First floor labor department ' s storage room ' s double doors had a gap between the door ' s meeting edges. This could allow smoke from the storage room to enter the egress corridor. A smoke tight seal at the meeting edges of the doors when closed shall be provided.

Based on observation the facility failed to provide adequate fire doors at hazardous locations. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that the following locations did not have 45 minute fire rated doors. They were: 1) FDST4-010W, 2) FDST4-003, 3) FDST3-004, 4) two doors at Clean Utility on 3rd floor, south tower, 5) clean utility at 2nd floor, south tower, 6) two doors at clean utility (converted from ante) on 2nd floor, south tower, 7) soiled utility in dialysis, 8) storage in dialysis, 9) two doors in cath pre/post op clean utility, 10) pump sub station storage, FDCVOR-007, and 10) south tower, cath lab clean utility.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that the following locations did not have a closer on the door. They were: 1) lab 1 (pathology storage) on the 1st floor, 2) cath pre/post storage, 3) cath pre/post clean utility, and 4) anesthesia equipment storage in the O.R. suite.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that at the following location the door did not close and latch: 1) FDST2-018.

Based on observations during the survey walk on the afternoon of 8/15/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to maintain a rated barrier. First floor ' s midtower ' s MICU soiled utility door did not latch at the door frame when the door was in a closed position.

Based on observation the facility failed to provide a complete sprinkler system. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there were the following issues. There was a missing head at the following location(s): 1) under the landing of the South Tower Stairwell #4.

Based on observations during the survey walk on the afternoon of 8/14/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the first floor ' s administration ' s IT office. The adjacent IT room has a halon system and also the adjacent admitting room has a wet system but that office has no suppression system.

Based on observation the facility failed to provide adequate medical gas. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there were the following issues with missing or improper labeling of medical gas shut off valves at the following locations. They were: 1) 2nd floor, south tower, cath lab holding, 2) 1st floor transitional care unit. This is based on the following: " Identification. (b) Shutoff Valves. Shutoff valves shall be identified as to the following. 3. The rooms or areas served. " - NFPA 99, 1999, 4-3.1.2.14.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there was a medical valve shut off in the same space that the outlets are located. This was in the following locations: 1) cath recovery on the first floor, and 2) level 1 PACU labeled " 18-21 " . Note the following section from NFPA 99, " Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet. Zone valves shall be readily operable from a standing position in the corridor on the same floor they serve. " - NFPA 99, 1999, 4-3.1.2.3(d).

Emergency Generator:

Based on observation the facility failed to provide adequate clearance around one of the generators in the generator farm. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there was combustible wood storage adjacent to one of the generators. NFPA does not site a specific distance to remove combustibles. The code states the following: " The room or space in which the EPS equipment is located shall not be used for storage purposes. " - NFPA 110, 2002: 7.11.1. The wood should moved back a sufficient distance to not pose a danger to the generator.

Based on observations during the survey walk on the afternoon of 8/14/2012, with the Director of Facility Maintenance and Engineering Team Leaders and technicians of the engineering staff, the facility failed to assure that the essential electrical system was in full compliance. Nurse call was powered by the life safety branch of the essential electrical system. This panel LL1 was located at south tower's first floor's electrical room. This equipment should be powered from the critical branch panel.

Also a receptacle in the telephone room was powered by the life safety branch of the essential electrical system from the first floor ' s electrical panel LLSA. This receptacle should be powered from a different branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observation the facility failed to provide a directory in an electrical panel and to properly label critical outlets in critical areas.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there was a missing directory on panel LL3 in the electrical room on the 3rd floor, south tower.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that the critical light switches did not have permanent labels in the ICU, 2nd floor, south tower.

" Critical Care Areas: Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panel board. Emergency System receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. " NFPA 70, 2002, 517.19(A).

Based on observation the facility failed to control the location of alcohol base hand rubs. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there were the following issues. There were alcohol based hand rubs within 6 " of electrical devices at the following locations: 1) monitoring station and access control on the 3rd floor, south tower, and 2) the revenue cycle utilization review department on the 3rd floor south tower,

Based on observation the facility failed to provide adequate smoke detectors. Surveyor observed between 10:30 and 11:30 am on 8/15/12 that North Tower levels 1, 2 and 3 nursing units had identical areas for nourishment open to corridor with unattended coffee bar. No smoke detection was observed to be present. This does not meet NFPA 101, 18.3.6.1. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5.

Based on observations during the survey walk on the afternoon of 8/15/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to maintain the egress corridor. The egress corridor contained both oxygen outlets at midtower's first floor's 1) imaging corridor and 2) imaging's sub waiting and 3) imaging corridor near the control room . Patient care can not occur in an egress corridor.
Corridors shall be separated from all other areas by partitions complying with 18.3.6.2. through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observation the facility failed to maintain exit signage. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there was the following issue. There was a missing exit sign in the central plant south exit.

