HospitalInspections.org

A. Based on review of the Life Safety Plans dated 10/09/09, based on random observation during the survey of February 5 through 8, 2013 and based on personnel interview including the Director of Engineering, the Director of Safety and the Director of Corporate Facilities the surveyor finds that portions of two buildings do not comply with 19.1.6.2.

Findings include.

1. Stair 7 is a two story stair in the 400 building that is not an exit. The stair is part of the one story (with Basement) portion of the 400 Building that is identified as Type I construction. The stair has a unrated monolithic ceiling with unrated access panels. The stair has unprotected steel (roof structure) above. This unprotected roof structure is not compatible with the designated construction type for the building and does not comply with 19.1.6.2.

2. The Emergency Room/Imaging one story addition is Type II (000) construction. The adjacent 1st Floor Lab is part of the 5 story, 400 building to the north. The 400 Building is identified as Type I (332) construction; however, a continuous two hour fire barrier is not identified separating all portions of the building with Type II (000) construction from the Type 1 Building. This reduces the construction type of the 400 Building to Type II (000) construction. The 400 building therefore does not comply with 19.1.6.2.

3. The provider identified a portion of the 1st Floor as Nuclear Medicine. The surveyor was not able to identify which building this space is located; However, the surveyor observed fire-proofed steel above the ceiling in Nuclear Medicine and observed unprotected steel in the corridor south of this space. The surveyor did not find a two hour fire barrier between these differing construction types.

4. 400 Building that is identified as Type I construction. The Basement Level Gift Shop Storage has two structural beams at the end of the room that have missing fire-proofing.

end

A. Based on review of the Life Safety Plans dated 10/09/09, based on random observation during the survey of February 5 through 8, 2013 and based on personnel interview including the Director of Engineering, the Director of Safety, the Director of Corporate Facilities, and the facilities architectural consultant, the surveyor finds that portions of two buildings do not comply with 19.1.6.2.

Findings include.

1. The Interconnecting Building/wing has been cited in this survey as part of the 350 Building. It connects the 350 Building to the 400 Building and is separated from the 400 Building by a two hour fire barrier. It is five stories in height and it is Type I (332) construction. This wing is only partially sprinklered on each floor.

The Building identified as the Emergency Room/Imaging Addition is a one story building of Type II (000) construction. It was built immediately north of the Interconnecting Wing and extends partially under the Interconnecting Wing at Central Waiting. This building may or may not be fully sprinklered.

The surveyor finds no evidence of a two hour fire separation between the 350 Building [that is Type I (332) Construction] and the one story addition that is identified as the Emergency Room/Imaging Addition [that is Type II (000) construction]. Based on this the surveyor finds that the 350 Building is five stories in height, is Type II (000) construction and does not comply with 19.1.6.2. Sprinkler protection does not change this citation.

2. The 1st Floor of the 350 Building has a pair of fire doors into the 400 Building opposite Room D155. A portion of the 350 building in front of these fire doors has unprotected structural steel [Type II (000) construction] in an area that is surrounded by two buildings that are both Type I construction.

All construction types are based on NFPA 220 and not on ICC.

end

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed Valentine Day decorations in the 5th Floor ICU that include combustible paper hanging from ceilings and and paper decorations on walls. The surveyor did not find that the decorations observed were deficient. However, the surveyor also observed seasonal decorative lighting on an extension cord. The surveyor inquired whether the facility has a written seasonal decoration policy. The provider indicated that they did not have a written seasonal decoration policy.

The provider lacks written guide lines to control compliance with 19.3.3.2 for temporary interior finishes and 19.7.5.4 for decorations.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that areas that are open to exit access corridors do not comply with 19.3.6.1 of NFPA 101 - 2000.

Findings include:

1. The 1st Floor Central Waiting area is a very large waiting area on both sides of a corridor. It includes a cafe food serving area and multiple seating aeras. It is sprinklered throughout. The areas open to the corridor are not supervised 24/7 and the smoke detection installed does not cover every part of the area open to the corridor in accordance with 19.3.6.1, exception # 1 and NFPA 72.

A. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the Interconnect Wing on Floors 2 through 5 link the 350 Building to the 400 Building and are used for inpatient movment. Although the provider identifies these wings as business occupancies, the surveyor finds that they are health care occupancies because patients are moved in beds through the wings.

1. Each floor has continuous storage closets on one side of the corridor. Each closet door has a dead-bolt lock that is not positive or automatic latching in accordance with 19.2.6.2.

A. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the 2nd Floor of the 350 Building has multiple patient room doors with white isolation boxes hung on the corridor side of the doors. These boxes obstruct the door opening width to less than 41 ½ " clear opening (typically only 39 " to 40 " ) and do not comply with 18.2.3.5 (the door widths may not be diminished below what they were designed as unless they exceed 41 1/2").


12799

B. Based on observations, the facility failed to provide corridor doors that resist the passage of smoke as required by NFPA 19.3.6.1.

1. On 2/5/13 at 11:15 AM, surveyors with the Director of Biomed and Safety observed that the gap between the meeting edges of the pair of doors at the North end of the suite (suite doors) into the Cardiac ICU on the 5th floor exceeded 1/8" when closed.

Based on observation and an interview, it was determined that the facility failed to maintain the doors and hardware per NFPA 101, Section 39.2.2.2 and 7.2.1. In the event of a fire the occupants may not be able to exit and escape from smoke and fire.

Findings include:

On 2/7/13, 2nd floor, during the walk through of the facility with the Director of Engineering, it was observed that the double cross corridor doors separating the psych office and the means of egress.One door contains a non-functional hardware (knob), and can not be opened without opening the second door first. The operation of the doors is not clear and the doors lack signage indicating which door is functional. The current arrangement does not meet with the requirements of NFPA 101, 7.2.1.5.5.

Based on observation, it was determined that the facility failed to maintain the closure of the corridor doors per NFPA 101, Section 18.3.6.3. In the event of a fire the occupants would not be protected from smoke and fire.

Findings include:

On 2/6/13 at 2:00 PM, Basement Peri-Op Office (E009), during the walk through of the facility with the Director of Engineering, it was observed that the door to corridor was held open with an unapproved hold open device (wedge) that does not comply with NFPA 101, 18.3.6.3.2.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds vertical openings are not protected in accordance with 8.2 of NFPA 101

Findings include:

1. The Basement Mechanical Room for the 400 Building has a vertical shaft that penetrates three or four floors. The shaft has an insulated duct inside. The shaft may be an air intake shaft. The shaft does not comply with 8.2:

a. The shaft does not appear on the Life Safety Plans as a fire rated shaft enclosure.

b. The shaft enclosure is used for storage; this does not comply with NFPA 90A.

c. The roof of the shaft appears to be wood/lumber (construction that is not compatible with the construction type identified for the 400 Building).

Based on random observation during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 39.3.1. This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the building.

Findings include:

1. On 2/7/13, Basement Mechanical room, by EKG, during the walk through of the facility with the Director of Engineering, it was observed that the mechanical room contains a triangular shaft at the block wall. The fire rating could not be determined from the Life Safety Code drawings and the access door was constructed of wood and not fire rated, 8.2.3.2.3.1.

2. On 2/7/13, 5th floor, Mechanical Room, during the walk through of the facility with the Director of Engineering, it was observed that the mechanical room contains several large unsealed floor penetrations.


3. On 2/7/13, 2nd floor, during the walk through of the facility with the Director of Engineering, it was observed the staff area, back wall, is a designated 2 hour rated building separation from the 400 building. The wall contains a door to a patio, utilized by both business and hospital psych. The wall contains a ventilation shaft which is not complete as a fire rated shaft enclosure above the ceiling tiles and does not meet 39.3.1.1.

Based on observation and the minimal drawings provided by the facility staff, there were multiple unsealed penetrations in the walls designated as one hour walls on the floor plans.

1. On 2/08/13 in the morning, based on observations, surveyor with Director of Engineering observed multiple unsealed penetrations at the designated one hour wall separating the tenant floors from the two story Lobby in Outpatient Care Center.

Based on observations, there were multiple unsealed penetrations in the wall designated as the one hour wall separating the Pavilion floors from the two story Main Entrance and Lobby.

1. On 2/07/13 surveyor observed tube system pipe penetrations above the toilet room nearest to Outpatient Registration that were not sealed for fire rated construction.

2. On 2/07/13, based on surveyor observations, there were multiple sleeves that were not sealed by fire rated construction in the floor of the Telecommunications Room on the Second Floor behind the elevators.

3. On 2/07/13, based on surveyor observations, there were unsealed penetrations in the designated one hour rated walls between the two story lobby an the of the Telecommunications Room on the Second Floor behind the elevators.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed doors with hold open devices do not comply with 19.2.2.2.6 and 7.2.1.8: Findings include:

1. Clean Utility Room A540 is large enough to be a hazardous area. The corridor door to the room has a magnetic hold open device but lacks smoke detection within five feet of the door.

2. 5th Floor pair of fire doors between the 350 Building and the East Building at the north connection. The fire doors took to much time to close to latch upon activation of the fire alarm system and at least one of the doors did not latch.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that fire doors with hold open devices are not installed to comply with 7.2.1.8 of NFPA 101.

Findings include:

1. 1st Floor Dietary Dry Storage Room: One pair or more of doors to this hazardous area have magnetic hold open devices but lack local smoke detection on each side of the doors that will detect smoke and release the doors.

2. The Fire Pump Room has a fire door that does not latch at all.

3. The pair of fire doors from the South Lobby to the Cafeteria failed to close and latch upon activation of the fire alarm system. One door failed to close to latch due to air pressure.

Based on random observation, during the survey walk through, not all fire doors are arranged to close and latch to comply with 39.2.2. or NFPA 72, 1999, 2-10.6.5.1.

Findings include:

On 2/7/13, 1st floor, during the walk through of the facility with the Director of Engineering, the surveyor observed the doors located in the designated 2 hour rated building separation. The doors link the 400 building (Corridor 102) to the 500 building. Smoke detections was not provided on both sides of the doors in accordance with 7.2.1.8 of NFPA 101. The doors also do not comply with 19.2.2.2.6 from the Hospital side of the doors.

Based on observations of hazardous areas the facility failed to properly separate combustible stored materials from building occupants. The separation between hazardous areas and the means of egress failed to meet with the requirements of NFPA 101, (2000), Section 39.3.2.1 and 8.4.1.1. This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the smoke zone.


Findings include:

A. On 2/7/13, 5th floor, Medical Records Room, during the walk through of the facility with the Director of Engineering, the room was found to have a high combustible fuel load of open paper files, cardboard boxes in a room not sprinkler protected. The door and walls to the Medical Records Room are deficient because:

1. The door to the room did not have an automatic door closer. (8.4.1.3 and 7.2.1.8)
2. The door was not a 3/4 hour fire rated with appropriately listed hardware (8.4.1.3)
3. A 1-hour rated enclosure could not be verified (8.2)

B. On 2/7/13, 4th floor, Cardiac Rehab, during the walk through of the facility with the Director of Engineering, it was observed that twelve small oxygen tanks were stored along the wall in the means of egress. The storage of the tanks and separation from combustibles did not meet with NFPA 99, 8.3.1.11.2(c)(1). The means of egress is being used for storage, and is not maintained free and clear of obstructions.

C. On 2/7/13, 4th floor, Stair S15, during the walk through of the facility with the Director of Engineering, it was observed that the vestibule outside the stair enclosure, contains a large soiled linen cart in the means of egress. The cart holds three bags; each bag has a 32 gallon capacity, making this a hazardous condition and does not meet with the requirements of NFPA 101, 8.4.

E. On 2/7/13, 3rd floor, during the walk through of the facility with the Director of Engineering, it was observed that the waiting area contains an abandoned optometrist office, which is separated from the waiting room by frosted glass panels. The room is currently being used for general storage and does not comply with the requirements for a one hour fire rated enclosure under NFPA 101, 39.3.2.1 and 8.4

F. On 2/7/13, 3rd floor, during the walk through of the facility with the Director of Engineering, it was observed that the reception area contains, sliding racks of open files. The general storage of the files is not separated from the waiting area and exit route or protected in accordance with Section 8.4.

Based on observations of hazardous areas the facility failed to properly separate combustible stored materials from the exit egress corridors. This required separation between hazardous areas and exit access corridors is to be in accordance with the requirements of NFPA 101, 2000 Edition, Section 18.3.2.1 and 8.2.3.2.3.1(2). This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the smoke zone.


Findings include:

1. On 2/5/13 at 1:40 PM, 3rd Floor, South End (Endo) Center Core, between the nursing station and nourishment is a Soiled Utility Room (E327). During the walk through of the facility with the Director of Engineering, it was observed that the corridor door failed to close and latch.

2. On 2/5/13 at 8:52 AM, 1st Floor Surgery, Equipment Room (E170) during the walk through of the facility with the Director of Engineering, it was observed the door failed to close and latch.

Hazardous area was not separated in a tenant space, as required by LSC Section 8.2.3.2.3.1(2).

On 2/07/13, in the afternoon, surveyor observered during the walk through with the Director of Engineering, that the Medical Records Room in the Ob/Gyn Office on the Fourth Floor was not separated. The door leading from Medical Records to the Nurse's Station was held open with a wedge.

A. Based on observation on February 7, 2013, with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that exit enclosures are not installed and maintained to provide a continuous, safe path to public way in accordance with Chapter 7 of NFPA 101 - 2000.

1. Five story, exit Stair S10 discharges into a designated 1st Floor, two hour enclosed, exit passageway. The exit passageway does not comply with 7.1.3.2.1, 7.1.3.2.2,and 7.2.6 of NFPA 101.

a. The exit passageway has a monolithic
ceiling with fire rated access panels.
The access panels are not self closing.

b. The fire doors from the CDU into the
exit passageway does not latch.

c. A wood pallet was left in the exit
passageway.

2. Stair S10 at the Basement Level does not comply with 7.1.3.2.1 of NFPA 101:

a. There is a large pump recessed into the
stair floor at the Basement Level.

b. There is a 16" x 16" metal box on the
stair wall at the intermediate landing
between the Basement and 1st Floor.
The provider did not know what the box
was and/or how it is permitted in the
stair enclosure.

3. Stair S5 is a required exit stair for the Basement of the 400 Building. The stair door at this level does not close to latch.

A. Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that exit enclosures are not installed and maintained to provide a continuous, safe path to public way in accordance with Chapter 7 of NFPA 101 - 2000.

Findings include:

1. Stair # 1 is located at the south end of the 350 Buildings and serves as a required exit for the 1st Floor through the 5th Floor (all are patient floors). The stair discharges into a 1st Floor Required Exit Passageway that is located entirely with the South Building (Bldg 06). The Exit Passageway is roughly 140' in length and does not comply with 7.1.3.2.1, 7.1.3.2.2, and 7.2.6 of NFPA 101. The surveyor observes that this building is only partially sprinklered at best.

a. A significant portion of this exit passageway has a monolithic ceiling. The provider had no details for this ceiling and did not know when it was constructed. It appears to be installed to provide a two hour barrier separating unapproved systems and penetrations above. However, the monolithic ceiling is suspended from above by channels and wire that are not protected as two hour support assemblies (8.2.3.1).

b. The monolithic ceiling has access panels that are not permitted under 7.1.3.2.1 d).

c. The access panels installed in the ceiling have fire ratings, however, if permitted because they were installed before the above requirement was adopted, the access panels still are not self closing.

d. The first vestibule in this exit passageway is in front of the 1st Floor Morgue. The walls at this locations do not extend above the ceiling of the Morgue as two hour barriers to the deck above.

e. An exit sign in the exit passageway identifies an exit path, to the west south of the Morgue, that is not an exit passageway.

f. The Life Safety Plans dated 10/09/09 identify an exit passageway with two hour walls on both sides at the south end of the exit passageway.

g. The south end of the exit passageway has paper faced batt insulation above the lay-in ceiling at this location. The space is at least partially sprinklered; however, the space above the ceiling (concealed space with combustible materials - paper faced fiberglass batt insulation ) is not sprinklered in accordance what NFPA 13.

h. The pair of doors to Materials Management (F190) lack U L Labels as 90 minute fire doors.

i. The door to Biohazard (F176) lacks U L Labels as 90 minute fire doors.

j. The Materials Management Building is a Type II (000) structure with metal walls. The provider lacks detailed information that identifies how this area is separated from the exit passageway by a two hour barrier.

k. The Loading Dock area is newer construction and is Type II (000). The provider lacks detailed information that demonstrates how the interior Loading Dock space is separated from the exit passageway by a two hour barrier that includes the top of wall termination detail.

