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Based upon observation, structural components of the building are not protected to meet the identified and required construction type. Failure to protect structural elements of the building can result in failure during a fire condition leading to premature building collapse.

Findings include:

A. On 07/24/2019 at 2:15pm, while in the company of the FD & E it was observed that an unprotected steel column and beam (identified as a required structural element) are present. This condition does not comply with the identified protected construction type in accordance with 19.1.6.1.
Location observed: East Tower Basement level Electrical room.


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B. On 07/23/2019 at 11:10am while accompanied by the RDPC, it was determined that the means of egress corridor which leads to a required exit stair is not of the same construction type as the remainder of the facility. The required means of egress corridor is a aluminum frame and glass construction which constitutes construction type II (000) and lacks separation from the remainder of the facility to comply with 19.1.1.4.1.
Location observed: 1st floor and Ground floor, part of the North/South corridor leading to the Cancer building and exit stair.

C. On 07/22/2019 at 1:48pm while accompanied by the RDPC, it was determined that structural steel is not protected in order to maintain the building's construction type to comply with 19.1.6.1. Locations observed:

1. 7th floor Mechanical Penthouse, Exit stair contains 2 exposed steel beams as part of the 2-hour fire rated stair wall construction.

2. 7th floor Mechanical Penthouse interstitial space (access from Center Stair level 7), contains multiple unprotected structural steel beams which does not comply with 19.1.6.1.

Based on observations, Aisles, passageways, corridors, exit discharges, exit locations, and accesses are clear and the means of egress is continuously maintained free of all obstructions to full use in case of emergency. This deficient practice could affect patients, staff and visitors if an egress path if obstructed during an evacuation.

Findings include:

A. On 07/24/2019 at 10:20am while accompanied by the RDPC, a required means of egress corridor was observed containing multiple pieces of equipment, gurneys, and shelving encroaching into the width of the egress corridor. This condition does not comply with 19.2.1 and 19.2.3.5.
Locations observed: 1st floor corridor leading from ED to Stair #8


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B. On 07/23/19 at 11:15am while accompanied by RD it was determined that in the 3 East building, East elevator bank lobby, included a 4 step therapy stair. This does not comply with NFPA 101, 19.3.6.1.(a).

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required including stair components within the stair enclosure. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. On 07/22/2019 while accompanied by the RPDC, insulated piping (HWR and HWS), electrical conduit, low voltage wiring all pass through exit stairs which do not serve the stairs. These items including the piping were observed to not be part of the original stair construction per the building construction floor plans. These installations do not comply with 7.1.3.2.1(10).
Example locations observed:

1. At 1:15pm West tower West stair (Stair #2) contains two insulated pipes running down the center of the stair from 7th floor Penthouse and back through the 2-hour wall at the 5th floor.

2. At 1:48pm West tower East stair (Stair #3)contains two insulated pipe running from the 7th floor down the height of the stair

3. At 2:10pm West tower Center stair (Stair #1)contains one insulated pipe running from the 7th floor down the height of the stair

4. At 2:18pm Stair #19 1st floor contains one insulated pipe elbowing above a doorway and continuing to a rated wall.

5. At 2:35pm Stair #17 1st floor contains one insulated pipe running down the height of the stair.

6. At 2:45pm Stair #15 level of discharge, storage room under the stair landing which is not separated from the stair by a 2-hour fire rated separation.

7. At 1:30pm Stair #6 level of discharge, has a room below the stair (ladder access only) which is not separated from the stair by a 2-hour fire rated construction. The bottom of the stair run (treads/risers) serves as the ceiling of the ladder access to the mechanical room below. The stair run contains spray on fire proofing however there is no U.L. listed fire rated assembly for this application. The spray on fire proofing does not constitute a horizontal fire resistant assembly,the stair treads and risers do not constitute a structural member to meet the requirements of ANSI E 119/UL263.