Based on observations during the survey walk on the afternoon of 8/15/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to provide an exit sign marking the exit path. This occurred in the egress corridor, near the south tower ' s first floor ' s electrical room and exterior doors leading to the generators. Exit, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Based on observation the facility failed to provide adequate smoke barriers. The inspector observed, while accompanied by the System Engineer, the Safety Officer, the Compliance Coordinator, the Engineering Tech, and the Safety Tech during the hours of the inspection from 1:00 pm to 5:00 pm on 8/14/2012 that there were penetrations in the smoke barriers. They were at the following door locations: 1) FDMT3-007, 2) FDST2-025, 3) ST4-019, 4) ST4-016, 5) FDST4-006, 6) FDST2-006, 7)FDST2-013, 8) FDST2-021, 9) FDNT2-005, 10) FDNT2-015, 11) FDMTI-008, 12) FDMICU-001, 13) FDNUC-001, 14) FDRAD-001, 15) FDCATHREC-006, 16) FDCATH-007, 17) FDDIAL-001, 18) FDRAD-007, 19) FDRAD-011, 20) FDMEDREC-001, 21) FDNTI-017, 22) FDPREOP-001, 23) FDREC-001, and FDREC-007.

Based on observations during the survey walk on the afternoon of 8/15/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to assure the doors in smoke barriers completely shut. This allowed a gap and prevented a smoke tight seal at the meeting edges of the doors when closed a the second floor ' s corridor connection between midtower and south tower.

Based on observations during the survey walk on the afternoon of 8/14/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to assure the doors in rated barriers had the required smoke control amenities. First floor labor department ' s storage room ' s double doors had a gap between the door ' s meeting edges. This could allow smoke from the storage room to enter the egress corridor. A smoke tight seal at the meeting edges of the doors when closed shall be provided.

Based on observation the facility failed to provide adequate fire doors at hazardous locations. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that the following locations did not have 45 minute fire rated doors. They were: 1) FDST4-010W, 2) FDST4-003, 3) FDST3-004, 4) two doors at Clean Utility on 3rd floor, south tower, 5) clean utility at 2nd floor, south tower, 6) two doors at clean utility (converted from ante) on 2nd floor, south tower, 7) soiled utility in dialysis, 8) storage in dialysis, 9) two doors in cath pre/post op clean utility, 10) pump sub station storage, FDCVOR-007, and 10) south tower, cath lab clean utility.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that the following locations did not have a closer on the door. They were: 1) lab 1 (pathology storage) on the 1st floor, 2) cath pre/post storage, 3) cath pre/post clean utility, and 4) anesthesia equipment storage in the O.R. suite.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that at the following location the door did not close and latch: 1) FDST2-018.

Based on observations during the survey walk on the afternoon of 8/15/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to maintain a rated barrier. First floor ' s midtower ' s MICU soiled utility door did not latch at the door frame when the door was in a closed position.

Based on observation the facility failed to provide a complete sprinkler system. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there were the following issues. There was a missing head at the following location(s): 1) under the landing of the South Tower Stairwell #4.

Based on observations during the survey walk on the afternoon of 8/14/2012, with the Engineering Team Leader and an engineering staff technician, the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the first floor ' s administration ' s IT office. The adjacent IT room has a halon system and also the adjacent admitting room has a wet system but that office has no suppression system.

Based on observation the facility failed to provide adequate medical gas. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there were the following issues with missing or improper labeling of medical gas shut off valves at the following locations. They were: 1) 2nd floor, south tower, cath lab holding, 2) 1st floor transitional care unit. This is based on the following: " Identification. (b) Shutoff Valves. Shutoff valves shall be identified as to the following. 3. The rooms or areas served. " - NFPA 99, 1999, 4-3.1.2.14.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there was a medical valve shut off in the same space that the outlets are located. This was in the following locations: 1) cath recovery on the first floor, and 2) level 1 PACU labeled " 18-21 " . Note the following section from NFPA 99, " Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet. Zone valves shall be readily operable from a standing position in the corridor on the same floor they serve. " - NFPA 99, 1999, 4-3.1.2.3(d).

Emergency Generator:

Based on observation the facility failed to provide adequate clearance around one of the generators in the generator farm. The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there was combustible wood storage adjacent to one of the generators. NFPA does not site a specific distance to remove combustibles. The code states the following: " The room or space in which the EPS equipment is located shall not be used for storage purposes. " - NFPA 110, 2002: 7.11.1. The wood should moved back a sufficient distance to not pose a danger to the generator.

Based on observations during the survey walk on the afternoon of 8/14/2012, with the Director of Facility Maintenance and Engineering Team Leaders and technicians of the engineering staff, the facility failed to assure that the essential electrical system was in full compliance. Nurse call was powered by the life safety branch of the essential electrical system. This panel LL1 was located at south tower's first floor's electrical room. This equipment should be powered from the critical branch panel.

Also a receptacle in the telephone room was powered by the life safety branch of the essential electrical system from the first floor ' s electrical panel LLSA. This receptacle should be powered from a different branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observation the facility failed to provide a directory in an electrical panel and to properly label critical outlets in critical areas.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that there was a missing directory on panel LL3 in the electrical room on the 3rd floor, south tower.

The inspector observed, while accompanied by the Safety Officer, the Compliance Coordinator, the Engineering Tech, the Life Safety Tech II, and the Network Manager during the hours of the inspection from 9:30 am to 4:30 pm on 8/15/2012 that the critical light switches did not have permanent labels in the ICU, 2nd floor, south tower.

" Critical Care Areas: Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panel board. Emergency System receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. " NFPA 70, 2002, 517.19(A).