2. Stair S-4 has a designated, new, 1st Floor, exit passageway from the 350 building that extends through part of the 400 Building to an exit stair in the East Building. Stair S4 is a required exit for five patients floors. The Exit Passageway does not comply with 7.1.3.2.2,and 7.2.6 of NFPA 101.

a. There is a pair of cross corridor 90 minute fire doors near Stair S4. The surveyor observed holes in the fire barrier above the doors and above the ceiling that were not sealed for two hour construction.

b. The door to Conference Room A133.02 opens to the exit passageway. The door has a 90 minute rating but lacks self closing hardware.

c. 1st Floor Outpatient Surgery has a pair of 90 minutes auto-open doors that open to the exit passageway. The doors have magnetic locking devices but lacks signs identifying the delay functions in accordance with 7.2.1.6.1. The next pair of doors to the east in the exit passageway also has magnetic locking devices to control access into the semi- restricted spaces beyond. This constitutes two electrotonic locking devices in a path of egress and is not permitted under 19.2.2.2.4, exception # 2.

d. On 02/07/13 and the morning of 02/08/13, with the Director of Safety present, a cart was found parked in the exit passageway in front of Room E160. The provider lacks adequate means to prevent re-occurrence.

3. Stair S4 is a required five story exit stair that extends to the Basement Level. Stair S4 is shown at the Basement Level, on the Life Safety Plans dated 10/09/09, as communicating to the Basement Level utility tunnels with nt two hour fire separation or enclosure of the exit stair at the Basement Level.

Based on observations, the facility failed to provide exit components having a fire resistance rating of at least two hours. The exit components are not arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building.

Findings include:

On 2/5/13 at 9:15 AM, during the walk through of the facility with the Director of Engineering, it was observed that the 1st floor, Stair Door (Stair S17) did not close and latch as required by NFPA 101, 18.3.1 and 8.2.5.4(1).

Based on observations, the facility failed to provide exit components having a fire rating equal to that of the stair, as required by Section 7.2.6.3.

On 2/07/13, surveyor observed penetrations in the First Floor exit passageway from Stair 1 to the exterior. There were several unsealed openings around penetrations above the the door into the exit passageway from the the Outpatient Treatment Area on the East.

Based on observations, the facility failed to provide stairs and exit components having a fire resistance rating of at least two hour. The exit components are to be arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building. NFPA 101, 39.2.2.3 and 7.2.2.

Findings include:

1. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that the exit stair (Stair S14) off of the 5th Floor elevator lobby does not comply with Chapter 7 of NFPA 101. The stairwell landing contains a door to a small room which contains a water heater. Doors opens into a normally unoccupied room and is not permitted to open into a rated exit stair per NFPA 101, Section 7.1.3.2(b) and 7.2.2.5.3.

2. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that exit stair (S14) is required to be a 2 hour rated enclosure based on NFPA 101, 39.3.1.1 and 8.2.5.4(1). The stair enclsoure wall(s) to roof/deck connection were observed not to be sealed with a UL fire rated product. This condition was observed on all floors for this stairwell.

3. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that exit stair (S15) is required to be a 2 hour rated enclosure based on NFPA 101, 39.3.1.1 and 8.2.5.4(1). The wall to roof/deck connection was observed not to be sealed with a UL fire rated product. This condition was observed on all floors for this stairwell

4. On 2/7/13, 4th floor, during the walk through of the facility with the Director of Engineering, it was observed that Stair S14 has stair doors that swins into the stairwell at the stair landing, obstructing the landing. The distance between the guard rail and the edge of the door provides an 8 " clearance. The current arrangement restricts anyone from the upper floor from proceeding down the stairs during an evacuation. The stair does not meet with NFPA 101, 7.2.2.3.2 or provide an unobstructed path of egress. This condition was observed on Floors 2 through 4.

Based on observation, of two stairs serving the upper level of this building, two of the exit stairs were found to be deficient and not in compliance with Chapter 7 of NFPA 10.

1. On 2/08/13, surveyor with Director of Engineering observed that the enclosed stairs from the Cardiac Rehab Mezzanine to grade were used to store holiday decorations.

2. On 2/08/13, surveyor with Director of Engineering observed that the enclosed stairs from the Diabetes and Endocrinology side of the Mezzanine to grade were used to store a filing cabinet with records, as well as combustible decorations along the exterior wall beneath a large window.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that the means of egress to a public way is not maintained in accordance with Chapter 7 of NFPA 101.

Findings include:

1. The a pair of cross corridor doors near Room A326 have an exit sign above the doors. The doors do not swing in the indicated direction of exit travel in accordance with 7.2.1.4.2.

2. 2nd Floor - Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the 2nd Floor of the 350 Building has a 50 foot dead end corridor near Room A227. There is no exit sign at the north end of the corridor

a. The corridor terminates at a pair of doors that extend into a vacant suite. The signs on the doors indicate " no admittance " .

b. The vacant suite is used for some unenclosed storage.

c. The suite is not supervised 24/7 and cannot serve as the exit path from a corridor The suite does not currently comply with the rules for corridors or suites.

d. Many of the plumbing fixtures have trap seals that have evaporated. This constitutes a potential infection control and life safety hazard. The surveyors found not evidence of Life Safety Interim Measures. See K130.

3. 2nd Floor Interconnect Wing. The exit access corridor between Stair S5 and S4 is a 100 ' dead end corridor and does not comply with 19.2.5.9.

a. The corridor is directed towards a 2nd Floor ICU Suite that is vacant. Stair S4 is inside the suite.

b. The pair of 1 ½ hour fire doors at the east end of the corridor are locked with a magnetic locking device that prevents further travel to the east. This pair of door is identified as a horizontal exit. There is an exit sign above the doors. The doors do not comply with 7.2.6, 7.2.1.6.1 or 7.2.1.6.2. Access to Stair S4 is blocked by these locked doors.

4. There are two sets of cross corridor doors in the 1st Floor corridor near Room A103. The 2nd set of doors have magnetic locking devices but lacks the 15 second delay signage that is require by 7.2.1.6.1. Further, the surveyors find that these locks are located in an area that is not fully sprinklered and the locks are not permitted under 7.2.1.6.1.

5. 1st Floor OP Surgery (Dwing): The suite has a pair of auto-open 1 ½ hour doors that open to the exit passageway. The doors have magnetic locking devices but lack a sign complying with 7.2.1.6.1.


12799


B. Based on observation, the facility failed to keep all means of egress readily accessible at all times in accordance with 7.1.

Findings include

1. On 2/07/13 in the afternoon during fire alarm testing with the Construction Planning Mgr., the surveyor observed that the fire alarm did not release the cross corridor doors at the West end of the Labor/Delivery Unit outside patient room A103. More than 15 lbs. of force was required to open the Labor/Delivery Unit doors manually, therefore the surveyor finds that the doors do not meet 7.2.1.4.5 and/or 7.2.1.6.1.

2. On 2/07/13 in the afternoon during fire alarm testing with the Construction Planning Manager, the surveyor observed that since the area the cross corridor doors at the West end of the Labor/Delivery Unit outside patient room A103 of the building is not sprinklered or the two smoke compartments that are adjacent to this pair of doors do not have smoke detection throughout, the delayed egress locks are not permitted under 7.2.1.6.1.

3. On 2/07/13 in the afternoon during fire alarm testing with the Construction Planning Manager, the surveyor observed that there were two delayed egress locks on each leaf of the cross corridor doors at the West end of the Labor/Delivery Unit outside patient room A103. Twos locks are not permitted under 7.2.1.6.1.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that exit paths are not maintained and readily accessible at all times in accordance with 7.1.

1. The 1st Floor Emergency Department has locking devices that do not comply:

a. A pair of 1 ½ hour fire doors between the
Emergency Department and Imaging
have magnetic locking devices. The
provider was not able to demonstrate
how these locks comply with 7.2.1.6.1 or
7.2.1.6.2.

b. The door with an exit sign above, from
the Emergency Department to the
Emergency Room Reception area, has a
magnetic locking device. The provider
was not able to demonstrate how these
locks comply with 7.2.1.6.1 or 7.2.1.6.2.

c. The 1st Floor Vending Area Waiting
Area from the Emergency Room has a
designated exit path through a door to
the South Lobby. The door has a locking
device that the provider identifies as
locked at night. The provider was not
able to demonstrate how these lock
complies with 7.2.1.6.1 or 7.2.1.6.2.

d. The 1st Floor Emergency Department
has two seclusion Room that share a
toilet room. The toilet room has two
doors each with a single cylinder dead
bolt lacks that lacks a thumbturn inside
for each lock.

2. The Emergency Department has an exit path that is directed with exit signs into the Ambulance Bay/Drive-thru Canopy area.

a. The Ambulance Canopy is used to
store vehicles and supplies. This
constitutes a hazardous area that is not
separated from the means of egress
directed through this space in accordance
with 19.3.2.1 and 7.5.2.1.

b. The exit path towards the Ambulance
Bay/Drive Thru has exit signs above two
pairs of doors that do not swing in the
designated direction of exit travel in
accordance with 7.2.4.2.

c. The interior vestibule space between the
Ambulance Bay and the Emergency
Department is a large storage space that
is not separated from the Emergency
Department and the exit path by one
hour construction in accordance with
19.3.2.1 and 19.3.6.1. Ceiling tiles in
this space were also displaced,
compromising both fire suppression and
detection

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyors find that exit paths are not maintained and readily accessible at all times in accordance with 7.1.

Findings include

1. The 5th Floor Rehab Suite is an inpatient treatment area. The exit access corridor from this suite to Exit Stair S11 lacks two remote exit paths in accordance with 19.2.6.2.4.

a. The required exit path to Stair S10 to the
west is not available and is not marked
with illuminated exit signs.

b. The two hour separation for the suites to
the west is not identified as a horizontal
exit nor is it identified as a smoke
barrier. The doors swing only in one
direction. Opposite swinging doors are
not provided for the required exit paths
in both directions.

c. The two hour barriers to the west cannot
comply as a horizontal exit. The doctor's
suites are business occupancies in a
health care area, on a health care floor, in
a health care building and the suites do
not comply with 19.2.6.2.4. Note: This
floor is not sprinklered.

d. Suite 510 and 504 have only one exit
path. The corridor lacks two remote
paths and does not comply with
19.2.6.2.4.

e. Suite 504 blocks access to Stair S10.
The suite is locked during some hours
and an exit access corridor through the
suite is not provided.

f. Suite 504 is open to the exit access
corridor to the east above the skylight.
This arrangement does not comply with
19.3.6.2.1.

g. Suite 504 has open file storage in the
reception area that is also open to the
entire suite and the exit access corridor
to the east. This arrangement does not
comply with 19.3.2.1, 19.3.6.1. and
19.3.6.2.1.

2. There is a pair of cross corridor doors with an exit sign above the doors (somewhere near Room D185). The doors have magnetic locking devices and a sign on the door identifying 15 second delay. The doors also have a sensor above the door that release the locks immediately when approved. The doors do not comply with 7.2.1.6.1 and/or 7.2.1.6.2

a. The sign identifying the door as a
delayed egress doors is not legible (not
enough contrast). Nor is the sign
accurate (the sensor releases the door
immediately).

b. There is a sensor above the doors that
releases the locks; however a push to
exit device is not installed strictly in
accordance with 7.2.1.6.2. The provider
is not able to demonstrate how the doors
will release and comply with 7.2.1.6.1 if
the sensor fails.

2. The 2nd Floor Psychiatric Unit has a seclusion room with a bathroom. The bathroom door has a single cylinder dead bolt lock with no thumbturn inside. The bathroom is not designed to be an observed selcusoin room.

3. There is a required exit access corridor in the Ambulatory Area (corridor shown between a suite that is 3550 GSF and a suite that is 4644 GSF - corridor number is not legible on the plans provided. The corridor lacks two remote exit paths in accordance with 19.2.5.9. The designated exit path to the North is through a horizontal exit into a 9807 square foot suite (OPS Holding and Post Op/Cardiac Cath). This path does not comply with 19.2.6.2.4. The path is the suite from the Horizontal Exit exceeds 100' of travel to a corridor door and therefore cannot serve as a 2nd remote exit path from the corridor cited.

4. There is a pair of cross corridor doors with an exit sign above the doors (somewhere near Room D185). The doors have magnetic locking devices and a sign on the door identifying 15 second delay. The doors also have a sensor above the door that release the locks immediately when approved. The doors do not comply with 7.2.1.6.1 and/or 7.2.1.6.2

a. The sign identifying the door as a
delayed egress doors is not legible (not
enough contrast). Nor is the sign
accurate (the sensor releases the door
immediately).

b. There is a sensor above the doors that
releases the locks; however a push to
exit device is not installed strictly in
accordance with 7.2.1.6.2. The provider
is not able to demonstrate how the doors
will release and comply with 7.2.1.6.1 if
the sensor fails.
.

Based on observations and interview the facility failed to provide all exit discharge paths meeting the requirements of NFPA 101, 39.2.7 and 7.7.

Findings include:

1. On 2/7/13, 1st floor, Stair S14 and S15. Exit stairs continuing beyond level of discharge were not provided with interrupter gate as required by NFPA 101, 7.7.3.

2. On 2/7/13, basement level, egress path from EKG through double doors by mechanical corridor. The corridor in this area leads to a 2-hour fire rated building separation. Staff was interviewed at the time of this finding and staff indicated that the EKG doors are secured after hours. Securing the doors in the designated exit creates a dead end corridor in excess of 50 feet. The exit arrangements from the mechanical corridor failed to meet NFPA 101, 39.2.5.2. and 7.1.10.1.

Based on observations the facility failed to provide exit access that is readily accessible to a public-way at all times. Obstructions during an emergency situation could be fatal if this were the only escape route.

Findings include:

On 2/5/13 at 2:30 PM, during the walk through of the facility with the Director of Engineering, it was observed that the 1st Floor LDR corridor door to exit Stair S16, contains a delayed-egress lock. The door was equipped with 15-second delayed-egress lock, and the sign posted on the door indicated that you must " push " until alarm sounds, " door can be opened in 15 seconds " . The door was equipped with a standard lever door knob; it was unclear as to what you " push " to release the door lock and operation of the latchset does not release the lock. The arrangement does not meet with NFPA 101, 7.2.1.6.1.

A. Based on observations during the survey walk-through, the facility failed to provide and maintain properly rated fire-resistance horizontal exits, in accordance with NFPA 101, 18.2. Without the barriers being constructed and maintained, the buildings are not properly separated and a fire could spread from one building to the other.

Findings include:

On 2/5/13 at 11:35 AM, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that the 2-hour Fire Wall separating the East Tower from the 350 Building was deficient. Upon investigation it was determined that the designated 2-hour rated wall, per facility Life Safety drawings dated 10-9-09, was "not" sealed above the suspended ceiling at the cross-corridor doors. The cross corridor wall and corridor wall intersection (corners) was incomplete. The unsealed penetrations lack fire rated material in accordance with NFPA 101, 8.2.2.2.


B. Based on observations during the walk through the facility failed to provide fire doors in accordance with LSC Sections 8.2 and 18.1.2.3 and NFPA 80 Sections 1-11.4 and 2-3.1.7. Without doors and proper hardware, the fire could spread from one compartment to another.

Findings include:

On 2/5/13, 1st floor, 2 hour separation wall between OR and OB/LDR, by C-Section room. It was observed that the cross corridor doors are 90 minute rated doors. It could not be determined if the door hardware installed is listed for 90 minute fire doors. This condition was discussed with the Director of Engineering at the time of the finding. Listing documentation for the door hardware was not available.

A. The facility failed to maintain a horizontal exit constructed in accordance with 7.2.4.

1. On 2/5/13, surveyor with Director of Biomed and Safety and Construction Planning Manager observed that there is a square opening cut from the angles securing Fire Damper 524 in the 2 hour fire barrier wall above the cross corridor doors on the Fifth floor near Stair S3. The hole is not sealed for fire rated construction.

A. Based on observation, the facility failed to provide normal and emergency lighting of the means of egress as required by 39.2.8 and 39.2.9, as well as 7.8 and 7.9.

1. On 2/07/2013, surveyors with Director of Engineering observed that there was no illumination of the exit discharge from the North exit passageway of the First Floor of the Radiology/Mammography Unit of the Pavilion.