B. While accompanied by the RPDC, the distance between guardrails in exit stair enclosures was observed to be in excess of 4" and does not comply with 19.2.2.3, 7.2.2.4.5.3.
Example locations observed:

1. 1:15am on 07/22/2019 West Tower Center stair
2. 1:25pm on 07/22/2019 West Tower East stair
3. 2:20pm on 07/22/2019 West Tower West stair
4. 9:15am on 07/23/2019 Exit Stair #17
5. 11:10am on 07/23/2019 Exit Stair # 18
6. 9:25am on 07/23/2019 Exit Stair # 3

C. On 07/23/2019 at 3:15pm while accompanied by the RDPC, Stair arrangements were observed that continue more than one-half story below the level of exit discharge without a means to prevent travel past the level of exit discharge. This condition does not comply with 7.7.3.4.
Example locations observed: Stair #2 and #6 (which contains a chain to prevent travel). Discussion proved that the same condition applies to other exit stairs.

D. On 07/24/2019 at 2:25pm while accompanied by the RDPC an exit stair vestibule/landing is constructed of aluminum framing and glass (curtain wall installation) which is directly open to the stair it serves. This condition does not comply with 19.1.6.1, 19.2.2.3, 7.2.2 to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2.

E. On 07/22/2019 at 10:50am while accompanied by the RDPC the Center Stair at the 7th floor level(mechanical) is not separated from adjacent spaces to comply with 19.3.1 and 7.1.3.2.1(2) due to the following:

1. Access panel in the stair wall is not fire rated.

2. The stair wall adjacent to the mechanical room and the interstitial space is one 4" thick concrete block in width which does not provide the required fire resistance. The same 4" thick concrete block wall contains multiple gaps and holes.

F. On 07/23/2019 at 2:45pm while accompanied by the RPDC, egress arrangements were observed in which the discharge from an interior stair did not provide a readily visible, identifiable way to the exterior from the point of stair discharge. The condition observed does not comply with 7.7.2 (3) and 7.7.3.3. Location observed: Ground floor, Stair #4 discharges into a room containing electrical closets, janitor closet along with a corridor access door (containing an exit sign above). However, due to the observed use of the room as storage for paint containers, the exit sign is an insufficient indicator to provide a readily visible, unobstructed way to the exterior.

Based on observation, not all designated fire barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors on the building because fire could pass between adjacent fire compartments if fire barriers are not properly constructed.

Findings include:

A. On 07/24/19 at 1:25pm, while accompanied by the RD, observation determined that the designated 2 hour fire barrier at the southeast side of the Ground Floor Medical Records Room does not carry a minimum 2 hour fire resistance rating, as required by 8.3.1.1, because exposed metal studs are visible for the length of the wall above the ceiling.

B. On 07/24/19 at 11:25am, while accompanied by the RD, observation determined that a fire damper in the designated 2 hour fire barrier, at the east side of the Ground Floor Laboratory (across the Corridor from the Toilet Room), is not properly installed in accordance with 8.3.5.7 and NFPA 90A 2012 5.4.7.1 because the fire damper is not provided with frame angles and gaps are visible between the fire damper and the wall.

C. On 07/24/19, while accompanied by the RD, observation determined that pipe or other penetrations through designated fire barriers are not sealed against the passage of fire as required by 8.3.5.1. Locations observed include:

1. 11:07am, Ground Floor, designated 2 hour barrier above ceiling at cross-corridor doors near Pathology Office.
2. 1:45pm, Ground Floor, designated 1 hour barrier above ceiling at northeast side of Same Day Surgery Waiting Room.

D. On 07/24/19, while accompanied by the RD, observation determined that doors in designated 2 hour fire barriers do not carry a minimum 1-1/2 hour fire resistance rating as required by Table 8.3.4.2. Locations observed include:

1. 12:48pm, Ground Floor, cross-corridor doors in designated 2 hour barrier at Dialysis/Apheresis Office.

2. 12:56pm, Ground Floor, cross-corridor doors in designated 2 hour barrier across from Multi-Faith Prayer Room.

E. On 07/24/19 at 12:56pm, while accompanied by the RD, observation determined that the Ground Floor cross-corridor doors in the designated 2 hour barrier across from the Multi-Faith Prayer Room do not close to latch as required by NFPA 80 2010 6.1.4.

F. On 07/24/19 at 11:21am, while accompanied by the RD, observation determined that a window in the Ground Floor designated 2 hour barrier at the north end of the west wall of the Laboratory does not carry a fire rating required by Table 8.3.4.2.


