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Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. At 9:33 AM on June 28, 2011, the following deficiencies were observed at the Mechanical Penthouse (Fifth Floor) entry point to the building from the Helipad. These deficiencies could affect any patients in the 433 bed facility, as well as any staff and visitors present, because fire from the Helipad or wood ramp structure could pass to the remainder of the building. Deficiencies observed include:

1. The building enclosure at the Helipad entry point was observed to be of Type II (000) construction, which is not consistent with the remainder of the building as defined by 19.1.6.2. and NFPA 20 1999 Table 3-1.
2. The floor assembly for the enclosure was observed to be of wood construction, as prohibited by 19.1.6.3.

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Based on random observation during the survey walk-through and staff interview, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. This deficiency could affect any patients in the 433 bed facility, as well as any staff and visitors present, because fire could pass from the combustible product to the remainder of the building.

Findings include:

A. A suspected combustible finish material ( a wood peg board) was observed, in Fourth Floor Conference Room 450.3 (now used for storage), which is located in a non-sprinklered portion of the building. During an interview held at 9:50 AM on June 28, 2011, the provider's Manager of Building Maintenance was not able to verify that the finish materials carry Class A or B flame spread ratings as required by 19.3.3.2.(1).

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients in the 433 bed facility, as well as any staff and visitors present, by permitting smoke to pass from rooms into exit corridors.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. Locations observed include:

1. 10:20 Am June 28, 2011: Door to Fourth Floor Solarium (Room 400.1).

2. 11:00 AM June 28, 2011: Two doors to the East Center Core Elevator Lobby.

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B. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. Locations observed include:

1. Third Floor:

a. 9:51 AM June 28, 2011: Door to North ICU Suite.

b. 10:19 AM June 28, 2011: Door to Solarium.

2. 11:00 AM June 28, 2011: Second Floor door to Caesarian Section Suite.

3. 11:21 AM June 28, 2011: Door to Second Floor Behavioral Health Unit Coffee Room.

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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.

Findings include:

A. At 9:40 AM on June 22, 2011, combustible materials were observed being stored in the Third Floor ICU South Passage (directly across from Exit Stair 8) in a manner prohibited by 19.3.2.1., because they are not separated from the remainder of the building by minimum 1 hour fire rated construction. This deficiency could affect any patients in the 12 beds in the Unit, as well as any staff and visitors present, because fire could pass from the stored combustibles to the remainder of the Unit.

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Based on random observation during the survey walk-through and staff interview, not all laboratories employing quantities of flammable, combustible, or hazardous materials are protected in accordance with NFPA 99.

Findings include:

A. Of the 3 doors to the Laboratory, the southwest door was observed to not carry a 3/4 hour fire resistance rating. During an interview held at the site at 9:15 AM on June 29, 2011, the provider's Maintenance Technician was not able to verify that the Laboratory is provided with a 1 hour fire rated enclosure in compliance with NFPA 99 1999 10-3.1.1. and 8.2.3.2.3.1.(2). This deficiency could affect any patients in the 433 bed facility, as well as any staff and visitors present, by allowing smoke or fire to pass from the Laboratory to the remainder of the building.

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Based on random observation during the survey walk-through, not all exit stair shafts or other exit enclosures are constructed or maintained as fire resistive assemblies in accordance with 39.3.1.1. These deficiencies could affect any patients in the facility, as well as any staff and visitors present, because egress paths could become compromised under a fire condition.

Findings include:

A. The following deficiencies were observed at the West Exit Passageway for the West Building:

1. At 9:45 AM on June 29, 2011, doors in the Exit Passageway walls were observed which do not carry a minimum 1 hour fire rating as required by 7,2,6,3, and 8.2.3.2.3.1(2). Doors observed include:

a. Door to Lobby.

b. Door to Offices.

2. At 9:45 AM on July 29, 2011, the door from the Medical Gas Closet was observed to open into the Exit Passageway as prohibited by 7.1.3.2.1(d).