2. On 2/07/2013, surveyors with the Director of Engineering observed that the facility did not provide two fixtures or a two bulb fixture as required by 7.8.1.4 so that the failure of a single bulb will not leave the exit discharge from the North exit passageway of the First Floor of the Radiology/Mammography Unit of the Pavilion in darkness.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed a vestibule corridor that is east of the 5th Floor ICU Suite. This vestibule has a pair of fire doors to the east that lack a sign that indicates "not an exit" on the west side of these doors, in accordance with 7.10.8. There is no exit path to the east beyond these doors.

B. Stair # S-2 is identified as a convenience stair by the provider. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed signs are not installed on the stair door that indicates "not an exit" on the corridor side of the stair door, in accordance with 7.10.8. This condition applies to Floors 1 through 5.

C. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that 3rd Floor Interconnect Wing lacks an illuminated exit sign to the east.

A. Based on observation February 6, 2013, with the Director of Corporate Facilities and the Director of Biomed and Safety present, and based upon review of the Life Safety Plans dated 10/09/09, the surveyor finds the following:

1. The 4th Floor of the 400 Building is a business occupancy. It is not fully sprinklered. Two new exit stairs in the East Building are not accessible from the 4th Floor of the 350/400 Buildings. Stair S10 is located behind a locked suite and is not accessible from all parts of the 4th Floor. This leaves only two stairs (including S5) in the 400 Building both of which discharge into the interior of the building at the 1st Floor. Neither of these stair comply with 7.7.1. The 350 Building has two stairs that comply with 7.7.1 and one stair that complies with 7.7.2.

Stair S5 does not comply with 7.7.1; However, it is not required as an exit from the 4th Floor but lacks a sign that indicate "not and exit" in accordance 7.10.8.1.

The Life Safety Plans dated 10/09/09, identify Stair S5 as an exit; this information is not accurate.

2. 2nd Floor " Girls " Psychiatric Unit lacks an illuminated exit sign to the Northwest.




12799


B. The hospital staff provided conflicting information regarding Stair #5. They say that it is an exit and plans for some floors indicate that it is an exit, however no illuminated exit sign is provided.

1. On the afternoon of 2/05/13, the Fifth Floor was observed by the surveyor not to have an illuminated exit sign in the short corridor between the 350 building and Restorative Services.

2. The surveyors observed similar conditions on other floors. The provider has conflicting information for this stair. The Life Safety Plans dated 10/09/09 indicate that Stair S5 is not an exit at the 2nd Floor. The provider is able to demonstrated whether Stair S5 is required as an exit and/or how it complies with 7.7.1 or 7.7.2 as an exit.

B. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that The 2nd Floor (interstitial floor) has a path to the west with an exit sign directing the exit path to the 350 Building. However, the 1 ½ hour fire rated door in this space at the separation between the east Tower and the 350 Building lacks an illuminated exit sign.



12798

A. Based on observations it was determined that the facility failed to provide and/or maintain the directional emergency illuminated exit signs in accordance with LSC, Section 7.10.2. The lack of visual indication during an emergency could lead to confusion as to the location of exits by building occupants.

Findings include:

1. On 2/6/13, during the walk through of the facility with the Director of Engineering, it was observed that the basement " crawl space " did not provide directional illuminated exit signs. Directional exit signage are not provided where it is not obvious where the exits are located.

Based on observation with the Director of Safety and the Director of Corporate Facilities 02/07/13, the surveyor finds that illuminated exit signs are not provided in accordance with 7.10 of NFPA 101.

Findings include

1. 1st Floor Dietary Dry Storage Room: all exit paths from this space are not clearly identified with exit signs.

Based on observations and interview, it was determined that the facility failed to provide and/or maintain the directional emergency illuminated exit signs in all locations.

Findings include:

1. On 2/7/13, 5th floor, back passage way contains a door to the waiting room for cardio / vascular area. The exit sign required above the door has been removed and a hole left in the ceiling tile. Exit routes are not clearly identified as required by NFPA 101, 39.2.10 and 7.10.1.1.

2. On 2/7/13, 2nd floor, Psych offices are located off of a dead end corridor. When staff was interviewed they indicated that exiting may be though a small office type area into the cardiac office. The path indicated was not marked as an exit route, and it was unclear if the path would always be available (different tenants) in an emergency. The exit routes are not clearly identified or marked as required by NFPA 101, 7.10.1.1.

The facility failed to mount exit signs where they are not obstructed by other building components as required by LSC Section 7.10.1.7.

1. On 2/07/13, at 4:20 PM, based on observations during the walk through and by interview with the Director of Engineering, it was agreed that the exit sign and area of refuge signs were not clearly visible behind the arches in the central corridor of the 5th Floor tenant spaces. These signs were mounted in the corridor near the door to Stair No. 1 and are not visible.

2. On 2/07/13, at 4:25 PM, based on observations during the walk through and by interview with the Director of Engineering, it was agreed that the exit sign and area of refuge signs were not clearly visible behind the arches in the central corridor of the 6th Floor tenant spaces. These signs were mounted in the corridor near the door to Stair No. 1 and are not visible.

Based on document review, 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 review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Identification of construction types, as defined by NFPA 220, for each different part of the building. Separations between buildings are not clearly defined. There are a lot of two hour barriers that do not define building separations. In some cases, it is not clear which building an area is part of

2. Ventilation, duct, and pipe shafts and their fire resistance ratings.

3. Plans do not identify the Elevator Identification Numbers that are used for the building.

3. Fire barrier walls and/or horizontal exits.

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

5. Hazardous area enclosures and their fire resistance ratings.

6. Accurate and current information identifying the extent of sprinklered protection of the building.

7. Designated suites, suite boundaries

8. All exit access corridors.

10. Use of areas, occupancies in some areas along legible labeling of room uses and room numbers. The plans provided were too small to read.

11. An exit analysis is provided for the entire complex; however, it is not evaluated separately for each floor. Some floors do not have access to all exit stairs identified. Examples: Two exit stairs in the East Building are not available to all buildings at the 2nd, 4th and 5th Floor. Stair S10 is not currently available to all floors of the 350 Building.

Based on document review, 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 review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Identification of construction types, as defined by NFPA 220, for each different part of the building. Separations between buildings are not clearly defined. There are a lot of two hour barriers that do not define building separations. In some cases, it is not clear which building an area is part of

2. Ventilation, duct, and pipe shafts and their fire resistance ratings.

3. Plans do not identify the Elevator Identification Numbers that are used for the building.

3. Fire barrier walls and/or horizontal exits.

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

a. Life Safety Plan identify two hour smoke barriers in the middle of the 2nd Floor Psychiatric Unit. Two hour smoke barriers were not found.

5. Hazardous area enclosures and their fire resistance ratings.

6. Accurate and current information identifying the extent of sprinklered protection of the building.

7. Designated suites, suite boundaries

a. The Life Safety Plans for the 2nd Floor Psychiatric Unit does not clearly identify suites and exit access corridors.
The corridor adjacent to Room 251 is not clearly identified as part of a suite and is not identified as an exit access corridor. This corridor is shown terminating at a suite (with 3095 square feet). This corridor does not comply with 19.2.5.9 and the two hour barrier at the west end of the corridor does not qualify as a horizontal exit.

The corridor between the 3000 square foot suite and the 3450 square foot suite is a required exit access corridor. This corridor terminates at the same 3095 square foot suite that is identified in item a above. This corridor also does not comply with 19.2.5.9.

Based upon item "a" and "b" the surveyor finds that the Boys Psychiatric Unit (3095 GSF) was not designed to be a suite and it is mis-identified on the plans. An exit access corridor through this space to Stair S10 is required and is not identified on plans.

No exit access corridors are identified for the 2nd Floor of the 400 Building.

b. The Life Safety Plans identify the CDU Suite as 6580 square feet in area. A portion (including but not limited to the large waiting area in this space) is open to adjacent lobby/exit access corridor. This area cannot be part of a suite. The plans do not accurately identify the boundaries of the suite.

c. The suite boundaries for all 1st Floor suites are not clearly defined.

8. All exit access corridors.

10. Use of areas, occupancies in some areas along legible labeling of room uses and room numbers. The plans provided were too small to read.

11. An exit analysis is provided for the entire complex; however, it is not evaluated separately for each floor. Some floors do not have access to all exit stairs identified. Examples: Two exit stairs in the East Building are not available to all buildings at the 2nd, 4th and 5th Floor. Stair S10 is not currently available to all floors of the 350 Building.




end

Based on document review, 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 review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Identification of construction types, as defined by NFPA 220, for each different part of the building. Separations between buildings are not clearly defined. There are a lot of two hour barriers that do not define building separations. In some cases, it is not clear which building an area is part of

2. Ventilation, duct, and pipe shafts and their fire resistance ratings.

3. Plans do not identify the Elevator Identification Numbers that are used for the building.

3. Fire barrier walls and/or horizontal exits.

a. The Life Safety Plans identify two hour walls at Storage Room B131. Two hour barriers were not found.

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

5. Hazardous area enclosures and their fire resistance ratings.

6. Accurate and current information identifying the extent of sprinklered protection of the building.

7. Designated suites, suite boundaries

a. The Life Safety Plans identify three 1st Floor Suites in the Emergency Department; however no suite boundaries are identified.

b. Exit access corridors are not clearly identified and the travel distance from some patient treatment areas in each suite appears to exceed 100' to a corridor door (or door directly to the outside. (19.2.5.8) In some cases that travel distance exceeds 50' where the path pass through two spaces to get to a corridor door (19.2.5.8). The Life Safety Plans provided for this survey are not scalable.

8. All exit access corridors.

10. Use of areas, occupancies in some areas along legible labeling of room uses and room numbers. The plans provided were too small to read.

Based on document review, 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 review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

2. All exit access corridors at the 1st Floor are not identified.

3. Use of areas, occupancies in some areas along legible labeling of room uses and room numbers. The plans provided were too small to read.

Based on document review for the previous 12 months, the facility failed to perform fire drills at least once per quarter per shift.

1. On 2/05/13 at 4:00 PM with Director of Biomed and Safety, the surveyor observed that no drill was conducted during the third shift for the Second Quarter of 2012 as required by LSC Section 19.7.1.2.

Based on observation the facility failed to provide and maintain a fire alarm system with approved devices or equipment installed according to NFPA 101, 2000 Edition, Sections 18.3.4 and 9.6.2 NFPA 72, (1999) 8.2.2. This deficient practice could affect all building occupants if the fire alarm system failed to operate during a fire.


Findings include:

1. On 2/5/13 at 1:12 PM, 3rd floor, West Horizontal Exit, between ICU and Ortho, during the walk through of the facility with the Director of Engineering, the area lacks a manual fire alarm pull station within 5 feet of the cross corridor doors at the horizontal exit. The drawings provided to the surveyor, dated 10/9/9, indicate the horizontal exit on the North side of the cross corridor doors leading South into Ortho from ICU. Clarification is needed to determine if this is a horizontal exit in both directions and if manual fire pull stations are required on the North and South sides of the exit.

2. On 2/5/13 at 1:15 PM, 3rd floor, East Horizontal Exit, between ICU and Ortho, during the walk through of the facility with the Director of Engineering, the area lacks a manual fire alarm pull station within 5 feet of the cross corridor doors at the horizontal exit. The drawings provided to the surveyor, dated 10/9/9, indicate the horizontal exit on the North side of the cross corridor doors leading South into Ortho from ICU. Clarification is needed to determine if this is a horizontal exit in both directions and if manual fire pull stations are required on the North and South sides of the exit.

Based on observations, the facility failed to install and maintain a fire alarm system that would provide an effective warning in accordance with NFPA 72.

Findings include:

On 2/7/13, 1st floor, during the walk through of the facility with the Director of Engineering, it was observed at there are fire doors located in the designated 2 hour rated building separation. The doors link the 400 building (Corridor 102) to the 500 building. Manual fire alarm pull stations were not provided within 5 feet of the doors. The current arrangement does not meet with NFPA 101, 39.3.4, or NFPA 72, 9.6.

A. The facility failed to provide a fire alarm system to give effective warning of a fire in accordance with NFPA 72.

1. On 2/07/13 in the afternoon during fire alarm testing, surveyor observed that the fire alarm was not audible in the short corridor between the Second Floor nurse's station and the doors to the former ICU. The surveyors also observed that the fire alarm system was barely audible in the vacant former ICU.

2. On 2/07/13 in the afternoon during the fire alarm testing, surveyor observed that the fire alarm was not audible in the short corridor between the two sets of cross corridor doors at the West end of the Labor/Delivery Unit, and outside patient room A103.

The facility failed to maintain the fire alarm system in accordance with NFPA 72, Section 7.1.1.2.

1. Based on document review, several items in the contractor's fire protection test report of 6/18/12 were noted as deficient. There was no evidence of correction.

Based on fire alarm record reviews and observations, the facility failed to properly install, test or maintain the fire alarm system in accordance with NFPA 101, 2000 Edition, Section 9.6 as well as NFPA 70 and NFPA 72.

Findings include:

On 2/7/13, 5th floor, center corridor the smoke detector was observed over four feet down from the highest point of the ceiling / roof area. The detectors in this area are not installed in accordance with NFPA 72, 2-3.4.1.

A. Based on document review and interview of the project architect of record, the surveyor finds that the East Tower is new health care occupancy and is required to be fully sprinklered in accordance with 18.3.5.1. The new building is fully sprinklered; however, it is not separated from the 350 Building by two hour fire rated construction and portions of the 350 Building are not sprinklered.

Findings include:

1. The 3rd Floor of the East Tower is separated from the 3rd Floor of the 350 Building by a one hour smoke barrier and not a two hour fire barrier. Based on the Life Safety Plans dated 10/09/09, portion of the 3rd Floor of the 350 Building are not sprinkled, therefor the East Tower does not comply with 18.3.5.1.

2. The 1st Floor of the East Tower is separated from the unsprinklered portions of the 1st
Floor of the 350 Building by a one hour smoke barrier and not a two hour fire barrier. Based on the Life Safety Plans dated 10/09/09 and based on direct observation with the Director of Safety present, the surveyor finds that portion of the 1st Floor of the 350 Building are not sprinkled, therefor the East Tower does not comply with 18.3.5.1.

end

A. Based on observation on 02/05/13 - 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that sprinker systems are not installed and maintained in accordance with NFPA 13.

1. The closet next to Room A300B lacks sprinkler protection in a building identified as fully sprinklered. The surveyor also notes that the above conditions are not being detected on quarterly or annual sprinkler inspections in accordance with NFPA 25.




12799

B. The facility did not provide a sprinkler system that was installed and maintained in accordance with NFPA 13.

1. On 2/05/13, surveyor with Director of Biomed and Safety observed the sprinkler piping above Patient Room 518 does not have an arm-over bracing to prevent uplift as required by NFPA 13, 1999 Edition, Section 6-2.3.4 or 6-2.1.3.

2. On 2/05/13, surveyors with Director of Biomed and Safety and Construction Planning Manager. observed boxes obstructing the sprinkler head in the Storage Cabinets 1 and 2 along the "Interconnect Corridor" between Stair S3 and Stair S5 on the Fifth Floor.

3. Similar conditions were observed by the surveyors on other floors in closets in the Interconnecting Wing between Stair S3 and Stair S5 (example: closet at west end of corridor near Elevator D).

A. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the sprinkler protection is not installed in accordance with NFPA 13.

Findings include:

1. The 1st Floor Emergency Department Addition is identified as fully sprinklered and cannot comply with 19.1.6.2 without full sprinkler protection. The Ambulance Bay/Drive-thru Canopy is structurally attached to the Hospital and is used for storage. This area lacks sprinkler protection in accordance with NFPA 13 - 1999.

A. Based upon random observation with the Director of Biomed/Safety and the Director of Corporate Facilities and based on document review of Life Safety Plans date 10/09/09, the surveyor finds that the sprinkler system is not installed at maintained in accordance with NFPA 13 and NFPA 25:

Findings Include:

1. The 1st Floor Mail Room has a closet with no sprinkler head; the area around this closet is sprinklered.

2. 1st Floor Corridor south of Pharmacy: There is a closet next to an ice machine in the corridor. The closet next to the ice machine lacks sprinkler protection in an otherwise sprinklered area.

3. The surveyor observed that this conditions are not being detected and documented on quarterly or annual sprinkler inspections in accordance with NFPA 25.

A. Based upon random observation with the Director of Biomed/Safety and the Director of Corporate Facilities and based on document review of Life Safety Plans date 10/09/09, the surveyor finds that the sprinkler system is not installed at maintained in accordance with NFPA 13 and NFPA 25:

Findings include:

1. The 5th Floor of Stair S5 has a test and drain valve that is not piped to a drain in accordance with NFPA 13. The provider had no knowledge as to what this was and/or why a drain is not required.

