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Based on random observation during the survey walk-through, not all non-conforming buildings are separated from health care occupancies as required by 19.1.1.4.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass into the health care occupancy.

Findings include:

A. During a test of the building fire alarm system conducted at 10:57 AM on January 30, 2014, the First Floor pair of doors between the Hospital and Professional Office Building 1, which are located in a 2 hour fire rated occupancy separation wall, were observed to not close to latch as required by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. Portions of the steel structure were observed that are not covered by fire proofing materials in accordance with the building's designated construction type. Locations observed include:

1. 2:45 PM January 28, 2014: Second floor D Wing North Exit Stair, steel beams.



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2. Afternoon of January 29, 2014: First Floor B wing:
a. Soiled Utility Room B135, steel beam.

b. Exit Stair B012, steel beam.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. This deficiency could affect any patients, staff, or visitors in the immediate area by compromising the protection offered by the egress corridors.

Findings include:

A. On the morning of January 29, 2014, the Waiting Alcove in the First Floor Imaging Unit Waiting Area (near Room I1219), which was observed to be open to a corridor and to not be visible from a constantly attended station, was observed to lack smoke detectors required by Exception 2. [subpart (b)] to 19.3.6.1.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. This deficiency could affect any patients, staff, or visitors in the immediate area by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. At 10:20 AM on January 29, 2014, the door to First Floor Same Day Surgery Room F131, which is used as a storage room, was observed to not be self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2).

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. Throughout the duration of the survey walk-through, snow was observed covering the sidewalks at most exterior exit doors from the facility as prohibited by 7.7.1. and 7.1.10.1.

B. At 1:49 PM on January 28, 2014, the delayed egress door leading from the Second Floor K Corridor to the D Wing (the Mother/Baby Unit) was observed top lack signage, required by 7.2.1.6.1(d) which reads "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS."

C. At 2:56 PM on January 29, 2014, the door from the Basement Central Supply Room was observed to lack a sensor which unlocks the Corridor door as required by 7.2.1.6.2(a).

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. On the afternoon of January 28, 2014, a duct penetration through the designated 2 hour rated fire barrier in Second Floor B Wing Room B231 was observed to lack a fire damper required by 8.2.3.2.4.1.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency.

Findings include:

A. At 3:15 PM on January 29, 2014, during the document review process, it was determined that fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2013 and 2014, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. First Shift:

a. January 16, 2013: 7:07 AM.

b. April 17, 2013: 7:15 AM.

c. July 7, 2013: 7:10 AM.

d. September 9, 2013: 7:05 AM.

e. January 8, 2014: 7:00 AM.

2. Second Shift:

a. February 28, 2013: 3:05 PM.

b. May 15, 2013: 3:05 PM.

c. August 21, 2013: 3:05 PM.

d. November 13, 2013: 3:05 PM.

3. Third Shift:

a. March 20, 2013: 6:10 AM.

b. June 13, 2013: 6:05 AM.

c. June 27, 2013: 6:05 AM.

d. September 19, 2013: 6:00 AM.

e. September 26, 2013: 6:05 AM.

f. October 23, 2013: 6:05 AM.

g. December 23, 2013: 6:29 AM.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect any patients, staff, or visitors in the building by preventing the building fire alarm system from activating in a timely manner or by permitting smoke to pass between adjacent smoke compartments.

Findings include:

A. At 2:16 PM on January 28, 2014, the pair of doors located in the Second Floor D Wing north smoke barrier wall, at which the ceiling on both sides of the wall is greater than 24" above the door head, were observed to lack a smoke detector within 5'-0" of the door as required by NFPA 72 1999 2-10.6.5.1.


B. Pairs of cross-corridor doors in designated horizontal exist were observed that lack fire alarm pull manual stations within 5'-0" of both sides of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2. Locations observed include:

1. 1:57 PM January 28, 2014: Second Floor pair of cross-corridor doors between C Wing and D Wing.

2. 9:48 AM January 29, 2014: First Floor Second Floor pair of cross-corridor doors between B Wing and C Wing.



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C. On the afternoon of January 28, 2014, the pair of cross-corridor doors in the designated horizontal exit between the A wing and the B Wing were observed that lack fire alarm pull manual stations within 5'-0" of both sides of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2.

D. Smoke detectors were observed that are located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1. Locations observed include:

1. Morning of January 29, 2014, First Floor:
a. Infusion Suite Nurses' Station.

b. A Wing CT Sim. Control room A187.

c. A Wing Soiled Utility Room A146.

2. Afternoon of January 29, 2014, First Floor:
a. B Wing Equipment Room B124.
b. Entrance to Vascular Unit near Men's Dressing Room.

c. Adjcacent to double door near Room T1229A.

2. Afternoon of January 29, 2014, Basement:

a. Central Sterile Processing Department Clean room.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

A. At 1:46 PM on January 29, 2014, the sprinkler head in the Basement Data Closet near professional Office Building 1 was observed to be greater than 12 inches below the ceiling as prohibited by NFPA 13 1999 5-6.4.1.1.


