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Based on observation, not all egress paths are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress could be impeded under emergency conditions if they are not maintained.
Findings include:

On March 26, 2019 at 2:35 PM, while in the company of the PM, observation determined that the exit corridor by the 9th Floor Bio-Med Room is being used for storing wheelchairs and central supply boxes which is prohibited by 18.2.1 and 7.1.10.1.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

A. On March 26, 2019 at 1:55 PM, while accompanied by the PM, observation determined that the following 1st Floor Exit Corridors lack directional exit signs required by 7.10.1.1:

1. At the Cross-Corridor by the EVS Storage Room.

2. Near Room 01-001.

3. At the Patient Transport Waiting Room.

B. On March 26, 2019 at 2:25 PM, while accompanied by the PM, observation determined that 9th Floor Exit Corridor 09-001 lacks directional exit signs to the Exit Stair as required by 7.10.1.1.

C. On March 26, 2019 at 2:45 PM, while accompanied by the PM, observation determined that the 11th Floor Exit Patient Suite Corridor lacks directional exit signs required by 7.10.1.1.

D. On March 26, 2019 at 2:55 PM, while accompanied by the PM, observation determined that the following 14th Floor Exit Corridors lack directional exit signs required by 7.10.1.1:

1. At the corner of Corridors 14-010 and 14-005.

2. At the Radiology Holding Room.

3. At the Exit Corridor door with magnetic locks.



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E. On March 26, 2019 at 1:50 PM, while accompanied by the DF, observation determined that the exit sign at the southeast cornier of the 27th Floor Mechanical Room directs building occupants into the side of an air handling unit; thus the exit sign thus identifies an incorrect path as prohibited by 7.10.1.1.

Based on document review, the facility failed to inspect, test, and maintain its fire alarm system. This deficient practice could affect patients, staff, and visitors in the building if the fire alarm system could fail to operate under emergency conditions if the fire alarm system is not properly maintained.

Findings include:

On March 27, 2019 at 1:52 PM, while accompanied by the DF, document review determined that the facility does not conduct periodic inspections, testing, and maintenance of its fire alarm system, as required by NFPA 72 2010 Table 14.3.1 and Table 14.4.5, because no records of such inspections, testing, or maintenance were available.

Based on observation, the facility failed to provide a complete automatic sprinkler system. This deficient practice could affect patients, staff, and visitors in the building because the automatic sprinkler system may fail to extinguish a fire if it is not properly installed.

Findings include:

On March 27, 2019 at 9:55 AM, while in the company of the PM,observation determined that sprinkler protection was not installed in the Soiled Utility Room, not in compliance with NFPA 13 2010 9.2.1.3.

Based on document review, the facility failed to inspect, test, and maintain its automatic sprinkler system as required. This deficient practice could affect patients, staff, and visitors in the hospital because the automatic sprinkler system could fail to operate under emergency conditions if it is not properly inspected, tested, and maintained.

Findings include:

On March 27, 2019 at 1:54 PM, while accompanied by the DF, document review determined that the facility does not conduct periodic inspections, testing, and maintenance of its automatic sprinkler system, as required by NFPA 25 2011 Table 5.1.1.2 and Table 13.1.1.2, because no records of such inspections, testing, or maintenance were available.

Based on observation, not all use areas are separated from exit access corridors as required. These deficiencies could affect patients, staff, or visitors in the building because smoke or fire could pass from the use areas into the remainder of the building if the use areas are not separated from corridors..

Findings include:

On March 27, 2019, while accompanied by the DF, observation determined that unsupervised waiting areas, which are open to a corridor, lack a smoke detector required by 18.3.6.1(2)(b). Locations observed include:

A. 9:29 AM: 24th Floor Waiting Room 2412 (Southwest Waiting Room).

B. 11:06 AM: 22nd Floor Waiting Room 2212 (Southwest Waiting Room).

Based on document review, not all fire door assemblies are inspected, tested, and maintained on an annual basis. This deficient practice could affect patients, staff, and visitors in the building because the doors may fail to operate when needed if they are not periodically inspected, tested, and maintained.

Findings include:

On March 27, 2019 at 1:39 PM, while accompanied by the DF, document review determined that the inspection and testing of swinging doors with builders hardware or fire door hardware does not include at least the verification of the following conditions as required by NFPA 80 2010 5.2.4.2:

A. No hole or breaks exist in surface of door or frame NFPA 80 2010 5.2.4.2(1).

B. Glazing, vision light frames, glazing beads intact and fastened NFPA 80 2010 5.2.4.2(2).

C. Door frame, hinges, hardware, non-combustible threshold are secured, aligned, in working order, and with no signs of damage NFPA 80 2010 5.2.4.2(3).

D. No parts are missing or broken NFPA 80 2010 5.2.4.2(4).

E. If a coordinator is present, inactive leaf closes first NFPA 80 2010 5.2.4.2(7).

F. Auxiliary hardware items that interfere with door operation are not installed on door or frame NFPA 80 2010 5.2.4.2(9).

G. No field modifications which void label have been performed NFPA 80 2010 5.2.4.2(10).

H. Gasketing and edge seals are inspected for presence and integrity NFPA 80 2010 5.2.4.2(11).