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Based on observation not all exit enclosures are separated from surrounding areas by a fire resistance rating that is required for the stair(s) it serves. This deficient practice could affect all patients in the facility, as well as any staff and visitors present, by not providing a sufficent number of exits from the building.

Findings include:

G. On 07/24/2019 at 2:25pm while accompanied by the RDPC exit passageway's were observed which do not maintain the fire rated construction of the stair(s) they serve to comply with 19.2.2.7, 7.2.6. and 7.1.3.2.1 and 8.3.5. Conditions and locations observed:

1. The exit passageway serving Stair #2 contains the following example items which do not serve the enclosure:
a. medical gas piping
b. recessed medical gas zone valve in a 2-hour enclosing wall could not be confirmed to maintain the rating of the wall.
c. electrical services, and communition services above the suspended ceiling
d. duct work which lacks damper installations
e. type of fire stopping installation for duct work penetration(s) at a 2-hour rated wall

2. The exit passageway serving Stair #2 has openings onto it from normally unoccupied spaces such as storage rooms and telecom/electrical rooms which does not comply with 7.1.3.2.1(9).

H. On 07/24/2019 at 9:15am while accompanied by the RDPC an exit passageway was observed serving Stairs #8 and #7 which has openings onto it from normally unoccupied spaces such as storage rooms and telecom/electrical rooms which does not comply with 7.1.3.2.1(9). Conditions and locations observed:

1. The exit passageway serving Stairs #8 and #7 contains the following example items that do not serve the enclosure:
a. electrical services, and communition services above the suspended ceiling
b. duct work which lacks damper installations
c. type of fire stopping installation for duct work penetration(s) at a fire rated wall

2. The exit passageway serving Stairs #8 and #7 has a large opening and broken gypsum wall board above Stair #8 discharge door which does not comply with 7.1.3.2.1.

Based on observation, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On 07/24/2019 at 11:45am while accompanied by the RDPC, the designated means of egress (exit sign above doorway) from the OB/LDR and Waiting area was observed leading to a means of egress corridor. The corridor lacks two required exits to comply with 19.2.5.2 and 7.5.1.1.2.
Location observed: First floor, East/West corridor between Nursery #2 Level II, and a large Waiting area (open to the corridor) has one designated exit to Stair #4.

Based on observation, the facility failed to provide exit paths that are maintained as a continuously protected path to a public way. This deficient practice could affect staff and patients during egress due to a fire emergency evacuation from the building.

Findings include:

A. On 07/24/2019 at 3:30 pm while in the company of the RDPC a directed exterior means of egress was observed in which the exterior railing does not comply with 19.2.1, 7.1.8, 7.2.2.4 for guard/handrails. Further the walking surface at the bottom of the ramp does not comply with 7.1.6.2 for changes in elevation due to the condition of the sidewalk and curb.
Location observed: Exit Stair #15 exterior discharge along a path directly adjacent to the dietary loading dock.

B. On 07/23/2019 at 3:15 pm while in the company of the RDPC a directed exterior means of egress was observed in which the exterior walking surface does not comply with 19.2.1, 7.1.6.3 and 7.1.6.4 due to the location of roof drains which are not obvious, and the compromised condition of the walking surface itself. Location observed: Exterior discharge adjacent to the 1st floor Transitional Unit.

Based on observation, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The finding is:

On 07/23/2019 at 10:20am, while accompanied by the RDPC it was determined that battery-powered emergency lights are provided in all critical care areas to comply with NFPA 99 2012 6.3.2.2.11.4 and NFPA 70 2011 517-63A.
Locations observed:

1. 1st floor, C-Section room A and B
2. 1st floor Nursery #2 Level II
3. 1st floor Endoscopy suite

Based upon observation, Exit and directional Exit signs are not provided to adequately identify means of egress from building areas. Failure to adequately identify means of egress paths can result in occuapnt confusion or inability of occupants to locate and follow a path to exit the building.

