HospitalInspections.org

Based on a review of plans dated 03/09/15 and observation, the facility failed to provide a protected path to a public way from required exit stairs. Failure to maintain required exits could result in loss of an exit path or delay of evacuation in an emergency.

Findings include:

1. At 11:40AM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor found the northwest stairs of Building C serves as a required exit for floors 2 through 4. The stair discharges into the 1st floor main lobby of Buildings A and B. The stair continues to the basement level. The DOF indicates the basement corridor is part of an exit enclosure; however, it is not identified on any plans as an exit passageway and the level of exit discharge is identified with an exit sign in the stair as the 1st floor lobby.

The surveyor finds from document review of plans dated 03/09/15, with the DOF in attendance, this exit stair is the only exit stair which is accessible from the 4th floor exit access corridor. Another exit stair which is accessible from other floors, Building C south stair, has a direct discharge to the outside. There is no complying exit access path to Building C south stair from the 4th floor. The surveyor finds the provider is not able to demonstrate how the Building C northwest stair complies with 7.7.1 and/or 7.7.2. The surveyor finds the exit discharge into the 1st floor lobby does not comply with 7.7.1. and that this exit path cannot comply with 7.7.2 because it is the only exit from the 4th Floor and therefore must discharge in accordance with 7.7.1. The surveyor also notes the ground floor of this building is not sprinklered and there are two elevator door openings in the ground floor corridor, described by the DOF as a possible exit enclosure. Lack of sprinkler protection means the stair cannot comply with 7.7.2. The elevator doors openings are not permitted within an exit enclosure under 9.4.6.
Based on the above, the exit discharge does not comply with 7.7.2 or 7.7.2

2. At 11:45AM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor observed the level of exit discharge for Building C northwest stair is identified as the 1st floor; however, the stair continues down to the basement level and lacks an interrupter gate or other effective means to restrict travel below the level of exit discharge in accordance with 7.7.3.

4. Corrected 09/16/2015

Based on a review of plans dated 03/09/15 and observation, the surveyor finds that a required exit stair lacks a protected path to a public way. Failure to maintain required exits could result in loss of an exit path or delay of evacuation in an emergency.

Findings include:

1. Corrected 09/16/2015

2. a. Corrected 09/16/2015
b. Corrected 09/16/2015
c. Corrected 09/16/2015
d. Corrected 09/16/2015

3. At 1:45 PM on March 13, 2015, with the DOF present, the VPOF and SO in attendance, the surveyor observed the exit discharge for the Building B center stair discharges into a ground floor space with two elevator door openings. The space is identified by the DOF as an exit enclosure with a door directly to the outside. It is identified on the plans with a two-hour fire rated enclosure; however, it is not identified as an exit passageway. The location cannot serve as an exit enclosure in accordance with 7.7.1; it does not comply with 9.4.7 which does not permit an elevator door in an exit enclosure.
Based on the above findings the surveyor finds that the provider is not able to demonstrate how the Building B center stair complies with 7.7.1 or 7.7.2 of NFPA 101 - 2000.

4. Corrected 09/16/2015
5. Corrected 09/16/2015
6. Corrected 09/16/2015

Based on observations and staff interviews during the survey walk-through, March 12-13, 2015, and based on document review, and staff interview, the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

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.