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

Findings include:

A. At 1:05 PM on June 28, 2011, the following deficiencies were observed at the Second Floor Cardio Suite. These deficiencies could affect any staff and visitors present in the rooms because their egress from the room could be slowed or prevented.
1. The egress path for the Suite was observed to pass through an Exam Room which is used for storage, as prohibited by 7.5.2.1.
2. The door from the Suite was observed to be equipped with a thumbturn deadbolt retractor, thus requiring more than 1 door releasing operation as prohibited by 7.2.1.5.4.

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B. At 2:30 PM on June 28, 2011, based on review of the provider's Life Safety Master Plans and documents which show which portions of the building are covered by an automatic sprinkler system, it was determined that Exit Stair 1 discharges interior to the building in a fire compartment which is not fully covered by the sprinkler system, which does not comply with Subpart (2) of 7.7.2. This deficiency could affect any patients in the 433 bed facility, as well as any staff and visitors present because the egress path could become compromised under fire conditions.

C. At 10:30 AM on July 28, 2011, the guardrails at Exit Stairs were observed to not be in compliance with Subpart (3) of 7.2.4.4.6. because a sphere 4" in diameter can pass through the openings in the guardrails. During an interview held in an Exit Stair at that time, the provider's Vice President of Facilities confirmed at all levels of all Exit Stairs within the building. This deficiency could affect any patients in the 433 bed facility, as well as any staff and visitors present because they could fall through the guardrail openings.

D. During an interview held at 8:30 Am on June 28, 2011, the provider's Vice President of Facilities confirmed that, due to ongoing construction, several exterior egress doors are currently obstructed in a manner which does not comply with 7.1.10.1. These deficiencies could affect any patients in the 433 bed facility, as well as any staff and visitors present, because the nearest exit may not be available to them under an emergency condition. The exterior exit doors currently closed due to ongoing construction include (all First Floor):

1. The exterior exit door which serves Exit Stair 6.

2. The exterior exit door which serves Exit Stairs 5 and 7.

3. The exterior exit door which serves Exit Stair 14.
4. The exterior exit door at the north end of the Surgical Department CVOR Corridor (immediately south of the door serving Exit Stair 14).

E. Dead end corridors of excessive length were observed as prohibited by 19.2.5.10. These deficiencies could affect any patients in the 433 bed facility, as well as any staff and visitors present, because they may be prevented from reaching an exit. Locations observed include:

1. 9:51 AM, June 28, 2011: Third Floor, as measured from the door to the North ICU Suite to the door to Exit Stair 5.

2. 11:00 AM June 28, 2011: Second Floor, as measured from the door to the Caesarian Section Suite to the door to Exit Stair 5.

F. At 10:37 AM on June 29, 2011, the exit ramp at the Ground Floor Loading Dock was observed to lack handrails required by 7.2.5.4. and 7.2.2.4.2. This deficiency could affect any staff present in the area because the ramp could be difficult to use under emergency conditions.

G. Doors were observed that are equipped with thumbturn deadbolt retractors, thus requiring more than 1 door releasing operation as prohibited by 7.2.1.5.4. These deficiencies could affect any staff and visitors present in the rooms because their egress from the room could be slowed or prevented. Locations observe include (all First Floor):

1. 8:57 AM June 29, 2011: The northwest door to the Cardiology Suite.

2. 8:58 AM June 29, 2011: The northeast door to the Cardiology Suite.

3. 9:03 AM June 29, 2011: The north door to the Infection Control Suite.

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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. These deficiencies could affect any patients in the facility, as well as any staff and visitors in the immediate area because fire could pass from the rated enclosure to the remainder of the building story.

Findings include:

A. The following deficiencies were observed at the First Floor South Corridor of the Physical Therapy Building, as prohibited by 8.2.3.2.4.2.:
1. At 10:10 AM on June 29, 2011, 4 pipe penetrations were observed in the 2 hour fire rated wall above the cross-corridor doors to the West Building which are not sealed against the passage of fire.