Findings include:

A. On 07/23/2019 while accompanied by the RDPC directional signage was not installed at the following locations to comply with 7.10.3.1. Example locations as follows:

1. At 10:45am, ED suite, both ends of central nurse station signs are obstructed
2. At 11:05am, Endoscopy exit corridor
3. At 10:05am Stairwell #4 exit discharge
4. At 10:30am Corridor outside of LDR area contains no exit signage


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B. On 07/24/2019, while in the company of the FD & E, it was observed that the Basement level lacks sufficiently visible exit signage to identify exit access to comply with 40.2.10/42.2.10 and 7.10.1.5.1. Locations observed:

1. At 2:00pm, the West Tower Basement level mechanical spaces lack visible exit signs to define avaialble exit access. The only exit signs visible where those provided at the doors to the stairs or tunnels to adjacent buildings. No directional or intermediate sign placement was provided to direct occupants when remote from the stairs. Not all signage was placed to be visible and was obscured by large ducts or piping systems.

2. At 2:20pm, the "New Tunnel" extending from the East Tower Basement level to the Power House Boiler room indicated an exit was available from the tunnel into the boiler room, however, the door was locked from the tunnel side preventing egress.

3. At 2:30pm, the Boiler room lacks visible exit signs to define the available exit access.


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C. On 07/24/19 at 11:15am, while accompanied by the RD, an exit sign located immediately outside the west exit from the Ground Floor Laboratory directs occupants into an adjacent higher hazard occupancy (the Loading Dock area), and not directly to the adjacent Exit Stair 12 as required by 7.10.1.1.

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:

On 07/23/19 at 2:32pm, while accompanied by the RD, observation determined that the egress path to the east of the Anti-Coagulation Unit is not identified by exit signs, as required by 7.10.1.1, becasue no exit signs exist over the west side of either set of two pairs of cross-corridor doors directly west of Nurse Station 100.

Based on observation, vertical openings between floors are not protected in order to maintain floor separations. These deficiencies may result in the effects of fire and smoke on one level to tranfer to another level, compromising the safety of patients, staff and visitors during a fire emergency. Location observed: 1st floor, shaft in corridor outside of "Kids ER"

Findings include:

At 10:30am on 07/24/2019 while accompanied by the RDPC a duct chase or shaft was observed which penetrated two floors and did not appear to comply with NFPA 90A due to the following:
1. Through floor fire dampers installation does not appear to comply with manufacturer's requirments.
2. Access door to the shaft is not fire rated to comply with the fire rating of the shaft.
3. The fire rating of the shaft is unknown due to the exposed studs on the inside of the shaft along with the thickness of the gypsum board enclosing wall.

Based on observation, hazardous areas are not separated from the required means of egress. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

Findings include:

A. On 07/23/2019 at 2:10pm while in the company of the RDPC the semi-restricted means of egress outside of each OR is being used as storage. This intervening room within the OR suite is considered hazardous due to the large amount of shelving and combustible items. This condition does not comply with 19.2.5.7.1.3(D) and 8.7.1.1(3) requiring a separate 1-hour fire rated enclosure with sprinkler protection.
Example conditions as follows:

1. Numerous racks (each approximately 48" long) containing shelving are placed along both sides of the corridor walls for an approximate 40' length. Some identified as EA10, EA04, EA02.

2. Items stored on shelves are wrapped in cardboard and plastic wrap.

3. Racks vary in the number of shelving units, however the minimum number of shelves used on each rack is 5.


B. On 07/23/2019 at 2:10pm while in the company of the RDPC a means of egress corridor serving PACU and the OR suite is being used as storage. The required means of egress is compromised due to the large amount of shelving and combustible items which do not comply with 19.2.5.7.1.3(D) and 8.7.1.1(3) requiring a 1-hour enclosure and sprinkler protection.
Example conditions as follows:

1. Numerous racks (each approximately 48" long) containing bins are placed perpendicular to the corridor walls producing small aisles of stored materials, thus reducing the required width of egress.

2. Items stored in the bins are wrapped in cardboard and plastic wrap.

3. Racks vary in the number of bins, however the minimum height of these racks are 5'.


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C. On 07/23/2019 at 10:20am while accompanied by RD it was determined that the 3 West-High, Linen room door does not latch to the door frame when tested. This does not comply with 19.3.2.

Based upon observation, fire alarm components are not installed in accordance with Code requirements. Failure to install components as required can result in delayed initiation of the fire alarm system to provide occupant notification of a fire/smoke condition.

