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The inspector observed, while accompanied by The Compliance Officer, Director of risk Management, and Regional Facility Manager during the hours of the inspection from 09:00 AM to 4:00 PM on 04/05/2017 that there were the following issues. They were the following issues:

A) There were at least three doors located at the OB and the ICU suite were not released from the magnetic lock device upon activation of the fire alarm system which prevent free egress out of building.

The inspector observed, while accompanied by The Compliance Officer, Director of risk Management, and Regional Facility Manager during the hours of the inspection from 09:00 AM to 4:00 PM on 04/05/2017 that there were the following issues. They were the following issues:

A) There were missing astragals for the smoke compartment cross corridors doors between imaging suite and day surgery suite. NFPA 101, 2003: 18.3.7.10 - Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullion shall be prohibited.





B) There were at least two pair of smoke compartment cross corridor door not fully closed to prevent passage of smoke.





C) There was penetration at the walls above the smoke barrier cross corridor doors was not sealed or fire caulked.

The inspector observed, while accompanied by The Compliance Officer, Director of risk Management, and Regional Facility Manager during the hours of the inspection from 09:00 AM to 4:00 PM on 04/05/2017 that there were the following issues. They were the following issues:

A) There were missing fire caulking at the electrical rooms.

Regional Facility Manager during the hours of the inspection from 09:00 AM to 4:00 PM on 04/05/2017 that there were the following issues. They were the following issues:

A) The plywood permanent installed on the wall inside the IT room did not have a fire rated label to be classified as class A, B, or C of flame spreading.

The inspector observed, while accompanied by The Compliance Officer, Director of risk Management, and Regional Facility Manager during the hours of the inspection from 09:00 AM to 4:00 PM on 04/05/2017 that there were the following issues. They were the following issues.

A.) There were missing a receptacle powered from the life safety branch at the new renovated 2011 generator automatic Transfer switch locations.





B.) The FCAP breaker was not identified as fire alarm control circuit control and marked red. Please provide label next to the FACP breaker.





C.) The crash carts were not powered from the generator critical branch.

The inspector observed, while accompanied by The Compliance Officer, Director of risk Management, and Regional Facility Manager during the hours of the inspection from 09:00 AM to 4:00 PM on 04/05/2017 that there were the following issues. They were the following issues:

A) Please update the signage at the medical gas storage room.
Where nitrous oxide is used, the medical gas closet shall have a door labeled: Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:
CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering







B) The mechanical exhaust was not within 12" of the floor provided at the medical gas storage room which exceed 3000 cu.ft of medical gas.
NFPA 99, 2002: 5.1.3.3.3.1(E).
Where the total volume of medical gases connected and in storage is less than 3000 cu.ft. at STP, natural ventilation shall be permitted - NFPA 99, 2002: 5.1.3.3.1(D). Where natural ventilation is permitted, it shall consist of two louvered openings, each having a minimum free area of 72 in. sq., with one located within 1 ft. of the floor and one located within 1 ft. of the ceiling
Re. NFPA 99, 2002: 5.1.3.3.3.1(B). - Where the total volume of medical gases connected and in storage is greater than 3,000 cu.ft. at STP, indoor supply locations shall be provided with dedicated mechanical ventilation systems that draw air from within 1 foot of the floor and operate continuously
Re. NFPA 99, 2002: 5.1.3.3.3.1(F).- Louvered natural ventilation opening shall not be located in an exit corridor
Re. NFPA 99, 2002: 5.1.3.3.3.1(G).- Mechanical natural ventilation shall be provided if the requirements of 5.1.3.3.3.1 cannot be met.