2. The 1st Floor Electrical Closet opposite Stair S7 is not sprinklered in an otherwise sprinklered building. This space also does not comply with the exceptions in NFPA 13 for unsprinklered spaces.

3. The 1st Floor Electrical Closet D181 is a shallow in depth closet that is not sprinklered in an otherwise sprinklered building. This space does not comply with the exceptions in NFPA 13 for unsprinklered spaces.

4. The above conditions are not being detected and documented during quarterly or annual inspections of the sprinkler system in accordance with NFPA 25.

5. The Basement corridor between Stair S5 and S11 has a continuos pipe chase that runs parallel to the corridor. This pipe chase is open to the corridor ceiling and is not separated from the corridor above the ceiling. The pipe chase is used for storage. The pipe chase is accessible as defined by NFPA 13. The pipe chase and the area open to the pipe chase above the corridor ceiling is not sprinklered in accordance with NFPA 13.

6. Basement Level Gift Shop Storage: sprinkler protection is installed above a lay-in ceiling and not below. This installation does not comply with NFPA 13.

7. The Basement Level closet behind Room B092 has a spriinkler head that is installed too low.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that the sprinkler system is not installed and maintained in accordance with NFPA 13 and NFPA 25:

Findings include:

1. 1st Floor Imaging Department - the MRI Equipment Room has voids in the ceiling and/or missing ceiling tiles that compromises both fire suppression and detection in this space.

Based on plans provided and observation, there was a large mechanical room off the two story lobby.

1. On 2/08/13 surveyor observed with the Director of Engineering that there was water leaking out of a Booster Pump in the Fire Pump Room. This equipment is not maintained to comply with NFPA 25.

The facility failed to maintain the fire alarm in accordance with NFPA 25, 1998 Edition.

1. Based on document review, the controller report for the fire alarm system of 10/02/12, states that the Basement Fire Pump Mechanical Room (B Left) failed and there was no evidence of follow up or correction.

Based on observation it was determined that the facility failed to properly inspect and document the maintenance of all portable fire extinguishers in accordance with NFPA 101, 2000 Edition 18.3.5.6, 9.7.4.1 and NFPA 10. All fire extinguishers must be mounted or secured in a safe attachment that would be accessible to staff in an emergency.

Findings include:

On 2/5/13 at 12:00 PM, during the walk through of the facility with the Director of Engineering, it was observed on the 3rd - 4th floor interstitial space, entering from Stair S16. As you enter the room on the right hand side is a sign identifying the location of a " fire extinguisher " ; however the extinguisher was not installed below the sign.

A. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed the HVAC installations are not installed and maintained in accordance with NFPA 90A.

Findings include:

1. 4th Floor Interconnect Wing: The Dialysis Locker Room has a new washer and dryer installed in this space. The provider had no information or knowledge as to how the dryer exhaust was directed to the outside.

Based on observations and interviews it was determined that the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems per NFPA 101, 2000, 39.5.2. Section 2.1, Mandatory References: This code section requires the facility to be in compliance with the NFPA 90A, Standard for the "Installation of Air-conditioning and Ventilating Systems", 1999 edition.

Findings include:

A. On 2/7/13, Basement, EKG mechanical room, observations and interviews during the walk through of the facility with the Director of Engineering, it was determined that the room contains several (3 or 4) large ducts that penetrate the back wall which contain fire dampers.

1. However, the ducts were installed without sleeves and the space between the duct and the wall was not closed off with retaining angles in accordance with the damper manufacturer's installation requirements. The walls are not rated based on the drawings and was unclear why the dampers were installed at this location.

2. The same ducts contain other dampers at locations where the walls have been removed or no longer exist above the suspended ceiling. Based on interviews with the Director of Engineering, it is unclear if the mechanical room is enclosed with any rated system. The location and function of the dampers is unclear at this time without additional investigation.

3. Fire dampers require a 4-year inspection / exercise / clean / lubricate / rest fusible link, per NFPA 90A, Section 3-4.7 Maintenance. The facility failed to provide documentation that the dampers were inspected or maintained in the last 4-years.

Based on observations, surveyors found that routine maintenance was not performed to ensure the safety of patients.

1. On 2/06/13, surveyors observed a large amount of lint had accumulated behind the dryers in the Peds/Adult Laundry in the Behavioral Health Unit. The provider lacked adequate preventative maintenance or an in-line lint trap.

A. Based on document review for Kitchen Hood Suppression systems, for semi-annual inspection, testing and maintenance for the past 12 months, the surveyor finds that the documentation for both kitchen hoods (Main Kitchen and Servery) does not comply with NFPA 17A and NFPA 96.

Findings include:

1. The semi annual inspections failed to find and identify the lack of separation between the fryers and open flames in the adjacent equipment in the Main Kitchen.

2. The documentation for the Main Kitchen and Servery is combined on one form for each semi-annual inspection. The documentation does not identify specifically the appliances protected under each hood and the documentation does not identify the number or type of links that were replaced for each system.

3. Based on observation with the Director of Safety and the Director of Corporate Facilities on 10/07/09, the surveyor finds that the kitchen hood suppression system for the 1st Floor Servery has an ANSUL pull station that is not in the path of egress from the protected system and further the path is obstructed and does not comply with NFPA 17A. This also does not show up on semi-annual inspection reports.


14416


B. The surveyor finds on the morning of 2/6/13 while in the company of the Director of Plant Operation & Maintenance at the First Floor Kitchen (South Building), protection of cooking surfaces are not provided either by separation or barrier at the deep fat fryer to the adjacent open flame range in noncompliance with NFPA 96, 1998, 9-1.2.3.

Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyors observed that the facility did not provide and/or maintain commercial cooking equipment in accordance with 9.2.3.

1. On 2/05/13 at 1:30 PM, surveyors observed that the Outpatient Therapy Kitchen the 5th floor near the doors to the Restorative Services Department in the 400 Building has a working stove, but does not have a Class K fire extinguisher as required by NFPA 10, 1998 Edition, Section 3-7.1.

2. The provider does not have specific written procedure for how and when this outpatient therapy stove may be used and therefore does not require a commercial hood and suppression system in accordance with NFPA 17A and 90.

A. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that Office B307 has a portable electric heater that does not comply with 19.7.8.

Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the 1st Floor Emergency Department Reception Desk has a portable electrical heater which does not comply with 19.7.8 of NFPA 101.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that exit access corridor are obstructed and not maintained in accordance with 7.1.10.

Findings include:

1. The 5th Floor exit access corridor north of the Rehab Suite to Stair S11 is partially obstructed by chairs and a fish tank.

2. The required 5th Floor exit access corridor from the Rehab Suite extending west to Stair S10 is partially obstructed by chairs and benches in the corridor. See also K038.

3. The 2nd Floor of the 400 Building is an inpatient psychiatric unit. There is a vestibule at the south end of the exit access corridor that provides access to Stair S5 and to an adjacent horizontal exit. This vestibule was obstructed to less than 8 ' -0 " in width by two benches and an unattended housekeeping cart.

Based on observations, it was determined that the facility failed to maintain the exit egress corridors free of all obstructions and hazardous materials to full instant use as required by NFPA 101, 7.1.10. Storing items in a corridor, exit path, egress route delays the building occupants from safely evacuating in an emergency.

Findings include:

1. On 2/5/13 at 1:00 PM, during the walk through of the facility with the Director of Engineering, it was observed that the 3rd Floor ICU is not a designated suite based on facility drawings dated 10/9/9. The exit access corridors in the ICU area were obstructed by multiple items (carts, chairs, etc.) that are stored in the corridor for a time longer than 30-minutes.

2. On 2/5/13 at 1:32 PM, during the walk through of the facility with the Director of Engineering, it was observed that the 3rd Floor Ortho is not a designated suite, based on facility drawings date 10/9/9. The exit access corridors in Ortho area were obstructed by multiple items (carts, chairs, etc.) that are stored in the exit corridor for a time longer than 30-minutes.

Based on observation with the Director of Safety and the Director of Corporate Facilities the surveyor finds medical gas tanks are not stored in accordance with NFPA 99 - 1999.

Findings include:

1. Basement Level of the 400 Building. Respiratory has oxygen tanks that are stored closer than 5'-0" to combustibles.

The surveyor find on the afternoon of 2/5/13 while in the company of the Director of Plant Operation & Maintenance at the Basement Level (East Building), unrelated electrical equipment (maintenance shop air compressor & public address system amplifier) installed within the medical gas manifold room (304) as prohibited by NFPA 99, 1999, 4-3.1.1.2, (a) 10.

The surveyor finds on the afternoon of 2/5/13 while in the company of the Director of Plant Operations and Maintenance on the First Floor (350 Building), medical gas zone valve installed (Well Born Nursery work room 127) within the same space as the outlets they serve (Room 127A) in noncompliance with NFPA 99, 1999, 4-3.1.2.3.

The surveyor finds on the morning of 2/6/13 while in the company of the Director of Plant Operations and Maintenance on the First Floor (400 Building), medical gas zone valve installed (Clinical Decision Unit) within the same space as the outlets they serve in noncompliance with NFPA 99, 1999, 4-3.1.2.3.

The surveyor finds the morning of 2/6/13 while in the company of the Director of Plant Operations and Maintenance, by direct observation and staff interview it could not be confirmed the location of the medical gas zone valves serving treatment bays 12 & 13 of the Emergency Room (Imaging/ER Building). NFPA 99, 1999, 4-3.1.2.14, (b).

Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager , the surveyor found that the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

1. The pavilion emergency generator did not have a remote shut down switch to comply with NFPA-110, Section 3-5.5.6.

2. The pavilion generator did not have a remote annunciator or a derangement signal at a 24 hour staffed location to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

A. Interim Life Safety Measures: 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.

1) The provider failed to implement and document adequate interim life safety measures for the conditions cited.





12799

B. Based on observations during the walk through, surveyors with Director of Biomed and Safety and Construction Planning Manager found that the hospital was not maintained to ensure the safety of patients.

1. At 11:15 AM on 2/06/13, based on surveyor observations, the 2nd Floor former ICU was vacant and renovation was ongoing. The corridors of the unit are required for access from the 2nd Floor North Corridor of the 350 Building (Building 01), but the area is under construction and lacks adequate interim life safety measures.

Door in connecting vestibule to designated tenant separation wall were not self-closing as required by 8.2.3.2.3.1 (1).

1. Pair of doors connecting Ambulatory Care Center to Cancer center do not latch due to air pressure.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 99 (1999).

Findings include:

All medical gas system alarm points are not monitored at the master alarm panel at a continuously attended location in accordance with NFPA-99, Section 4-3.1.2.2(b)2 and (b)3.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the manager of building operations, the surveyor found that 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 by the loss of a single transfer switch.

Findings include but are not necessarily limited to:

1. Critical panel C3B was serving the medical gas alarm panel. This does not meet the requirements of NFPA-70, Section 517-32 and 33. Medical gas alarm panels are one of the items listed in NFPA-70, Section 517-32 that shall only be served from the life safety branch of the emergency system.

2. Life Safety panels E63 and E66: The nurse call equipment is connected to the Life Safety Branch of emergency power instead of the Critical Branch, in accordance with NFPA-70, Section 517-32.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that electrical installations and materials do not comply with NFPA 70 - 1999. Findings include

1. Electrical extension cords are used for permanent electrical service and do not comply with NFPA 70: Valentine Day string of lights at the 5th Floor ICU Nurse's Station

A. Based on observation February 8, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that electrical installations and materials do not comply with NFPA 70 - 1999.

Findings include

1. The Old Generator Room (Boiler House) has storage in front of electrical panels and switchgear. 3'-0" of clear space is not provided and maintained in front of electrical panels and gear.




17659

B. Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. The generator room was not equipped with any electrical receptacles served by the life safety branch of the emergency power as required by NFPA-70, Section 517-32. These may be needed to perform maintenance on generators during an extended power outage.

2. The main water service was not bonded to ground in accordance with NFPA-70, Section 250-50. Improper grounding could create a shock hazard for all occupants of the building.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that electrical installations and materials are not installed and maintained in accordance with NFPA 70 - 1999.

Findings include:

1. The 5th Floor Doctor's Suite 507 has an electrical panel that lacks circuit identification on all circuits in accordance with NFPA 70.

2. The 5th Floor exit access corridor north of the Rehab Suite has a fish tank with an electrical extension cord that does not comply with NFPA 70

3. 1st Floor Imaging Department - the MRI Equipment Room has a microwave that obstructs access to an electrical panel. 3'-0" of clear space in front of the panel is not maintained in accordance with NFPA 70.

4. 1st Floor Cardiac Cath Area (near doors to the north): Data cables and electrical cables are supported by plumbing pipes above the ceiling and they are supported by the lay-in ceiling. These installations do not comply with NFPA 70.

5. 1st Floor Nuclear Medicine: Panel NB has a number of electrical circuits that are not labeled.

6. The 1st Floor LAB has one or more plug strips which are connected to electrical power via a yellow extension cord.

7. 1st Floor Cath Lab # 3 is used for storage. The storage blocks access to electrical panels. A clear path and 3 ' -0 " of clear space is not maintained.

8. Mechanical Room B314.01 has an orange electrical extension cord in permanent use in the middle of the room.

B. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that two or three cath labs were in use and could not be inspected. Cath Lab # 3 was inspected and does not comply wit h NFPA 70-1999 and NFPA 99 -1999.

a. The surveyor observed that lighting
with battery back up is not provided
in accordance with 3-3.2.1 (a) 5. e
of NFPA 99.

b. The surveyor observed no
electrical outlets that are supplied
only from normal electrical power
in accordance with NFPA 99,
3-3.2.1.2 (a) 1 and 517-19 of NFPA
70 - 1999. This deficiency could
cause injury to patients due to
transfer switch failure.

The provider was not able to demonstrate that the same conditions would not be found in Cath Lab # 1 and # 2

Based on observations, the facility failed to install electrical wiring in accordance with NFPA 101, 39.5.1, Section 9.1.2 as well as NFPA 70, 1999 Edition, National Electrical Code.

Findings include:

1. On 2/7/13, 3rd floor, in the elevator lobby, above the ceiling tiles by the Neurology Office is a Junction box that lacks a cover plate, which does not meet with NFPA 70 (1999) 370-25.

2. On 2/7/13, 2nd floor, in the elevator lobby, above the ceiling tiles by the Cardiac office corridor is a Junction box that lacks a cover plate, which does not meet with NFPA 70 (1999) 370-25.

The facility failed to properly control the amount of garbage to accumulate , thus creating a hazard.

1. On 2/07/13, surveyor with Director of Engineering observed that there was not 3'-0" clear space in front of the electrical panels as required by NFPA 70.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the manager of building operations, portions of the elevator control system are not installed in accordance with ASME A17.3. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. Elevator 6 and 7 (surgical elevators): The machine room (hydraulic) in the Lower Level was not equipped with a smoke detector for elevator recall as required by ASME A17.3-211.3.

2. The surveyors observed that the surgical elevator machine room had a louvered doors. The machine room is a hazardous area and the louver does not comply with 7.2.1.8 of NFPA 101. and/or ASME A17.3.

3. The surveyor observed that the elevator machine room for elevator 6 and 7 was not equipped with a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.3-102.2.c.3.

4. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects for elevators 1, 2, 3, 4, 5, 6, and 7 as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.

A. Based on review of the Life Safety Plans dated 10/09/09, based on random observation during the survey of February 5 through 8, 2013 and based on personnel interview including the Director of Engineering, the Director of Safety and the Director of Corporate Facilities the surveyor finds that portions of two buildings do not comply with 19.1.6.2.

Findings include.

1. Stair 7 is a two story stair in the 400 building that is not an exit. The stair is part of the one story (with Basement) portion of the 400 Building that is identified as Type I construction. The stair has a unrated monolithic ceiling with unrated access panels. The stair has unprotected steel (roof structure) above. This unprotected roof structure is not compatible with the designated construction type for the building and does not comply with 19.1.6.2.

2. The Emergency Room/Imaging one story addition is Type II (000) construction. The adjacent 1st Floor Lab is part of the 5 story, 400 building to the north. The 400 Building is identified as Type I (332) construction; however, a continuous two hour fire barrier is not identified separating all portions of the building with Type II (000) construction from the Type 1 Building. This reduces the construction type of the 400 Building to Type II (000) construction. The 400 building therefore does not comply with 19.1.6.2.