The finding is:

On 07/24/2019 at 2:20pm while in the company of the DF & E, it was observed in the East Tower Basement level main corridor that multiple wall mounted smoke detectors were provided which were located more than 12" from the ceiling deck above in non-compliance with NFPA 72-2010, 17.7.3.2.1.

Based on observation the facility failed to install complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The findings are:

A. On the following dates and times accompanied by the SE, the surveyor finds:

1. 07/23/19 at 1:15pm in the Transitional Care Department, the high vaulted ceiling with skylights does not have sprinklers installed within 3 feet of the top of the vault. NFPA 13, 2010, 8.6.4.1.3

2. 07/23/19 at 2:05pm in the Emergency Department a skylight more than three feet deep over one end of the nurse station is without fire sprinkler protection. NFPA 13, 2010, 8.6.7

3. 07/23/19 at 9:40am, 4th Floor the Evacuation Equipment Closet is not provided with fire sprinklers. NFPA 13, 2010, 8.1

4. 07/23/19 at 9:45am, 4th Floor the Communication Closet is not provided with fire sprinklers. NFPA 13, 2010, 8.1

5. 07/23/19 at 8:55am in Exit Stair #21, fire sprinkler protection is not provided under the first accessible landing above the bottom of the stair shaft. NFPA 13, 2010, 8.15.3.2.1

6. 07/23/19 at 2:00pm in the Emergency Department, the center of the nurse station fire sprinkler coverage is obstructed by the ceiling soffit. NFPA 13, 2010, 8.6.5

7. 07/24/19 at 10:00am in Exit Stair #20, fire sprinkler protection is not provided under the first accessible landing above the bottom of the stair shaft. NFPA 13, 2010, 8.15.3.2.1


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B. On 07/22/2019 at 2:30pm while accompanied by the RDPC bathrooms within each patient room lacked sprinkler protection to comply with NFPA 13 2010 8.1. Location observed: Patient tower 5th floor odd numbered patient rooms.

C. On 07/22/2019 at 2:00pm while accompanied by the RDPC a patient bathroom lacked sprinkler protection to comply with NFPA 13 2010 8.1. Location observed: Patient tower 6th floor room #645.

D. On 07/22/2019 at 1:06pm while accompanied by the RDPC the interstitial space below Penthouse PR#3 lacks sprinkler protection, access to the interstitial space is from an access panel in the wall of the Center stair (Exit Stair #1) at the 7th floor. this condition does not comply with NFPA 13 2010 8.1.


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E. 07/23/19 at 9:55am while accompanied by RD an observation determined that on the on 4th floor, Rehab Closet adjacent to patient room 409, a pendant sprinkler head was painted. This does not comply with NFPA 13 2010, 6.2.6.4.4.

F. 07/23/19 at 10:15am while accompanied by RD an observation determined that on the 3rd floor, Patient room 346, toilet room is not sprinkler protected. This does not comply with NFPA 13, 2010, 8.1

G. 07/23/19 at 10:25am while accompanied by RD an observation determined that on the 3rd floor West-High, Rehab Services, toilet room is not sprinkler protected. This does not comply with NFPA 13, 2010, 8.1

H. 07/23/19 at 10:30am while accompanied by RD an observation determined that on the 3rd floor West-Low, Patient room 310, toilet room is not sprinkler protected. This does not comply with NFPA 13, 2010, 8.1

Based on observation, not all portable wall hung fire extinguishers are maintained and accessible for use. This deficient practice may jepardize the protection of patients, visitors and staff during a fire event by delaying access to a means of extinguishment.

The finding is:

On 07/22/2017 at 11:10am while accompanied by the RDPC wall hung fire extinguishers were observed which do not contain an indication of routine monthly inspections. 6 out of 6 extinguishers observed, contained tags which did not indicated that the inspections for either June or July were conducted. This condition does not comply with NFPA 10.

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

Findings include:

A. On 07/24/2019 at 2:15 while accompanied by the RDPC, an egress door was observed to be equipped with an unapproved hold open device, (dead bolt and door stop). Further the door did not close to the latched position to comply with 19.3.6. Location observed: Endoscopy #7 egress door.


