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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.

Findings include:

A. The First Floor Imaging Department Patient Holding Bays were observed to constitute patient treatment areas which are not separated from exit access corridors as required by 19.3.6.1.

B. Corrected 10/22/10

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. A door was observed from the Lower Level Boiler Room, a room not normally occupied, to Exit Stair 4 as prohibited by 7.1.3.2.1(b).

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. During an interview held at the site on the morning of June 22, 2010, the provider's Corporate Administrative Director of Facilities stated that a series of locking devices in the Second Floor Mother/baby Unit [when activated by the infant abduction (HUGS) system] release only upon activation of the building fire alarm system; the locking assemblies thus do not comply with 19.2.2.2.4. Locations at which these locking mechanisms have been identified as being installed include:
1. Door to Exit Stair 5 (located at the north end of the Nursing Wing).

2. Door to Convenience Stair adjacent to Elevator serving the Helipad.

3. Pair of doors at the northeast corner of the Well Baby Nursery.

4. Pair of doors at the southwest corner of the Well Baby Nursery.

5. Door to Exit Stair 4 (located south of the Well Baby Nursery).

6. Pair of doors in the designated 2 hour fire barrier between the Nursing Wing and the West Wing.

B. Corrected 10/22/10.
C. Corrected 10/22/10

D. The north egress path for the Kitchen was observed to pass through a hazardous area (the Loading ock) as prohibited by 7.5.2.1.

E. Corrected 10/22/10

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar year 2009, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. March 18, 2009: 4:00 PM.

b. May 19, 2009: 3:45 PM.

c. July 22, 2009: 3:45 PM.

d. November 18, 2009: 3:45 PM.

2. Third Shift:
a. February 24, 2009: 6:30 AM.

b. June 25, 2009: 6:30 AM.

c. September 22, 2009: 6:30 AM.

d. December 17, 2009: 6:30 AM.


UPDATE 10/22/10: Most tests are being conducted within 1-2 hour time frame per shift. A greater time variance is requested.

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.

Findings include:

A. Carts 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:

1. Fourth Floor:

a. Nursing Wing: 4 work stations on wheels, across from Patient Sleeping Room 419.

b. Phase I Wing, work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.
2. Third Floor:

a. ICU Corridor, scale.

b. Phase I Wing, work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.
3. Second Floor Phase I Wing:

a. Work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.

b. Bassinets in Corridor across from Patient Sleeping Room 238.

4. First Floor:

a. Surgical Department:

1) Carts, gurneys, and equipment in:

a) North East-West Corridor.

b) North-South Corridor.

c) South East-West Corridor.

2) C-Arm adjacent to Anesthesia Office.

b. Carts and equipment in Exit Passageway immediately east of Surgical Department.

c. Corrected 10/22/10
d. Corrected 10/22/10
e. Corrected 10/22/10

Based on random observation during the survey walk-through, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99.

Findings include:

A. Manual medical gas shutoff (zone) valves were observed that are located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d). Locations observed include (all First Floor):

1. Corrected 10/22/10

2. Imaging Department Patient Holding Bays.





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B. Corrected 10/22/10

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. 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.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. The Second Floor Phase I Wing Post-Partum Rooms (identified, during an interview held at the site on the morning of June 22, 2010, by Unit staff as being included in the provider's rooming-in program) were observed to lack a minimum of 4 electrical receptacles, as required by NFPA 70 1999 517-18(b), at bassinet locations.