3. The provider identified a portion of the 1st Floor as Nuclear Medicine. The surveyor was not able to identify which building this space is located; However, the surveyor observed fire-proofed steel above the ceiling in Nuclear Medicine and observed unprotected steel in the corridor south of this space. The surveyor did not find a two hour fire barrier between these differing construction types.

4. 400 Building that is identified as Type I construction. The Basement Level Gift Shop Storage has two structural beams at the end of the room that have missing fire-proofing.

end

A. Based on review of the Life Safety Plans dated 10/09/09, based on random observation during the survey of February 5 through 8, 2013 and based on personnel interview including the Director of Engineering, the Director of Safety, the Director of Corporate Facilities, and the facilities architectural consultant, the surveyor finds that portions of two buildings do not comply with 19.1.6.2.

Findings include.

1. The Interconnecting Building/wing has been cited in this survey as part of the 350 Building. It connects the 350 Building to the 400 Building and is separated from the 400 Building by a two hour fire barrier. It is five stories in height and it is Type I (332) construction. This wing is only partially sprinklered on each floor.

The Building identified as the Emergency Room/Imaging Addition is a one story building of Type II (000) construction. It was built immediately north of the Interconnecting Wing and extends partially under the Interconnecting Wing at Central Waiting. This building may or may not be fully sprinklered.

The surveyor finds no evidence of a two hour fire separation between the 350 Building [that is Type I (332) Construction] and the one story addition that is identified as the Emergency Room/Imaging Addition [that is Type II (000) construction]. Based on this the surveyor finds that the 350 Building is five stories in height, is Type II (000) construction and does not comply with 19.1.6.2. Sprinkler protection does not change this citation.

2. The 1st Floor of the 350 Building has a pair of fire doors into the 400 Building opposite Room D155. A portion of the 350 building in front of these fire doors has unprotected structural steel [Type II (000) construction] in an area that is surrounded by two buildings that are both Type I construction.

All construction types are based on NFPA 220 and not on ICC.

end

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed Valentine Day decorations in the 5th Floor ICU that include combustible paper hanging from ceilings and and paper decorations on walls. The surveyor did not find that the decorations observed were deficient. However, the surveyor also observed seasonal decorative lighting on an extension cord. The surveyor inquired whether the facility has a written seasonal decoration policy. The provider indicated that they did not have a written seasonal decoration policy.

The provider lacks written guide lines to control compliance with 19.3.3.2 for temporary interior finishes and 19.7.5.4 for decorations.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that areas that are open to exit access corridors do not comply with 19.3.6.1 of NFPA 101 - 2000.

Findings include:

1. The 1st Floor Central Waiting area is a very large waiting area on both sides of a corridor. It includes a cafe food serving area and multiple seating aeras. It is sprinklered throughout. The areas open to the corridor are not supervised 24/7 and the smoke detection installed does not cover every part of the area open to the corridor in accordance with 19.3.6.1, exception # 1 and NFPA 72.

A. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the Interconnect Wing on Floors 2 through 5 link the 350 Building to the 400 Building and are used for inpatient movment. Although the provider identifies these wings as business occupancies, the surveyor finds that they are health care occupancies because patients are moved in beds through the wings.

1. Each floor has continuous storage closets on one side of the corridor. Each closet door has a dead-bolt lock that is not positive or automatic latching in accordance with 19.2.6.2.

A. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the 2nd Floor of the 350 Building has multiple patient room doors with white isolation boxes hung on the corridor side of the doors. These boxes obstruct the door opening width to less than 41 ½ " clear opening (typically only 39 " to 40 " ) and do not comply with 18.2.3.5 (the door widths may not be diminished below what they were designed as unless they exceed 41 1/2").


12799

B. Based on observations, the facility failed to provide corridor doors that resist the passage of smoke as required by NFPA 19.3.6.1.

1. On 2/5/13 at 11:15 AM, surveyors with the Director of Biomed and Safety observed that the gap between the meeting edges of the pair of doors at the North end of the suite (suite doors) into the Cardiac ICU on the 5th floor exceeded 1/8" when closed.

Based on observation and an interview, it was determined that the facility failed to maintain the doors and hardware per NFPA 101, Section 39.2.2.2 and 7.2.1. In the event of a fire the occupants may not be able to exit and escape from smoke and fire.

Findings include:

On 2/7/13, 2nd floor, during the walk through of the facility with the Director of Engineering, it was observed that the double cross corridor doors separating the psych office and the means of egress.One door contains a non-functional hardware (knob), and can not be opened without opening the second door first. The operation of the doors is not clear and the doors lack signage indicating which door is functional. The current arrangement does not meet with the requirements of NFPA 101, 7.2.1.5.5.

Based on observation, it was determined that the facility failed to maintain the closure of the corridor doors per NFPA 101, Section 18.3.6.3. In the event of a fire the occupants would not be protected from smoke and fire.

Findings include:

On 2/6/13 at 2:00 PM, Basement Peri-Op Office (E009), during the walk through of the facility with the Director of Engineering, it was observed that the door to corridor was held open with an unapproved hold open device (wedge) that does not comply with NFPA 101, 18.3.6.3.2.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds vertical openings are not protected in accordance with 8.2 of NFPA 101

Findings include:

1. The Basement Mechanical Room for the 400 Building has a vertical shaft that penetrates three or four floors. The shaft has an insulated duct inside. The shaft may be an air intake shaft. The shaft does not comply with 8.2:

a. The shaft does not appear on the Life Safety Plans as a fire rated shaft enclosure.

b. The shaft enclosure is used for storage; this does not comply with NFPA 90A.

c. The roof of the shaft appears to be wood/lumber (construction that is not compatible with the construction type identified for the 400 Building).

Based on random observation during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 39.3.1. This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the building.

Findings include:

1. On 2/7/13, Basement Mechanical room, by EKG, during the walk through of the facility with the Director of Engineering, it was observed that the mechanical room contains a triangular shaft at the block wall. The fire rating could not be determined from the Life Safety Code drawings and the access door was constructed of wood and not fire rated, 8.2.3.2.3.1.

2. On 2/7/13, 5th floor, Mechanical Room, during the walk through of the facility with the Director of Engineering, it was observed that the mechanical room contains several large unsealed floor penetrations.


3. On 2/7/13, 2nd floor, during the walk through of the facility with the Director of Engineering, it was observed the staff area, back wall, is a designated 2 hour rated building separation from the 400 building. The wall contains a door to a patio, utilized by both business and hospital psych. The wall contains a ventilation shaft which is not complete as a fire rated shaft enclosure above the ceiling tiles and does not meet 39.3.1.1.

Based on observation and the minimal drawings provided by the facility staff, there were multiple unsealed penetrations in the walls designated as one hour walls on the floor plans.

1. On 2/08/13 in the morning, based on observations, surveyor with Director of Engineering observed multiple unsealed penetrations at the designated one hour wall separating the tenant floors from the two story Lobby in Outpatient Care Center.

Based on observations, there were multiple unsealed penetrations in the wall designated as the one hour wall separating the Pavilion floors from the two story Main Entrance and Lobby.

1. On 2/07/13 surveyor observed tube system pipe penetrations above the toilet room nearest to Outpatient Registration that were not sealed for fire rated construction.

2. On 2/07/13, based on surveyor observations, there were multiple sleeves that were not sealed by fire rated construction in the floor of the Telecommunications Room on the Second Floor behind the elevators.

3. On 2/07/13, based on surveyor observations, there were unsealed penetrations in the designated one hour rated walls between the two story lobby an the of the Telecommunications Room on the Second Floor behind the elevators.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed doors with hold open devices do not comply with 19.2.2.2.6 and 7.2.1.8: Findings include:

1. Clean Utility Room A540 is large enough to be a hazardous area. The corridor door to the room has a magnetic hold open device but lacks smoke detection within five feet of the door.

2. 5th Floor pair of fire doors between the 350 Building and the East Building at the north connection. The fire doors took to much time to close to latch upon activation of the fire alarm system and at least one of the doors did not latch.

Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that fire doors with hold open devices are not installed to comply with 7.2.1.8 of NFPA 101.

Findings include:

1. 1st Floor Dietary Dry Storage Room: One pair or more of doors to this hazardous area have magnetic hold open devices but lack local smoke detection on each side of the doors that will detect smoke and release the doors.

2. The Fire Pump Room has a fire door that does not latch at all.

3. The pair of fire doors from the South Lobby to the Cafeteria failed to close and latch upon activation of the fire alarm system. One door failed to close to latch due to air pressure.

Based on random observation, during the survey walk through, not all fire doors are arranged to close and latch to comply with 39.2.2. or NFPA 72, 1999, 2-10.6.5.1.

Findings include:

On 2/7/13, 1st floor, during the walk through of the facility with the Director of Engineering, the surveyor observed the doors located in the designated 2 hour rated building separation. The doors link the 400 building (Corridor 102) to the 500 building. Smoke detections was not provided on both sides of the doors in accordance with 7.2.1.8 of NFPA 101. The doors also do not comply with 19.2.2.2.6 from the Hospital side of the doors.

Based on observations of hazardous areas the facility failed to properly separate combustible stored materials from building occupants. The separation between hazardous areas and the means of egress failed to meet with the requirements of NFPA 101, (2000), Section 39.3.2.1 and 8.4.1.1. This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the smoke zone.


Findings include:

A. On 2/7/13, 5th floor, Medical Records Room, during the walk through of the facility with the Director of Engineering, the room was found to have a high combustible fuel load of open paper files, cardboard boxes in a room not sprinkler protected. The door and walls to the Medical Records Room are deficient because:

1. The door to the room did not have an automatic door closer. (8.4.1.3 and 7.2.1.8)
2. The door was not a 3/4 hour fire rated with appropriately listed hardware (8.4.1.3)
3. A 1-hour rated enclosure could not be verified (8.2)

B. On 2/7/13, 4th floor, Cardiac Rehab, during the walk through of the facility with the Director of Engineering, it was observed that twelve small oxygen tanks were stored along the wall in the means of egress. The storage of the tanks and separation from combustibles did not meet with NFPA 99, 8.3.1.11.2(c)(1). The means of egress is being used for storage, and is not maintained free and clear of obstructions.

C. On 2/7/13, 4th floor, Stair S15, during the walk through of the facility with the Director of Engineering, it was observed that the vestibule outside the stair enclosure, contains a large soiled linen cart in the means of egress. The cart holds three bags; each bag has a 32 gallon capacity, making this a hazardous condition and does not meet with the requirements of NFPA 101, 8.4.

E. On 2/7/13, 3rd floor, during the walk through of the facility with the Director of Engineering, it was observed that the waiting area contains an abandoned optometrist office, which is separated from the waiting room by frosted glass panels. The room is currently being used for general storage and does not comply with the requirements for a one hour fire rated enclosure under NFPA 101, 39.3.2.1 and 8.4

F. On 2/7/13, 3rd floor, during the walk through of the facility with the Director of Engineering, it was observed that the reception area contains, sliding racks of open files. The general storage of the files is not separated from the waiting area and exit route or protected in accordance with Section 8.4.

Based on observations of hazardous areas the facility failed to properly separate combustible stored materials from the exit egress corridors. This required separation between hazardous areas and exit access corridors is to be in accordance with the requirements of NFPA 101, 2000 Edition, Section 18.3.2.1 and 8.2.3.2.3.1(2). This deficient practice would allow a fire to spread without proper fire separation and affect all occupants in the smoke zone.


Findings include:

1. On 2/5/13 at 1:40 PM, 3rd Floor, South End (Endo) Center Core, between the nursing station and nourishment is a Soiled Utility Room (E327). During the walk through of the facility with the Director of Engineering, it was observed that the corridor door failed to close and latch.

2. On 2/5/13 at 8:52 AM, 1st Floor Surgery, Equipment Room (E170) during the walk through of the facility with the Director of Engineering, it was observed the door failed to close and latch.

Hazardous area was not separated in a tenant space, as required by LSC Section 8.2.3.2.3.1(2).

On 2/07/13, in the afternoon, surveyor observered during the walk through with the Director of Engineering, that the Medical Records Room in the Ob/Gyn Office on the Fourth Floor was not separated. The door leading from Medical Records to the Nurse's Station was held open with a wedge.

A. Based on observation on February 7, 2013, with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that exit enclosures are not installed and maintained to provide a continuous, safe path to public way in accordance with Chapter 7 of NFPA 101 - 2000.

1. Five story, exit Stair S10 discharges into a designated 1st Floor, two hour enclosed, exit passageway. The exit passageway does not comply with 7.1.3.2.1, 7.1.3.2.2,and 7.2.6 of NFPA 101.

a. The exit passageway has a monolithic
ceiling with fire rated access panels.
The access panels are not self closing.

b. The fire doors from the CDU into the
exit passageway does not latch.

c. A wood pallet was left in the exit
passageway.

2. Stair S10 at the Basement Level does not comply with 7.1.3.2.1 of NFPA 101:

a. There is a large pump recessed into the
stair floor at the Basement Level.

b. There is a 16" x 16" metal box on the
stair wall at the intermediate landing
between the Basement and 1st Floor.
The provider did not know what the box
was and/or how it is permitted in the
stair enclosure.

3. Stair S5 is a required exit stair for the Basement of the 400 Building. The stair door at this level does not close to latch.

A. Based on observation with the Director of Safety and the Director of Corporate Facilities and based on document review of the Life Safety Plans dated 10/09/09, the surveyor finds that exit enclosures are not installed and maintained to provide a continuous, safe path to public way in accordance with Chapter 7 of NFPA 101 - 2000.

Findings include:

1. Stair # 1 is located at the south end of the 350 Buildings and serves as a required exit for the 1st Floor through the 5th Floor (all are patient floors). The stair discharges into a 1st Floor Required Exit Passageway that is located entirely with the South Building (Bldg 06). The Exit Passageway is roughly 140' in length and does not comply with 7.1.3.2.1, 7.1.3.2.2, and 7.2.6 of NFPA 101. The surveyor observes that this building is only partially sprinklered at best.

a. A significant portion of this exit passageway has a monolithic ceiling. The provider had no details for this ceiling and did not know when it was constructed. It appears to be installed to provide a two hour barrier separating unapproved systems and penetrations above. However, the monolithic ceiling is suspended from above by channels and wire that are not protected as two hour support assemblies (8.2.3.1).

b. The monolithic ceiling has access panels that are not permitted under 7.1.3.2.1 d).

c. The access panels installed in the ceiling have fire ratings, however, if permitted because they were installed before the above requirement was adopted, the access panels still are not self closing.

d. The first vestibule in this exit passageway is in front of the 1st Floor Morgue. The walls at this locations do not extend above the ceiling of the Morgue as two hour barriers to the deck above.

e. An exit sign in the exit passageway identifies an exit path, to the west south of the Morgue, that is not an exit passageway.

f. The Life Safety Plans dated 10/09/09 identify an exit passageway with two hour walls on both sides at the south end of the exit passageway.

g. The south end of the exit passageway has paper faced batt insulation above the lay-in ceiling at this location. The space is at least partially sprinklered; however, the space above the ceiling (concealed space with combustible materials - paper faced fiberglass batt insulation ) is not sprinklered in accordance what NFPA 13.

h. The pair of doors to Materials Management (F190) lack U L Labels as 90 minute fire doors.

i. The door to Biohazard (F176) lacks U L Labels as 90 minute fire doors.

j. The Materials Management Building is a Type II (000) structure with metal walls. The provider lacks detailed information that identifies how this area is separated from the exit passageway by a two hour barrier.

k. The Loading Dock area is newer construction and is Type II (000). The provider lacks detailed information that demonstrates how the interior Loading Dock space is separated from the exit passageway by a two hour barrier that includes the top of wall termination detail.

2. Stair S-4 has a designated, new, 1st Floor, exit passageway from the 350 building that extends through part of the 400 Building to an exit stair in the East Building. Stair S4 is a required exit for five patients floors. The Exit Passageway does not comply with 7.1.3.2.2,and 7.2.6 of NFPA 101.

a. There is a pair of cross corridor 90 minute fire doors near Stair S4. The surveyor observed holes in the fire barrier above the doors and above the ceiling that were not sealed for two hour construction.

b. The door to Conference Room A133.02 opens to the exit passageway. The door has a 90 minute rating but lacks self closing hardware.

c. 1st Floor Outpatient Surgery has a pair of 90 minutes auto-open doors that open to the exit passageway. The doors have magnetic locking devices but lacks signs identifying the delay functions in accordance with 7.2.1.6.1. The next pair of doors to the east in the exit passageway also has magnetic locking devices to control access into the semi- restricted spaces beyond. This constitutes two electrotonic locking devices in a path of egress and is not permitted under 19.2.2.2.4, exception # 2.

d. On 02/07/13 and the morning of 02/08/13, with the Director of Safety present, a cart was found parked in the exit passageway in front of Room E160. The provider lacks adequate means to prevent re-occurrence.