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B. On 07/24/19 at 2:32pm, while accompanied by the RD, observation determined that the west pair of doors to the Ground Floor Kitchen is not positive latching to comply with 19.3.6.3.5.


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C. On 07/23/2019 while accompanied by the RDPC corridor doors do not latch to a closed position which does not comply with 19.3.6.3.
Locations observed:
1. At 11:05am 1st floor pair of corridor entry doors to Interventional Radiology Holding area
2. At 11:00am 1st floor door across the corridor from Interventional Radiology Holding

Based on observation/staff interview/document review the facility failed to provide fire stop protection appliances within the ventilation duct system. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 7/23/19 at 10:30am in the company of the SE, the surveyor finds the ventilation for the patient tower floors 2 thru 6 is a high pressure induction system. The perimeter room induction ventilators are supplied from air handlers located in Penthouse Machine Rooms PR1 & PR2 through multiple duct risers in rated shafts. Duct take-offs on each floor supply 1 to 2 induction units. These take-offs and resulting shaft penetrations are not provided with automatic fire stop appliances to comply with NFPA 90A, 2012, 5.3.4.

B. On 7/23/19 at 9:25am in the company of the SE, the surveyor finds the ducts from the high pressure air handling units in Penthouse Machine Room PR-2 (as viewed above the ceiling on sixth floor in the Visitor Lounge) have fire dampers installed but not within the fire barrier which does not comply with NFPA 80, 2010, 19.2.1.1.1.

Based on observation, the facility failed to install and maintain elevator systems as required. This deficient practice could affect patients, staff, and visitors in the hospital because smoke and fire could be permitted to spread throughout the building via the elevator shafts if the systems are not properly installed.

Findings include:

On 07/23/19 at 1:53pm, while accompanied by the RD, observation determined that the heat detector in the Ground Floor Center Elevator Machine Room is not located within 2 feet of the sprinkler head as required by NFPA 72 2010 21.4.2.

Based on observation during the survey walk through the facility failed to install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 7/24/19 at 10:55am accompanied by the SE, the surveyor finds that heat detectors are not installed within 2 feet of each sprinkler head for elevator shutdown. (19.5.3 / ANSI A17.1, 2007, 2.8.3.3.2 & NFPA 72, 2010, 21.4.2) Location observed : Basement elevator machine room for elevators 27 & 28

Based on staff interview the facility lacks electrical bonding of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:

On 7/24/19 at 11:30am in the company of the DF, and interview with the facilities electrician, it could not be confirmed that electrical bonding of the facility's medical gas piping system has been completed. NFPA 70, 2011, 250.104 (B)

Based on observation the facility failed to provide a compliant Category 1 medical compressed air system. This deficient practice could result in contamination of this patient use system.

The finding is:

On 7/24/19 at 10:45am in the company of the SE, the surveyor finds the intake for the patient medical air compressors is installed in the supply side plenum of air handler No. 45 which contains electric fan motors which does not comply with NFPA 99, 2012, 5.1.3.6.3.12.
Location observed: Basement Mechanical Room 16

Based on observation, the facility failed to install and maintain its piped-in medical gas system in the manner required. This deficient practice could affect patients, staff, and visitors in the building because the medical gas piping system could fail to operate when needed if not properly installed and maintained.

The finding is:

On 07/24/2019 at 1:50pm while accompanied by the RDPC, observation determined that medical gas station outlets are located in which there is not a complete wall between the outlets and the shut off valve suppling them. This condition does not comply with NFPA 99 2012, 5.1.4.8(3). Locations observed:

1. At 1:35pm Ground floor Gama Knife suite lacks complete separation between station outlets in bays 1,2 and 3 and the shut off valve.

2. At 2:30pm Day Surgery shut off valve reads 1-12, 20-21 and 37-38 other rooms, areas are missing.

Based upon observation, the Essential Electrical System (EES) is not maintained in accordance with a Type 1 EES. Failure to maintain the EES as a Type 1 system can result in loss of electrical service for critical patient care needs.