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B. Sprinkler heads were observed that are missing escutcheon plates as prohibited by NFPA 25 1998 2-4.1.8. Locations observed include:

1. Afternoon of January 28, 2014: Second Floor A Wing Soiled utility Room A263.

2. Morning of January 29, 2014: First Floor Emergency Department Men's Locker Room Toilet ED1240A.

C. On the afternoon of January 28, 2014, the sprinkler heads in Second Floor B Wing Therapy Charting Room B220 were observed to be covered with dust as prohibited by NFPA 25 1998 2-2.2.1.

Based on document review, the facility's fire pump is not tested as required by 9.7.1.1. this deficiency could affect any patients, staff, or visitors in the building because the fire pump could fail to operate under emergency power conditions.

Findings include:

A. At 9:05 AM on January 30, 2014, the fire pump test records dated August 26, 2013 did not indicate that the annual test of the building's fire pump had been conducted under emergency power as required by NFPA 25 1998 5-3.3.4.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include (all First Floor Surgery Department, 12:30 PM January 29, 2014):

1. North Corridor, gurneys.
2. South Corridor, equipment at west end.
3. All Corridors, trash receptacles at scrub sinks.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99. This deficiency could affect any patients, staff, or visitors in the immediate area because the medical gases could contribute to a fire.

Findings include:

A. At 2:37 PM on January 28, 2014, 6 medical gas tanks were observed being stored, in the Second Floor D Wing Clean Utility Room, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2).

Based on random observation during the survey walk-through, not all anesthetizing locations are protected in accordance with NFPA 99. This deficiency could affect any patients receiving treatment in the Caesarian Section Room because the supply of medical gases could be cut off without staff knowledge.

Findings include:

A. At 2:22 PM on January 28, 2014, a medical gas zone valve serving Second Floor D Wing Patient Sleeping Room D221 was also observed to serve Caesarian Section Room D256, as prohibited by NFPA 99 1999 4-3.1.2.3.(n) because the zone valves are not dedicated to the anesthetizing location.

Based on random observation during the survey walk through while accompanied by the Engineering Coordinator, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect any occupants of these units using medical gas if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. Morning of January 29, 2014: Panels S1CR7 circuit 23 is a critical panel circuit serving the med gas alarm in the ER area, and the med gas alarm in the post partum area was also served from a critical panel which does not meet the requirements of NFPA-70, Section 517-32.

Based on random observation during the survey walk through while accompanied by the Engineering Coordinator, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any patient undergoing surgery if the transfer switch serving the operating rooms fails.

Findings include:

A. Morning of January 29, 2014: Operating room 11 was not equipped with a normal receptacle to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

Based on random observation during the survey walk-through, not all non-conforming buildings are separated from health care occupancies as required by 19.1.1.4.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass into the health care occupancy.

Findings include:

A. During a test of the building fire alarm system conducted at 10:57 AM on January 30, 2014, the First Floor pair of doors between the Hospital and Professional Office Building 1, which are located in a 2 hour fire rated occupancy separation wall, were observed to not close to latch as required by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. Portions of the steel structure were observed that are not covered by fire proofing materials in accordance with the building's designated construction type. Locations observed include:

1. 2:45 PM January 28, 2014: Second floor D Wing North Exit Stair, steel beams.



16339


2. Afternoon of January 29, 2014: First Floor B wing:
a. Soiled Utility Room B135, steel beam.

b. Exit Stair B012, steel beam.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. This deficiency could affect any patients, staff, or visitors in the immediate area by compromising the protection offered by the egress corridors.

Findings include:

A. On the morning of January 29, 2014, the Waiting Alcove in the First Floor Imaging Unit Waiting Area (near Room I1219), which was observed to be open to a corridor and to not be visible from a constantly attended station, was observed to lack smoke detectors required by Exception 2. [subpart (b)] to 19.3.6.1.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. This deficiency could affect any patients, staff, or visitors in the immediate area by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. At 10:20 AM on January 29, 2014, the door to First Floor Same Day Surgery Room F131, which is used as a storage room, was observed to not be self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2).

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. Throughout the duration of the survey walk-through, snow was observed covering the sidewalks at most exterior exit doors from the facility as prohibited by 7.7.1. and 7.1.10.1.

B. At 1:49 PM on January 28, 2014, the delayed egress door leading from the Second Floor K Corridor to the D Wing (the Mother/Baby Unit) was observed top lack signage, required by 7.2.1.6.1(d) which reads "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS."

C. At 2:56 PM on January 29, 2014, the door from the Basement Central Supply Room was observed to lack a sensor which unlocks the Corridor door as required by 7.2.1.6.2(a).

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. On the afternoon of January 28, 2014, a duct penetration through the designated 2 hour rated fire barrier in Second Floor B Wing Room B231 was observed to lack a fire damper required by 8.2.3.2.4.1.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency.

Findings include:

A. At 3:15 PM on January 29, 2014, during the document review process, it was determined that fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2013 and 2014, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. First Shift:

a. January 16, 2013: 7:07 AM.

b. April 17, 2013: 7:15 AM.

c. July 7, 2013: 7:10 AM.

d. September 9, 2013: 7:05 AM.

e. January 8, 2014: 7:00 AM.