3. Stair S4 is a required five story exit stair that extends to the Basement Level. Stair S4 is shown at the Basement Level, on the Life Safety Plans dated 10/09/09, as communicating to the Basement Level utility tunnels with nt two hour fire separation or enclosure of the exit stair at the Basement Level.

Based on observations, the facility failed to provide exit components having a fire resistance rating of at least two hours. The exit components are not arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building.

Findings include:

On 2/5/13 at 9:15 AM, during the walk through of the facility with the Director of Engineering, it was observed that the 1st floor, Stair Door (Stair S17) did not close and latch as required by NFPA 101, 18.3.1 and 8.2.5.4(1).

Based on observations, the facility failed to provide exit components having a fire rating equal to that of the stair, as required by Section 7.2.6.3.

On 2/07/13, surveyor observed penetrations in the First Floor exit passageway from Stair 1 to the exterior. There were several unsealed openings around penetrations above the the door into the exit passageway from the the Outpatient Treatment Area on the East.

Based on observations, the facility failed to provide stairs and exit components having a fire resistance rating of at least two hour. The exit components are to be arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building. NFPA 101, 39.2.2.3 and 7.2.2.

Findings include:

1. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that the exit stair (Stair S14) off of the 5th Floor elevator lobby does not comply with Chapter 7 of NFPA 101. The stairwell landing contains a door to a small room which contains a water heater. Doors opens into a normally unoccupied room and is not permitted to open into a rated exit stair per NFPA 101, Section 7.1.3.2(b) and 7.2.2.5.3.

2. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that exit stair (S14) is required to be a 2 hour rated enclosure based on NFPA 101, 39.3.1.1 and 8.2.5.4(1). The stair enclsoure wall(s) to roof/deck connection were observed not to be sealed with a UL fire rated product. This condition was observed on all floors for this stairwell.

3. On 2/7/13, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that exit stair (S15) is required to be a 2 hour rated enclosure based on NFPA 101, 39.3.1.1 and 8.2.5.4(1). The wall to roof/deck connection was observed not to be sealed with a UL fire rated product. This condition was observed on all floors for this stairwell

4. On 2/7/13, 4th floor, during the walk through of the facility with the Director of Engineering, it was observed that Stair S14 has stair doors that swins into the stairwell at the stair landing, obstructing the landing. The distance between the guard rail and the edge of the door provides an 8 " clearance. The current arrangement restricts anyone from the upper floor from proceeding down the stairs during an evacuation. The stair does not meet with NFPA 101, 7.2.2.3.2 or provide an unobstructed path of egress. This condition was observed on Floors 2 through 4.

Based on observation, of two stairs serving the upper level of this building, two of the exit stairs were found to be deficient and not in compliance with Chapter 7 of NFPA 10.

1. On 2/08/13, surveyor with Director of Engineering observed that the enclosed stairs from the Cardiac Rehab Mezzanine to grade were used to store holiday decorations.

2. On 2/08/13, surveyor with Director of Engineering observed that the enclosed stairs from the Diabetes and Endocrinology side of the Mezzanine to grade were used to store a filing cabinet with records, as well as combustible decorations along the exterior wall beneath a large window.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that the means of egress to a public way is not maintained in accordance with Chapter 7 of NFPA 101.

Findings include:

1. The a pair of cross corridor doors near Room A326 have an exit sign above the doors. The doors do not swing in the indicated direction of exit travel in accordance with 7.2.1.4.2.

2. 2nd Floor - Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the 2nd Floor of the 350 Building has a 50 foot dead end corridor near Room A227. There is no exit sign at the north end of the corridor

a. The corridor terminates at a pair of doors that extend into a vacant suite. The signs on the doors indicate " no admittance " .

b. The vacant suite is used for some unenclosed storage.

c. The suite is not supervised 24/7 and cannot serve as the exit path from a corridor The suite does not currently comply with the rules for corridors or suites.

d. Many of the plumbing fixtures have trap seals that have evaporated. This constitutes a potential infection control and life safety hazard. The surveyors found not evidence of Life Safety Interim Measures. See K130.

3. 2nd Floor Interconnect Wing. The exit access corridor between Stair S5 and S4 is a 100 ' dead end corridor and does not comply with 19.2.5.9.

a. The corridor is directed towards a 2nd Floor ICU Suite that is vacant. Stair S4 is inside the suite.

b. The pair of 1 ½ hour fire doors at the east end of the corridor are locked with a magnetic locking device that prevents further travel to the east. This pair of door is identified as a horizontal exit. There is an exit sign above the doors. The doors do not comply with 7.2.6, 7.2.1.6.1 or 7.2.1.6.2. Access to Stair S4 is blocked by these locked doors.

4. There are two sets of cross corridor doors in the 1st Floor corridor near Room A103. The 2nd set of doors have magnetic locking devices but lacks the 15 second delay signage that is require by 7.2.1.6.1. Further, the surveyors find that these locks are located in an area that is not fully sprinklered and the locks are not permitted under 7.2.1.6.1.

5. 1st Floor OP Surgery (Dwing): The suite has a pair of auto-open 1 ½ hour doors that open to the exit passageway. The doors have magnetic locking devices but lack a sign complying with 7.2.1.6.1.


12799


B. Based on observation, the facility failed to keep all means of egress readily accessible at all times in accordance with 7.1.

Findings include

1. On 2/07/13 in the afternoon during fire alarm testing with the Construction Planning Mgr., the surveyor observed that the fire alarm did not release the cross corridor doors at the West end of the Labor/Delivery Unit outside patient room A103. More than 15 lbs. of force was required to open the Labor/Delivery Unit doors manually, therefore the surveyor finds that the doors do not meet 7.2.1.4.5 and/or 7.2.1.6.1.

2. On 2/07/13 in the afternoon during fire alarm testing with the Construction Planning Manager, the surveyor observed that since the area the cross corridor doors at the West end of the Labor/Delivery Unit outside patient room A103 of the building is not sprinklered or the two smoke compartments that are adjacent to this pair of doors do not have smoke detection throughout, the delayed egress locks are not permitted under 7.2.1.6.1.

3. On 2/07/13 in the afternoon during fire alarm testing with the Construction Planning Manager, the surveyor observed that there were two delayed egress locks on each leaf of the cross corridor doors at the West end of the Labor/Delivery Unit outside patient room A103. Twos locks are not permitted under 7.2.1.6.1.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that exit paths are not maintained and readily accessible at all times in accordance with 7.1.

1. The 1st Floor Emergency Department has locking devices that do not comply:

a. A pair of 1 ½ hour fire doors between the
Emergency Department and Imaging
have magnetic locking devices. The
provider was not able to demonstrate
how these locks comply with 7.2.1.6.1 or
7.2.1.6.2.

b. The door with an exit sign above, from
the Emergency Department to the
Emergency Room Reception area, has a
magnetic locking device. The provider
was not able to demonstrate how these
locks comply with 7.2.1.6.1 or 7.2.1.6.2.

c. The 1st Floor Vending Area Waiting
Area from the Emergency Room has a
designated exit path through a door to
the South Lobby. The door has a locking
device that the provider identifies as
locked at night. The provider was not
able to demonstrate how these lock
complies with 7.2.1.6.1 or 7.2.1.6.2.

d. The 1st Floor Emergency Department
has two seclusion Room that share a
toilet room. The toilet room has two
doors each with a single cylinder dead
bolt lacks that lacks a thumbturn inside
for each lock.

2. The Emergency Department has an exit path that is directed with exit signs into the Ambulance Bay/Drive-thru Canopy area.

a. The Ambulance Canopy is used to
store vehicles and supplies. This
constitutes a hazardous area that is not
separated from the means of egress
directed through this space in accordance
with 19.3.2.1 and 7.5.2.1.

b. The exit path towards the Ambulance
Bay/Drive Thru has exit signs above two
pairs of doors that do not swing in the
designated direction of exit travel in
accordance with 7.2.4.2.

c. The interior vestibule space between the
Ambulance Bay and the Emergency
Department is a large storage space that
is not separated from the Emergency
Department and the exit path by one
hour construction in accordance with
19.3.2.1 and 19.3.6.1. Ceiling tiles in
this space were also displaced,
compromising both fire suppression and
detection

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyors find that exit paths are not maintained and readily accessible at all times in accordance with 7.1.

Findings include

1. The 5th Floor Rehab Suite is an inpatient treatment area. The exit access corridor from this suite to Exit Stair S11 lacks two remote exit paths in accordance with 19.2.6.2.4.

a. The required exit path to Stair S10 to the
west is not available and is not marked
with illuminated exit signs.

b. The two hour separation for the suites to
the west is not identified as a horizontal
exit nor is it identified as a smoke
barrier. The doors swing only in one
direction. Opposite swinging doors are
not provided for the required exit paths
in both directions.

c. The two hour barriers to the west cannot
comply as a horizontal exit. The doctor's
suites are business occupancies in a
health care area, on a health care floor, in
a health care building and the suites do
not comply with 19.2.6.2.4. Note: This
floor is not sprinklered.

d. Suite 510 and 504 have only one exit
path. The corridor lacks two remote
paths and does not comply with
19.2.6.2.4.

e. Suite 504 blocks access to Stair S10.
The suite is locked during some hours
and an exit access corridor through the
suite is not provided.

f. Suite 504 is open to the exit access
corridor to the east above the skylight.
This arrangement does not comply with
19.3.6.2.1.

g. Suite 504 has open file storage in the
reception area that is also open to the
entire suite and the exit access corridor
to the east. This arrangement does not
comply with 19.3.2.1, 19.3.6.1. and
19.3.6.2.1.

2. There is a pair of cross corridor doors with an exit sign above the doors (somewhere near Room D185). The doors have magnetic locking devices and a sign on the door identifying 15 second delay. The doors also have a sensor above the door that release the locks immediately when approved. The doors do not comply with 7.2.1.6.1 and/or 7.2.1.6.2

a. The sign identifying the door as a
delayed egress doors is not legible (not
enough contrast). Nor is the sign
accurate (the sensor releases the door
immediately).

b. There is a sensor above the doors that
releases the locks; however a push to
exit device is not installed strictly in
accordance with 7.2.1.6.2. The provider
is not able to demonstrate how the doors
will release and comply with 7.2.1.6.1 if
the sensor fails.

2. The 2nd Floor Psychiatric Unit has a seclusion room with a bathroom. The bathroom door has a single cylinder dead bolt lock with no thumbturn inside. The bathroom is not designed to be an observed selcusoin room.

3. There is a required exit access corridor in the Ambulatory Area (corridor shown between a suite that is 3550 GSF and a suite that is 4644 GSF - corridor number is not legible on the plans provided. The corridor lacks two remote exit paths in accordance with 19.2.5.9. The designated exit path to the North is through a horizontal exit into a 9807 square foot suite (OPS Holding and Post Op/Cardiac Cath). This path does not comply with 19.2.6.2.4. The path is the suite from the Horizontal Exit exceeds 100' of travel to a corridor door and therefore cannot serve as a 2nd remote exit path from the corridor cited.

4. There is a pair of cross corridor doors with an exit sign above the doors (somewhere near Room D185). The doors have magnetic locking devices and a sign on the door identifying 15 second delay. The doors also have a sensor above the door that release the locks immediately when approved. The doors do not comply with 7.2.1.6.1 and/or 7.2.1.6.2

a. The sign identifying the door as a
delayed egress doors is not legible (not
enough contrast). Nor is the sign
accurate (the sensor releases the door
immediately).

b. There is a sensor above the doors that
releases the locks; however a push to
exit device is not installed strictly in
accordance with 7.2.1.6.2. The provider
is not able to demonstrate how the doors
will release and comply with 7.2.1.6.1 if
the sensor fails.
.

Based on observations and interview the facility failed to provide all exit discharge paths meeting the requirements of NFPA 101, 39.2.7 and 7.7.

Findings include:

1. On 2/7/13, 1st floor, Stair S14 and S15. Exit stairs continuing beyond level of discharge were not provided with interrupter gate as required by NFPA 101, 7.7.3.

2. On 2/7/13, basement level, egress path from EKG through double doors by mechanical corridor. The corridor in this area leads to a 2-hour fire rated building separation. Staff was interviewed at the time of this finding and staff indicated that the EKG doors are secured after hours. Securing the doors in the designated exit creates a dead end corridor in excess of 50 feet. The exit arrangements from the mechanical corridor failed to meet NFPA 101, 39.2.5.2. and 7.1.10.1.

Based on observations the facility failed to provide exit access that is readily accessible to a public-way at all times. Obstructions during an emergency situation could be fatal if this were the only escape route.

Findings include:

On 2/5/13 at 2:30 PM, during the walk through of the facility with the Director of Engineering, it was observed that the 1st Floor LDR corridor door to exit Stair S16, contains a delayed-egress lock. The door was equipped with 15-second delayed-egress lock, and the sign posted on the door indicated that you must " push " until alarm sounds, " door can be opened in 15 seconds " . The door was equipped with a standard lever door knob; it was unclear as to what you " push " to release the door lock and operation of the latchset does not release the lock. The arrangement does not meet with NFPA 101, 7.2.1.6.1.

A. Based on observations during the survey walk-through, the facility failed to provide and maintain properly rated fire-resistance horizontal exits, in accordance with NFPA 101, 18.2. Without the barriers being constructed and maintained, the buildings are not properly separated and a fire could spread from one building to the other.

Findings include:

On 2/5/13 at 11:35 AM, 5th floor, during the walk through of the facility with the Director of Engineering, it was observed that the 2-hour Fire Wall separating the East Tower from the 350 Building was deficient. Upon investigation it was determined that the designated 2-hour rated wall, per facility Life Safety drawings dated 10-9-09, was "not" sealed above the suspended ceiling at the cross-corridor doors. The cross corridor wall and corridor wall intersection (corners) was incomplete. The unsealed penetrations lack fire rated material in accordance with NFPA 101, 8.2.2.2.


B. Based on observations during the walk through the facility failed to provide fire doors in accordance with LSC Sections 8.2 and 18.1.2.3 and NFPA 80 Sections 1-11.4 and 2-3.1.7. Without doors and proper hardware, the fire could spread from one compartment to another.

Findings include:

On 2/5/13, 1st floor, 2 hour separation wall between OR and OB/LDR, by C-Section room. It was observed that the cross corridor doors are 90 minute rated doors. It could not be determined if the door hardware installed is listed for 90 minute fire doors. This condition was discussed with the Director of Engineering at the time of the finding. Listing documentation for the door hardware was not available.

A. The facility failed to maintain a horizontal exit constructed in accordance with 7.2.4.

1. On 2/5/13, surveyor with Director of Biomed and Safety and Construction Planning Manager observed that there is a square opening cut from the angles securing Fire Damper 524 in the 2 hour fire barrier wall above the cross corridor doors on the Fifth floor near Stair S3. The hole is not sealed for fire rated construction.

A. Based on observation, the facility failed to provide normal and emergency lighting of the means of egress as required by 39.2.8 and 39.2.9, as well as 7.8 and 7.9.

1. On 2/07/2013, surveyors with Director of Engineering observed that there was no illumination of the exit discharge from the North exit passageway of the First Floor of the Radiology/Mammography Unit of the Pavilion.

2. On 2/07/2013, surveyors with the Director of Engineering observed that the facility did not provide two fixtures or a two bulb fixture as required by 7.8.1.4 so that the failure of a single bulb will not leave the exit discharge from the North exit passageway of the First Floor of the Radiology/Mammography Unit of the Pavilion in darkness.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed a vestibule corridor that is east of the 5th Floor ICU Suite. This vestibule has a pair of fire doors to the east that lack a sign that indicates "not an exit" on the west side of these doors, in accordance with 7.10.8. There is no exit path to the east beyond these doors.

B. Stair # S-2 is identified as a convenience stair by the provider. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed signs are not installed on the stair door that indicates "not an exit" on the corridor side of the stair door, in accordance with 7.10.8. This condition applies to Floors 1 through 5.

C. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that 3rd Floor Interconnect Wing lacks an illuminated exit sign to the east.