Findings include:

A. On 7/24/2019 at 1:00pm while in the company of the FD & E it was observed that not all Critical Care bed locations are provided with power from both the Essential Electrical System and the Normal power electrical system because no normal power receptacles were available at the "Old" PACU bed locations, (9 & 10 bed locations observed but all others identified as same) to comply with NFPA 99-2012, 6.3.2.2.1.2 and NFPA 70-2011, 517.19(A).

B. On 07/24/2019 at 1:05pm while in the company of the FD and E, it was observed that the electrical panel identified as serving the "Old" PACU could not aid in identifying circuits because the panel directory did not identify individual circuits serving particular bed stations. Only a "11912 recovery outlets" designation was provided at multiple circuits, not in compliance NFPA 70-2011, 408.4(A).

C. On 07/24/2019, while in the company of the FD & E, it was observed that Essential Electrical System (EES) branch panels contained mixed loads on the Life Safety branch panels resulting in loads that are not permitted to be fed from the Life Safety branch of the EES which does not comply with NFPA 99-2012, 6.4.2.2.3.2..

1. At 1:30pm, Panel 2-LS2 was observed to have "In Use lights", "Tube System", "Telemetry transformers & receivers", and "Fiber cabinet" (if not used as part of the emergency communication system) loads.

2. At 1:35pm, Panel 3-LS2 was observed to have "Fiber cabinet" (if not used as part of the emergency communication system) and "Telemetry transformers & receivers" loads.

3. At 1:40pm, Panel 4-LS2 was observed to have "Telemetry transformers & receivers" loads.

4. At 1:45pm, Panel 5-LS1 was observed to have "Fiber cabinet" & "GE cabinet" (if not used as part of the emergency communication system) and "Telemetry transformers & receivers" loads. This panel was also not provided with the 3' working clearance required by NFPA 70-2011, 110.26(A)(1) due to the placement of the frestanding IT equipment cabinet in front of the wall mounted electrical panel with less than 3' clearance between.


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Based on observation, not all electrical receptacles are installed as required. this deficient practice could affect patients, staff, and visitors in the building because electrical power may not be available for use when required if they are not properly identified.

The finding is:

D. While accompanied by the RDPC, observation determined that electrical receptacles, served by the emergency power system, in critical care areas are not labeled as to electrical panel and circuit from which they are fed to comply with NFPA 70 2011 517-19(A).
Example locations include:

1. 07/24/2019 at 11:11am: 1st floor Emergency Department
2. 07/23/2019 at 11:14am: Caesarian Section suite
3. 07/23/2019 at 9:47am: 1st floor PACU
4. 07/23/2019 at 2:50pm; Level II Nursery
5. 07/24/2019 at 2:00pm: 1st floor Endoscopy

Based upon observation, medical gas storage is not in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to properly store medical gases were to permit stored gases to contribute to the accelarated spread or intensity of a fire at the location.

Findings include:

A On 7/23/19 at 9:25am in the company of the SE, the surveyor finds in the Ground Floor medical gas cylinder and manifold room a compressed flammable gas cylinder of acetylene stored along with compressed oxidizing gas cylinders in non-compliance with NFPA 99, 2012, 11.3.2.2.


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B. On 07/24/2019 at 10:50am while in the company of the RDPC it was observed that cylinder racks for 12 tanks, 4 tanks and mobile cart stands for E-size tanks which constitute greater than 300 cu. ft. per smoke compartment, was located in numerous storage rooms, clean holding rooms and were not separated from combustible storage to comply with NFPA 99-2012, 11.3.2.3. Example locations: Ground floor CT suite, MRI suite, Holding area, Xray

C. On 07/24/2019 at 3:50pm while in the company of the RDPC it was observed that the medgas storage room located in the Ground floor near the Dietary loading dock and Stair # 15, contains numerous tanks which are not restrained to comply NFPA 99-2012, 5.1.3.3.2.

D. On 07/24/2019 at 3:55pm while in the company of the RDPC empty, partial and full cylinders are not stored in a segregated manner within the same enclosure to comply with NFPA 99, 2012 11.6.5.2. The marking/signage for cylinders is laying on top of groups of cylinders making it unclear which group is empty or full since there is no segregation. This condition does not comply with NFPA 99, 2012, 11.6.5.3. Location observed: Ground floor Medgas Storage room located adjacent to Stair #15