2. At 10:20 Am on June 29, 2011, the top of the 2 hour fire rated wall between the Physical Therapy Building and the East Building was observed to not be sealed against the passage of fire.

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Based on random observation during the survey walk-through, not all exterior egress paths are illuminated in such a manner that the failure of one fixture will not leave the area in darkness as prohibited by 39.2.8.

Findings include:

A. Exterior egress paths were observed that are not provided with lighting, on emergency power, that are equipped so that the failure of 1 fixture (bulb) will not leave the area in darkness. These deficiencies could affect any patients in the facility, as well as any staff and visitors present, because exterior egress paths could be difficult to use under power outage conditions. Locations observed include:

1. 9:45 AM June 29, 2011: West Building, east exit from Physical Therapy Unit.

2. 10:30 AM June 29, 2011: South Building, southeast exit from Exit Stair.

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Based on random observation during the survey walk-through, (staff interview, and document review,)exit signs did not illuminate a continuous path of egress in all cases in accordance with 39.2.10.1. and 7.10.

Findings include:

A. At 9:40 Am on June 29, 2011, the egress path from the Ground Floor Near North Exit Stair was observed to not be identified by signage, as required by 7.10.1.1, because the exit sign is obstructed by stored materials. This deficiency could affect any patients in the facility, as well as any staff and visitors present, because the egress path cold be difficult to identify under emergency conditions.

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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.

Findings include:

A. During a test of the building fire alarm system conducted on the afternoon of June 29, 2011, locations were observed from which more than two unsynchronized visual notification (strobe) devices less than 55'-0" apart were visible, as prohibited by NFPA 72 1999 4-4.4.2.2. These deficiencies could affect any patients in the 433 bed facility, as well as any staff and visitors present, because building occupants could become disoriented under fire alarm conditions. Locations observed include:

1. Third Floor Corridor between South and East Wings.

2. Second Floor area at Southwest Nurses' Station.

3. First Floor MRI/Radiology Department.

B. At 1:45 PM on June 28, 2011, a smoke detector was observed, in Second Floor Women's Locker Room 254, which is located within 3'-0" of a supply air diffuser as prohibited by NFPA 72 1999 2-3.5.1. These deficiencies could affect any patients in the 433 bed facility, as well as any staff and visitors present, because the smoke detector could fail to operate under fire conditions.

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Based on observations it was determined that the facility failed to maintain the smoke detectors in accordance with the manufacturer's specifications per NFPA 101. Section 9.6. This deficient practice could affect staff, visitors and patients..

Findings include:

A. On 6/28/11 at 1:45 PM, during the walk through on the 2nd floor Women's Locker (254), it was observed that the smoke detector was located in the direct air supply. The supply air should be 3'-0", from the smoke detector so that the detect can activate in a timely manner.

Based on random observation during the survey walk-through and staff interview, 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 in the 433 bed facility, as well as any staff and visitors present, because the building automatic sprinkler system could fail to operate as designed under fire conditions.

Findings include:

A. At 1:12 PM on June 28, 2011, sprinkler heads were observed which are obstructed in a manner prohibited by NFPA 13 1999 5-7.5.3. Locations observed include (all Second Floor):

1. Toilet Room 2005.

2. Toilet Room 2008.

B. At 1:25 PM on June 28, 2011, Ground Floor Electrical Room G103 (located within the Physical Therapy Department) that lack sprinkler heads required by NFPA 13 1999 5-1.1.(1). During an interview held at the site at that time, the provider's Manager of Building Maintenance confirmed that the room cited is within a smoke compartment which is designated as being fully sprinklered.

C. At 12:52 PM on June 28, 2011, materials were observed being stored less than 18" below standard pendant or upright spray sprinkler heads, in Second Floor Storage Room 2407 (within the Cardio Suite near Exam Room 6), as prohibited by NFPA 13 1999 5-6.6.