A. Based on observation February 6, 2013, with the Director of Corporate Facilities and the Director of Biomed and Safety present, and based upon review of the Life Safety Plans dated 10/09/09, the surveyor finds the following:

1. The 4th Floor of the 400 Building is a business occupancy. It is not fully sprinklered. Two new exit stairs in the East Building are not accessible from the 4th Floor of the 350/400 Buildings. Stair S10 is located behind a locked suite and is not accessible from all parts of the 4th Floor. This leaves only two stairs (including S5) in the 400 Building both of which discharge into the interior of the building at the 1st Floor. Neither of these stair comply with 7.7.1. The 350 Building has two stairs that comply with 7.7.1 and one stair that complies with 7.7.2.

Stair S5 does not comply with 7.7.1; However, it is not required as an exit from the 4th Floor but lacks a sign that indicate "not and exit" in accordance 7.10.8.1.

The Life Safety Plans dated 10/09/09, identify Stair S5 as an exit; this information is not accurate.

2. 2nd Floor " Girls " Psychiatric Unit lacks an illuminated exit sign to the Northwest.




12799


B. The hospital staff provided conflicting information regarding Stair #5. They say that it is an exit and plans for some floors indicate that it is an exit, however no illuminated exit sign is provided.

1. On the afternoon of 2/05/13, the Fifth Floor was observed by the surveyor not to have an illuminated exit sign in the short corridor between the 350 building and Restorative Services.

2. The surveyors observed similar conditions on other floors. The provider has conflicting information for this stair. The Life Safety Plans dated 10/09/09 indicate that Stair S5 is not an exit at the 2nd Floor. The provider is able to demonstrated whether Stair S5 is required as an exit and/or how it complies with 7.7.1 or 7.7.2 as an exit.

B. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that The 2nd Floor (interstitial floor) has a path to the west with an exit sign directing the exit path to the 350 Building. However, the 1 ½ hour fire rated door in this space at the separation between the east Tower and the 350 Building lacks an illuminated exit sign.



12798

A. Based on observations it was determined that the facility failed to provide and/or maintain the directional emergency illuminated exit signs in accordance with LSC, Section 7.10.2. The lack of visual indication during an emergency could lead to confusion as to the location of exits by building occupants.

Findings include:

1. On 2/6/13, during the walk through of the facility with the Director of Engineering, it was observed that the basement " crawl space " did not provide directional illuminated exit signs. Directional exit signage are not provided where it is not obvious where the exits are located.

Based on observation with the Director of Safety and the Director of Corporate Facilities 02/07/13, the surveyor finds that illuminated exit signs are not provided in accordance with 7.10 of NFPA 101.

Findings include

1. 1st Floor Dietary Dry Storage Room: all exit paths from this space are not clearly identified with exit signs.

Based on observations and interview, it was determined that the facility failed to provide and/or maintain the directional emergency illuminated exit signs in all locations.

Findings include:

1. On 2/7/13, 5th floor, back passage way contains a door to the waiting room for cardio / vascular area. The exit sign required above the door has been removed and a hole left in the ceiling tile. Exit routes are not clearly identified as required by NFPA 101, 39.2.10 and 7.10.1.1.

2. On 2/7/13, 2nd floor, Psych offices are located off of a dead end corridor. When staff was interviewed they indicated that exiting may be though a small office type area into the cardiac office. The path indicated was not marked as an exit route, and it was unclear if the path would always be available (different tenants) in an emergency. The exit routes are not clearly identified or marked as required by NFPA 101, 7.10.1.1.

The facility failed to mount exit signs where they are not obstructed by other building components as required by LSC Section 7.10.1.7.

1. On 2/07/13, at 4:20 PM, based on observations during the walk through and by interview with the Director of Engineering, it was agreed that the exit sign and area of refuge signs were not clearly visible behind the arches in the central corridor of the 5th Floor tenant spaces. These signs were mounted in the corridor near the door to Stair No. 1 and are not visible.

2. On 2/07/13, at 4:25 PM, based on observations during the walk through and by interview with the Director of Engineering, it was agreed that the exit sign and area of refuge signs were not clearly visible behind the arches in the central corridor of the 6th Floor tenant spaces. These signs were mounted in the corridor near the door to Stair No. 1 and are not visible.

Based on document review, 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 review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Identification of construction types, as defined by NFPA 220, for each different part of the building. Separations between buildings are not clearly defined. There are a lot of two hour barriers that do not define building separations. In some cases, it is not clear which building an area is part of

2. Ventilation, duct, and pipe shafts and their fire resistance ratings.

3. Plans do not identify the Elevator Identification Numbers that are used for the building.

3. Fire barrier walls and/or horizontal exits.

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

5. Hazardous area enclosures and their fire resistance ratings.

6. Accurate and current information identifying the extent of sprinklered protection of the building.

7. Designated suites, suite boundaries

8. All exit access corridors.

10. Use of areas, occupancies in some areas along legible labeling of room uses and room numbers. The plans provided were too small to read.

11. An exit analysis is provided for the entire complex; however, it is not evaluated separately for each floor. Some floors do not have access to all exit stairs identified. Examples: Two exit stairs in the East Building are not available to all buildings at the 2nd, 4th and 5th Floor. Stair S10 is not currently available to all floors of the 350 Building.

Based on document review, 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 review of the facility's fire protection plan documents, it was determined that the facility has not prepared and maintained comprehensive building information, Life Safety plans and/or construction documents which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Ventilation, duct, and pipe shafts and their fire resistance ratings.

2. Barriers for two story spaces

3. Elevator shafts with fire ratings

3. Fire barrier walls and/or horizontal exits.

4. Tenant separation barriers

5. Exits and exit enclosures

6. Hazardous area enclosures and their fire resistance ratings.

7. Accurate and current information identifying the extent of sprinklered protection of the building.

8. Information at a scale that is large enough to read.

Based on document review, 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 review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Identification of construction types, as defined by NFPA 220, for each different part of the building. Separations between buildings are not clearly defined. There are a lot of two hour barriers that do not define building separations. In some cases, it is not clear which building an area is part of

2. Ventilation, duct, and pipe shafts and their fire resistance ratings.

3. Plans do not identify the Elevator Identification Numbers that are used for the building.

3. Fire barrier walls and/or horizontal exits.

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

a. Life Safety Plan identify two hour smoke barriers in the middle of the 2nd Floor Psychiatric Unit. Two hour smoke barriers were not found.

5. Hazardous area enclosures and their fire resistance ratings.

6. Accurate and current information identifying the extent of sprinklered protection of the building.

7. Designated suites, suite boundaries

a. The Life Safety Plans for the 2nd Floor Psychiatric Unit does not clearly identify suites and exit access corridors.
The corridor adjacent to Room 251 is not clearly identified as part of a suite and is not identified as an exit access corridor. This corridor is shown terminating at a suite (with 3095 square feet). This corridor does not comply with 19.2.5.9 and the two hour barrier at the west end of the corridor does not qualify as a horizontal exit.

The corridor between the 3000 square foot suite and the 3450 square foot suite is a required exit access corridor. This corridor terminates at the same 3095 square foot suite that is identified in item a above. This corridor also does not comply with 19.2.5.9.

Based upon item "a" and "b" the surveyor finds that the Boys Psychiatric Unit (3095 GSF) was not designed to be a suite and it is mis-identified on the plans. An exit access corridor through this space to Stair S10 is required and is not identified on plans.

No exit access corridors are identified for the 2nd Floor of the 400 Building.

b. The Life Safety Plans identify the CDU Suite as 6580 square feet in area. A portion (including but not limited to the large waiting area in this space) is open to adjacent lobby/exit access corridor. This area cannot be part of a suite. The plans do not accurately identify the boundaries of the suite.

c. The suite boundaries for all 1st Floor suites are not clearly defined.

8. All exit access corridors.

10. Use of areas, occupancies in some areas along legible labeling of room uses and room numbers. The plans provided were too small to read.

11. An exit analysis is provided for the entire complex; however, it is not evaluated separately for each floor. Some floors do not have access to all exit stairs identified. Examples: Two exit stairs in the East Building are not available to all buildings at the 2nd, 4th and 5th Floor. Stair S10 is not currently available to all floors of the 350 Building.




end

Based on document review, 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 review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Identification of construction types, as defined by NFPA 220, for each different part of the building. Separations between buildings are not clearly defined. There are a lot of two hour barriers that do not define building separations. In some cases, it is not clear which building an area is part of

2. Ventilation, duct, and pipe shafts and their fire resistance ratings.

3. Plans do not identify the Elevator Identification Numbers that are used for the building.

3. Fire barrier walls and/or horizontal exits.

a. The Life Safety Plans identify two hour walls at Storage Room B131. Two hour barriers were not found.

4. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

5. Hazardous area enclosures and their fire resistance ratings.

6. Accurate and current information identifying the extent of sprinklered protection of the building.

7. Designated suites, suite boundaries

a. The Life Safety Plans identify three 1st Floor Suites in the Emergency Department; however no suite boundaries are identified.

b. Exit access corridors are not clearly identified and the travel distance from some patient treatment areas in each suite appears to exceed 100' to a corridor door (or door directly to the outside. (19.2.5.8) In some cases that travel distance exceeds 50' where the path pass through two spaces to get to a corridor door (19.2.5.8). The Life Safety Plans provided for this survey are not scalable.

8. All exit access corridors.

10. Use of areas, occupancies in some areas along legible labeling of room uses and room numbers. The plans provided were too small to read.

Based on document review, 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 review of the facility's fire protection plan documents, including Life Safety Plans dated 10/09/09, it was determined that the facility has not prepared and maintained comprehensive building information, which shows critical elements of its egress, fire/smoke compartmentalization systems, and required life safety systems, which demonstrate compliance with 19.7.1.1. Critical elements are not shown accurately shown on floor plans include (but are not necessarily limited to):

1. Smoke barrier walls; The Life Safety Plans dated 10/09/09 that were furnished by the provider for the survey do not clearly identify the size of smoke compartments for each floor or zone. Further the plan key identifies smoke barriers and one, two and three hour smoke resistant walls. The smoke barriers and ratings are not clearly identified. The Plan Key does not clearly indicate that the smoke resistant walls are intended to identify smoke barriers.

2. All exit access corridors at the 1st Floor are not identified.

3. Use of areas, occupancies in some areas along legible labeling of room uses and room numbers. The plans provided were too small to read.

Based on document review for the previous 12 months, the facility failed to perform fire drills at least once per quarter per shift.

1. On 2/05/13 at 4:00 PM with Director of Biomed and Safety, the surveyor observed that no drill was conducted during the third shift for the Second Quarter of 2012 as required by LSC Section 19.7.1.2.

Based on observation the facility failed to provide and maintain a fire alarm system with approved devices or equipment installed according to NFPA 101, 2000 Edition, Sections 18.3.4 and 9.6.2 NFPA 72, (1999) 8.2.2. This deficient practice could affect all building occupants if the fire alarm system failed to operate during a fire.


Findings include:

1. On 2/5/13 at 1:12 PM, 3rd floor, West Horizontal Exit, between ICU and Ortho, during the walk through of the facility with the Director of Engineering, the area lacks a manual fire alarm pull station within 5 feet of the cross corridor doors at the horizontal exit. The drawings provided to the surveyor, dated 10/9/9, indicate the horizontal exit on the North side of the cross corridor doors leading South into Ortho from ICU. Clarification is needed to determine if this is a horizontal exit in both directions and if manual fire pull stations are required on the North and South sides of the exit.

2. On 2/5/13 at 1:15 PM, 3rd floor, East Horizontal Exit, between ICU and Ortho, during the walk through of the facility with the Director of Engineering, the area lacks a manual fire alarm pull station within 5 feet of the cross corridor doors at the horizontal exit. The drawings provided to the surveyor, dated 10/9/9, indicate the horizontal exit on the North side of the cross corridor doors leading South into Ortho from ICU. Clarification is needed to determine if this is a horizontal exit in both directions and if manual fire pull stations are required on the North and South sides of the exit.

Based on observations, the facility failed to install and maintain a fire alarm system that would provide an effective warning in accordance with NFPA 72.

Findings include:

On 2/7/13, 1st floor, during the walk through of the facility with the Director of Engineering, it was observed at there are fire doors located in the designated 2 hour rated building separation. The doors link the 400 building (Corridor 102) to the 500 building. Manual fire alarm pull stations were not provided within 5 feet of the doors. The current arrangement does not meet with NFPA 101, 39.3.4, or NFPA 72, 9.6.

A. The facility failed to provide a fire alarm system to give effective warning of a fire in accordance with NFPA 72.

1. On 2/07/13 in the afternoon during fire alarm testing, surveyor observed that the fire alarm was not audible in the short corridor between the Second Floor nurse's station and the doors to the former ICU. The surveyors also observed that the fire alarm system was barely audible in the vacant former ICU.

2. On 2/07/13 in the afternoon during the fire alarm testing, surveyor observed that the fire alarm was not audible in the short corridor between the two sets of cross corridor doors at the West end of the Labor/Delivery Unit, and outside patient room A103.

The facility failed to maintain the fire alarm system in accordance with NFPA 72, Section 7.1.1.2.

1. Based on document review, several items in the contractor's fire protection test report of 6/18/12 were noted as deficient. There was no evidence of correction.

Based on fire alarm record reviews and observations, the facility failed to properly install, test or maintain the fire alarm system in accordance with NFPA 101, 2000 Edition, Section 9.6 as well as NFPA 70 and NFPA 72.

Findings include:

On 2/7/13, 5th floor, center corridor the smoke detector was observed over four feet down from the highest point of the ceiling / roof area. The detectors in this area are not installed in accordance with NFPA 72, 2-3.4.1.

A. Based on document review and interview of the project architect of record, the surveyor finds that the East Tower is new health care occupancy and is required to be fully sprinklered in accordance with 18.3.5.1. The new building is fully sprinklered; however, it is not separated from the 350 Building by two hour fire rated construction and portions of the 350 Building are not sprinklered.

Findings include:

1. The 3rd Floor of the East Tower is separated from the 3rd Floor of the 350 Building by a one hour smoke barrier and not a two hour fire barrier. Based on the Life Safety Plans dated 10/09/09, portion of the 3rd Floor of the 350 Building are not sprinkled, therefor the East Tower does not comply with 18.3.5.1.

2. The 1st Floor of the East Tower is separated from the unsprinklered portions of the 1st
Floor of the 350 Building by a one hour smoke barrier and not a two hour fire barrier. Based on the Life Safety Plans dated 10/09/09 and based on direct observation with the Director of Safety present, the surveyor finds that portion of the 1st Floor of the 350 Building are not sprinkled, therefor the East Tower does not comply with 18.3.5.1.

end

A. Based on observation on 02/05/13 - 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that sprinker systems are not installed and maintained in accordance with NFPA 13.

1. The closet next to Room A300B lacks sprinkler protection in a building identified as fully sprinklered. The surveyor also notes that the above conditions are not being detected on quarterly or annual sprinkler inspections in accordance with NFPA 25.




12799

B. The facility did not provide a sprinkler system that was installed and maintained in accordance with NFPA 13.

1. On 2/05/13, surveyor with Director of Biomed and Safety observed the sprinkler piping above Patient Room 518 does not have an arm-over bracing to prevent uplift as required by NFPA 13, 1999 Edition, Section 6-2.3.4 or 6-2.1.3.

2. On 2/05/13, surveyors with Director of Biomed and Safety and Construction Planning Manager. observed boxes obstructing the sprinkler head in the Storage Cabinets 1 and 2 along the "Interconnect Corridor" between Stair S3 and Stair S5 on the Fifth Floor.

3. Similar conditions were observed by the surveyors on other floors in closets in the Interconnecting Wing between Stair S3 and Stair S5 (example: closet at west end of corridor near Elevator D).

A. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the sprinkler protection is not installed in accordance with NFPA 13.

Findings include:

1. The 1st Floor Emergency Department Addition is identified as fully sprinklered and cannot comply with 19.1.6.2 without full sprinkler protection. The Ambulance Bay/Drive-thru Canopy is structurally attached to the Hospital and is used for storage. This area lacks sprinkler protection in accordance with NFPA 13 - 1999.

A. Based upon random observation with the Director of Biomed/Safety and the Director of Corporate Facilities and based on document review of Life Safety Plans date 10/09/09, the surveyor finds that the sprinkler system is not installed at maintained in accordance with NFPA 13 and NFPA 25:

Findings Include:

1. The 1st Floor Mail Room has a closet with no sprinkler head; the area around this closet is sprinklered.

2. 1st Floor Corridor south of Pharmacy: There is a closet next to an ice machine in the corridor. The closet next to the ice machine lacks sprinkler protection in an otherwise sprinklered area.