2. Second Shift:

a. February 28, 2013: 3:05 PM.

b. May 15, 2013: 3:05 PM.

c. August 21, 2013: 3:05 PM.

d. November 13, 2013: 3:05 PM.

3. Third Shift:

a. March 20, 2013: 6:10 AM.

b. June 13, 2013: 6:05 AM.

c. June 27, 2013: 6:05 AM.

d. September 19, 2013: 6:00 AM.

e. September 26, 2013: 6:05 AM.

f. October 23, 2013: 6:05 AM.

g. December 23, 2013: 6:29 AM.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect any patients, staff, or visitors in the building by preventing the building fire alarm system from activating in a timely manner or by permitting smoke to pass between adjacent smoke compartments.

Findings include:

A. At 2:16 PM on January 28, 2014, the pair of doors located in the Second Floor D Wing north smoke barrier wall, at which the ceiling on both sides of the wall is greater than 24" above the door head, were observed to lack a smoke detector within 5'-0" of the door as required by NFPA 72 1999 2-10.6.5.1.


B. Pairs of cross-corridor doors in designated horizontal exist were observed that lack fire alarm pull manual stations within 5'-0" of both sides of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2. Locations observed include:

1. 1:57 PM January 28, 2014: Second Floor pair of cross-corridor doors between C Wing and D Wing.

2. 9:48 AM January 29, 2014: First Floor Second Floor pair of cross-corridor doors between B Wing and C Wing.



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C. On the afternoon of January 28, 2014, the pair of cross-corridor doors in the designated horizontal exit between the A wing and the B Wing were observed that lack fire alarm pull manual stations within 5'-0" of both sides of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2.

D. Smoke detectors were observed that are located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1. Locations observed include:

1. Morning of January 29, 2014, First Floor:
a. Infusion Suite Nurses' Station.

b. A Wing CT Sim. Control room A187.

c. A Wing Soiled Utility Room A146.

2. Afternoon of January 29, 2014, First Floor:
a. B Wing Equipment Room B124.
b. Entrance to Vascular Unit near Men's Dressing Room.

c. Adjcacent to double door near Room T1229A.

2. Afternoon of January 29, 2014, Basement:

a. Central Sterile Processing Department Clean room.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

A. At 1:46 PM on January 29, 2014, the sprinkler head in the Basement Data Closet near professional Office Building 1 was observed to be greater than 12 inches below the ceiling as prohibited by NFPA 13 1999 5-6.4.1.1.


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B. Sprinkler heads were observed that are missing escutcheon plates as prohibited by NFPA 25 1998 2-4.1.8. Locations observed include:

1. Afternoon of January 28, 2014: Second Floor A Wing Soiled utility Room A263.

2. Morning of January 29, 2014: First Floor Emergency Department Men's Locker Room Toilet ED1240A.

C. On the afternoon of January 28, 2014, the sprinkler heads in Second Floor B Wing Therapy Charting Room B220 were observed to be covered with dust as prohibited by NFPA 25 1998 2-2.2.1.

Based on document review, the facility's fire pump is not tested as required by 9.7.1.1. this deficiency could affect any patients, staff, or visitors in the building because the fire pump could fail to operate under emergency power conditions.

Findings include:

A. At 9:05 AM on January 30, 2014, the fire pump test records dated August 26, 2013 did not indicate that the annual test of the building's fire pump had been conducted under emergency power as required by NFPA 25 1998 5-3.3.4.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include (all First Floor Surgery Department, 12:30 PM January 29, 2014):

1. North Corridor, gurneys.
2. South Corridor, equipment at west end.
3. All Corridors, trash receptacles at scrub sinks.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99. This deficiency could affect any patients, staff, or visitors in the immediate area because the medical gases could contribute to a fire.

Findings include:

A. At 2:37 PM on January 28, 2014, 6 medical gas tanks were observed being stored, in the Second Floor D Wing Clean Utility Room, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2).

Based on random observation during the survey walk-through, not all anesthetizing locations are protected in accordance with NFPA 99. This deficiency could affect any patients receiving treatment in the Caesarian Section Room because the supply of medical gases could be cut off without staff knowledge.

Findings include:

A. At 2:22 PM on January 28, 2014, a medical gas zone valve serving Second Floor D Wing Patient Sleeping Room D221 was also observed to serve Caesarian Section Room D256, as prohibited by NFPA 99 1999 4-3.1.2.3.(n) because the zone valves are not dedicated to the anesthetizing location.

Based on random observation during the survey walk through while accompanied by the Engineering Coordinator, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect any occupants of these units using medical gas if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. Morning of January 29, 2014: Panels S1CR7 circuit 23 is a critical panel circuit serving the med gas alarm in the ER area, and the med gas alarm in the post partum area was also served from a critical panel which does not meet the requirements of NFPA-70, Section 517-32.

Based on random observation during the survey walk through while accompanied by the Engineering Coordinator, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any patient undergoing surgery if the transfer switch serving the operating rooms fails.

Findings include:

A. Morning of January 29, 2014: Operating room 11 was not equipped with a normal receptacle to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.