3. The surveyor observed that this conditions are not being detected and documented on quarterly or annual sprinkler inspections in accordance with NFPA 25.

A. Based upon random observation with the Director of Biomed/Safety and the Director of Corporate Facilities and based on document review of Life Safety Plans date 10/09/09, the surveyor finds that the sprinkler system is not installed at maintained in accordance with NFPA 13 and NFPA 25:

Findings include:

1. The 5th Floor of Stair S5 has a test and drain valve that is not piped to a drain in accordance with NFPA 13. The provider had no knowledge as to what this was and/or why a drain is not required.

2. The 1st Floor Electrical Closet opposite Stair S7 is not sprinklered in an otherwise sprinklered building. This space also does not comply with the exceptions in NFPA 13 for unsprinklered spaces.

3. The 1st Floor Electrical Closet D181 is a shallow in depth closet that is not sprinklered in an otherwise sprinklered building. This space does not comply with the exceptions in NFPA 13 for unsprinklered spaces.

4. The above conditions are not being detected and documented during quarterly or annual inspections of the sprinkler system in accordance with NFPA 25.

5. The Basement corridor between Stair S5 and S11 has a continuos pipe chase that runs parallel to the corridor. This pipe chase is open to the corridor ceiling and is not separated from the corridor above the ceiling. The pipe chase is used for storage. The pipe chase is accessible as defined by NFPA 13. The pipe chase and the area open to the pipe chase above the corridor ceiling is not sprinklered in accordance with NFPA 13.

6. Basement Level Gift Shop Storage: sprinkler protection is installed above a lay-in ceiling and not below. This installation does not comply with NFPA 13.

7. The Basement Level closet behind Room B092 has a spriinkler head that is installed too low.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that the sprinkler system is not installed and maintained in accordance with NFPA 13 and NFPA 25:

Findings include:

1. 1st Floor Imaging Department - the MRI Equipment Room has voids in the ceiling and/or missing ceiling tiles that compromises both fire suppression and detection in this space.

Based on plans provided and observation, there was a large mechanical room off the two story lobby.

1. On 2/08/13 surveyor observed with the Director of Engineering that there was water leaking out of a Booster Pump in the Fire Pump Room. This equipment is not maintained to comply with NFPA 25.

The facility failed to maintain the fire alarm in accordance with NFPA 25, 1998 Edition.

1. Based on document review, the controller report for the fire alarm system of 10/02/12, states that the Basement Fire Pump Mechanical Room (B Left) failed and there was no evidence of follow up or correction.

Based on observation it was determined that the facility failed to properly inspect and document the maintenance of all portable fire extinguishers in accordance with NFPA 101, 2000 Edition 18.3.5.6, 9.7.4.1 and NFPA 10. All fire extinguishers must be mounted or secured in a safe attachment that would be accessible to staff in an emergency.

Findings include:

On 2/5/13 at 12:00 PM, during the walk through of the facility with the Director of Engineering, it was observed on the 3rd - 4th floor interstitial space, entering from Stair S16. As you enter the room on the right hand side is a sign identifying the location of a " fire extinguisher " ; however the extinguisher was not installed below the sign.

A. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed the HVAC installations are not installed and maintained in accordance with NFPA 90A.

Findings include:

1. 4th Floor Interconnect Wing: The Dialysis Locker Room has a new washer and dryer installed in this space. The provider had no information or knowledge as to how the dryer exhaust was directed to the outside.

Based on observations and interviews it was determined that the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems per NFPA 101, 2000, 39.5.2. Section 2.1, Mandatory References: This code section requires the facility to be in compliance with the NFPA 90A, Standard for the "Installation of Air-conditioning and Ventilating Systems", 1999 edition.

Findings include:

A. On 2/7/13, Basement, EKG mechanical room, observations and interviews during the walk through of the facility with the Director of Engineering, it was determined that the room contains several (3 or 4) large ducts that penetrate the back wall which contain fire dampers.

1. However, the ducts were installed without sleeves and the space between the duct and the wall was not closed off with retaining angles in accordance with the damper manufacturer's installation requirements. The walls are not rated based on the drawings and was unclear why the dampers were installed at this location.

2. The same ducts contain other dampers at locations where the walls have been removed or no longer exist above the suspended ceiling. Based on interviews with the Director of Engineering, it is unclear if the mechanical room is enclosed with any rated system. The location and function of the dampers is unclear at this time without additional investigation.

3. Fire dampers require a 4-year inspection / exercise / clean / lubricate / rest fusible link, per NFPA 90A, Section 3-4.7 Maintenance. The facility failed to provide documentation that the dampers were inspected or maintained in the last 4-years.

Based on observations, surveyors found that routine maintenance was not performed to ensure the safety of patients.

1. On 2/06/13, surveyors observed a large amount of lint had accumulated behind the dryers in the Peds/Adult Laundry in the Behavioral Health Unit. The provider lacked adequate preventative maintenance or an in-line lint trap.

A. Based on document review for Kitchen Hood Suppression systems, for semi-annual inspection, testing and maintenance for the past 12 months, the surveyor finds that the documentation for both kitchen hoods (Main Kitchen and Servery) does not comply with NFPA 17A and NFPA 96.

Findings include:

1. The semi annual inspections failed to find and identify the lack of separation between the fryers and open flames in the adjacent equipment in the Main Kitchen.

2. The documentation for the Main Kitchen and Servery is combined on one form for each semi-annual inspection. The documentation does not identify specifically the appliances protected under each hood and the documentation does not identify the number or type of links that were replaced for each system.

3. Based on observation with the Director of Safety and the Director of Corporate Facilities on 10/07/09, the surveyor finds that the kitchen hood suppression system for the 1st Floor Servery has an ANSUL pull station that is not in the path of egress from the protected system and further the path is obstructed and does not comply with NFPA 17A. This also does not show up on semi-annual inspection reports.


14416


B. The surveyor finds on the morning of 2/6/13 while in the company of the Director of Plant Operation & Maintenance at the First Floor Kitchen (South Building), protection of cooking surfaces are not provided either by separation or barrier at the deep fat fryer to the adjacent open flame range in noncompliance with NFPA 96, 1998, 9-1.2.3.

Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyors observed that the facility did not provide and/or maintain commercial cooking equipment in accordance with 9.2.3.

1. On 2/05/13 at 1:30 PM, surveyors observed that the Outpatient Therapy Kitchen the 5th floor near the doors to the Restorative Services Department in the 400 Building has a working stove, but does not have a Class K fire extinguisher as required by NFPA 10, 1998 Edition, Section 3-7.1.

2. The provider does not have specific written procedure for how and when this outpatient therapy stove may be used and therefore does not require a commercial hood and suppression system in accordance with NFPA 17A and 90.

A. Based on observation on 02/06/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that Office B307 has a portable electric heater that does not comply with 19.7.8.

Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that the 1st Floor Emergency Department Reception Desk has a portable electrical heater which does not comply with 19.7.8 of NFPA 101.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that exit access corridor are obstructed and not maintained in accordance with 7.1.10.

Findings include:

1. The 5th Floor exit access corridor north of the Rehab Suite to Stair S11 is partially obstructed by chairs and a fish tank.

2. The required 5th Floor exit access corridor from the Rehab Suite extending west to Stair S10 is partially obstructed by chairs and benches in the corridor. See also K038.

3. The 2nd Floor of the 400 Building is an inpatient psychiatric unit. There is a vestibule at the south end of the exit access corridor that provides access to Stair S5 and to an adjacent horizontal exit. This vestibule was obstructed to less than 8 ' -0 " in width by two benches and an unattended housekeeping cart.

Based on observations, it was determined that the facility failed to maintain the exit egress corridors free of all obstructions and hazardous materials to full instant use as required by NFPA 101, 7.1.10. Storing items in a corridor, exit path, egress route delays the building occupants from safely evacuating in an emergency.

Findings include:

1. On 2/5/13 at 1:00 PM, during the walk through of the facility with the Director of Engineering, it was observed that the 3rd Floor ICU is not a designated suite based on facility drawings dated 10/9/9. The exit access corridors in the ICU area were obstructed by multiple items (carts, chairs, etc.) that are stored in the corridor for a time longer than 30-minutes.

2. On 2/5/13 at 1:32 PM, during the walk through of the facility with the Director of Engineering, it was observed that the 3rd Floor Ortho is not a designated suite, based on facility drawings date 10/9/9. The exit access corridors in Ortho area were obstructed by multiple items (carts, chairs, etc.) that are stored in the exit corridor for a time longer than 30-minutes.

Based on observation with the Director of Safety and the Director of Corporate Facilities the surveyor finds medical gas tanks are not stored in accordance with NFPA 99 - 1999.

Findings include:

1. Basement Level of the 400 Building. Respiratory has oxygen tanks that are stored closer than 5'-0" to combustibles.

The surveyor find on the afternoon of 2/5/13 while in the company of the Director of Plant Operation & Maintenance at the Basement Level (East Building), unrelated electrical equipment (maintenance shop air compressor & public address system amplifier) installed within the medical gas manifold room (304) as prohibited by NFPA 99, 1999, 4-3.1.1.2, (a) 10.

The surveyor finds on the afternoon of 2/5/13 while in the company of the Director of Plant Operations and Maintenance on the First Floor (350 Building), medical gas zone valve installed (Well Born Nursery work room 127) within the same space as the outlets they serve (Room 127A) in noncompliance with NFPA 99, 1999, 4-3.1.2.3.

The surveyor finds on the morning of 2/6/13 while in the company of the Director of Plant Operations and Maintenance on the First Floor (400 Building), medical gas zone valve installed (Clinical Decision Unit) within the same space as the outlets they serve in noncompliance with NFPA 99, 1999, 4-3.1.2.3.

The surveyor finds the morning of 2/6/13 while in the company of the Director of Plant Operations and Maintenance, by direct observation and staff interview it could not be confirmed the location of the medical gas zone valves serving treatment bays 12 & 13 of the Emergency Room (Imaging/ER Building). NFPA 99, 1999, 4-3.1.2.14, (b).

Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager , the surveyor found that the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

1. The pavilion emergency generator did not have a remote shut down switch to comply with NFPA-110, Section 3-5.5.6.

2. The pavilion generator did not have a remote annunciator or a derangement signal at a 24 hour staffed location to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

A. Interim Life Safety Measures: 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.

1) The provider failed to implement and document adequate interim life safety measures for the conditions cited.

A. Interim Life Safety Measures: 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.

1) The provider failed to implement and document adequate interim life safety measures for the conditions cited.





12799

B. Based on observations during the walk through, surveyors with Director of Biomed and Safety and Construction Planning Manager found that the hospital was not maintained to ensure the safety of patients.

1. At 11:15 AM on 2/06/13, based on surveyor observations, the 2nd Floor former ICU was vacant and renovation was ongoing. The corridors of the unit are required for access from the 2nd Floor North Corridor of the 350 Building (Building 01), but the area is under construction and lacks adequate interim life safety measures.

Door in connecting vestibule to designated tenant separation wall were not self-closing as required by 8.2.3.2.3.1 (1).

1. Pair of doors connecting Ambulatory Care Center to Cancer center do not latch due to air pressure.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 99 (1999).

Findings include:

All medical gas system alarm points are not monitored at the master alarm panel at a continuously attended location in accordance with NFPA-99, Section 4-3.1.2.2(b)2 and (b)3.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the manager of building operations, the surveyor found that 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 by the loss of a single transfer switch.

Findings include but are not necessarily limited to:

1. Critical panel C3B was serving the medical gas alarm panel. This does not meet the requirements of NFPA-70, Section 517-32 and 33. Medical gas alarm panels are one of the items listed in NFPA-70, Section 517-32 that shall only be served from the life safety branch of the emergency system.

2. Life Safety panels E63 and E66: The nurse call equipment is connected to the Life Safety Branch of emergency power instead of the Critical Branch, in accordance with NFPA-70, Section 517-32.

A. Based on observation February 5, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that electrical installations and materials do not comply with NFPA 70 - 1999. Findings include

1. Electrical extension cords are used for permanent electrical service and do not comply with NFPA 70: Valentine Day string of lights at the 5th Floor ICU Nurse's Station

A. Based on observation February 8, 2013, with the Director of Corporate Facilities and the Director of BioMed and Safety present, the surveyor observed that electrical installations and materials do not comply with NFPA 70 - 1999.

Findings include

1. The Old Generator Room (Boiler House) has storage in front of electrical panels and switchgear. 3'-0" of clear space is not provided and maintained in front of electrical panels and gear.




17659

B. Based on random observation during the survey walk-through while accompanied by the lead engineer and the building operations manager, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. The generator room was not equipped with any electrical receptacles served by the life safety branch of the emergency power as required by NFPA-70, Section 517-32. These may be needed to perform maintenance on generators during an extended power outage.

2. The main water service was not bonded to ground in accordance with NFPA-70, Section 250-50. Improper grounding could create a shock hazard for all occupants of the building.

A. Based upon random observation on February 7, 2013, with the Director of Biomed/Safety and the Director of Corporate Facilities, the surveyor finds that electrical installations and materials are not installed and maintained in accordance with NFPA 70 - 1999.

Findings include:

1. The 5th Floor Doctor's Suite 507 has an electrical panel that lacks circuit identification on all circuits in accordance with NFPA 70.

2. The 5th Floor exit access corridor north of the Rehab Suite has a fish tank with an electrical extension cord that does not comply with NFPA 70

3. 1st Floor Imaging Department - the MRI Equipment Room has a microwave that obstructs access to an electrical panel. 3'-0" of clear space in front of the panel is not maintained in accordance with NFPA 70.

4. 1st Floor Cardiac Cath Area (near doors to the north): Data cables and electrical cables are supported by plumbing pipes above the ceiling and they are supported by the lay-in ceiling. These installations do not comply with NFPA 70.

5. 1st Floor Nuclear Medicine: Panel NB has a number of electrical circuits that are not labeled.

6. The 1st Floor LAB has one or more plug strips which are connected to electrical power via a yellow extension cord.

7. 1st Floor Cath Lab # 3 is used for storage. The storage blocks access to electrical panels. A clear path and 3 ' -0 " of clear space is not maintained.

8. Mechanical Room B314.01 has an orange electrical extension cord in permanent use in the middle of the room.

B. Based on observation on 02/07/13, with the Director of Safety and the Director of Corporate Facilities present, the surveyor observed that two or three cath labs were in use and could not be inspected. Cath Lab # 3 was inspected and does not comply wit h NFPA 70-1999 and NFPA 99 -1999.

a. The surveyor observed that lighting
with battery back up is not provided
in accordance with 3-3.2.1 (a) 5. e
of NFPA 99.

b. The surveyor observed no
electrical outlets that are supplied
only from normal electrical power
in accordance with NFPA 99,
3-3.2.1.2 (a) 1 and 517-19 of NFPA
70 - 1999. This deficiency could
cause injury to patients due to
transfer switch failure.

The provider was not able to demonstrate that the same conditions would not be found in Cath Lab # 1 and # 2

Based on observations, the facility failed to install electrical wiring in accordance with NFPA 101, 39.5.1, Section 9.1.2 as well as NFPA 70, 1999 Edition, National Electrical Code.

Findings include:

1. On 2/7/13, 3rd floor, in the elevator lobby, above the ceiling tiles by the Neurology Office is a Junction box that lacks a cover plate, which does not meet with NFPA 70 (1999) 370-25.

2. On 2/7/13, 2nd floor, in the elevator lobby, above the ceiling tiles by the Cardiac office corridor is a Junction box that lacks a cover plate, which does not meet with NFPA 70 (1999) 370-25.

The facility failed to properly control the amount of garbage to accumulate , thus creating a hazard.

1. On 2/07/13, surveyor with Director of Engineering observed that there was not 3'-0" clear space in front of the electrical panels as required by NFPA 70.

Based on random observation during the survey walk-through while accompanied by the lead engineer and the manager of building operations, portions of the elevator control system are not installed in accordance with ASME A17.3. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. Elevator 6 and 7 (surgical elevators): The machine room (hydraulic) in the Lower Level was not equipped with a smoke detector for elevator recall as required by ASME A17.3-211.3.

2. The surveyors observed that the surgical elevator machine room had a louvered doors. The machine room is a hazardous area and the louver does not comply with 7.2.1.8 of NFPA 101. and/or ASME A17.3.

3. The surveyor observed that the elevator machine room for elevator 6 and 7 was not equipped with a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.3-102.2.c.3.

4. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects for elevators 1, 2, 3, 4, 5, 6, and 7 as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.