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D. By direct observation the morning of 6/29/11 within the "Maintenance Hallway", the surveyor finds the installation of the of the sprinkler heads to be more than 12 inches from the ceiling/deck above (NFPA 13, 5-6.4.1.1). This installation can result in delayed sprinkler activation by not having the sprinkler heads located within the heat capture zone.

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Based on random observation during the survey walk-through and document review, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. Duct penetrations through the walls of 2 hour fire rated ventilation shafts were observed which lack fire dampers required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. These deficiencies could affect any patients in the 433 bed facility, as well as any patients or staff present, because fire could pass between building stories through the undampered openings in the shaft enclosures. Locations observed include:

1. 9:25 AM June 28, 2011: Mechanical Penthouse (Fifth Floor), 3 ducts in shaft behind Exit Stair 2.

2. 10:32 AM June 28, 2011: "North Patient Tower;" this condition was observed to be typical of each Patient Room toilet exhaust on the building stories listed below. Based on review of Life Safety Master Plans presented to surveyors by the provider, there appear to be approximately 40 such penetrations each on the:
a. Fourth Floor.
b. Third Floor.

c. Second Floor.

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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 in the 433 bed facility, as well as any staff and visitors present, because the items stored in the corridors could prevent them from exiting the building.

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:

1. 9:22 AM June 28, 2011: Fourth Floor Corridor near Nurses' Station 410.C1, 8 work stations on wheels.

2. Second Floor:

a. 1:05 PM June 28, 2011:

B. Gurneys, rolling shelves, and other equipment were observed which obstruct egress in a manner prohibited by 7.1.10.2.1. Locations and obstructing items observed include:

1. 1:05 PM June 28, 2011: Second Floor Exam Room 2212, egress path obstructed by stored equipment and an audiology booth.

2. 1:50 PM June 28, 2011: Second Floor Caesarian Section Suite egress path to Exit Stair 6, egress path obstructed by supply carts, 3 stools, and a table.

3. 2:40 PM June 28, 2011: First Floor Emergency Department, all Passages obstructed by 10 patients on gurneys and 2 patients in wheelchairs.

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C. 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):

1. 1:36 PM June 28, 2011: Wheelchairs were observed being stored in the Exit Passageway serving Exit Stair 2. Surveyor 14290 notes that red tape had been placed on the floor (in the ara of some electrical and medical gas alarm panels) which, according to the provider's Maintenance Technician, was intended to identify locations in the Corridor where items could not be stored, indicating that other locations are being considered to be acceptable storage locations.

2. 8:50 AM June 29, 2011: Wheelchairs and gurneys were observed in all Corridors of the First Floor Radiology Department. Surveyor 14290 notes that red tape had been placed on the floor in the North Corridor (in the ara of some electrical panels) which, according to the provider's Maintenance Technician, was intended to identify locations in the Corridor where items could not be stored, indicating that other locations are being considered to be acceptable storage locations.

3. 11:28 AM June 29, 2011: 4 Laboratory blood draw carts and 2 chairs were observed in the Corridor immediately outside a pair of Exam Rooms in the Ambulatory Care Center.

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Based on random observation during the survey walk-through, not all soiled linen or trash receptacles are stored in accordance with 19.7.5.5. This deficiency could affect any patients in the Emergency Department, as well as any staff and visitors present, because fire from the receptacles could prevent egress under emergency conditions.

Findings include:

A. At 2:45 PM on June 28, 2011, soiled linen and trash receptacles with capacities in excess of 32 gallons in were observed to be stored in Passages within the First Floor Emergency Department, and not in a room protected as a hazardous area as required by 19.7.5.5.

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Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. At 9:00 AM on June 29, 2011, 4 medical gas tanks were observed being stored in the First Floor "Lab" Room which are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). This deficiency could affect any patients in the facility, as well as any staff and visitors present, because the medical gas tanks could contribute to an adjacent fire.

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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. At 9:35 Am on June 29, 2011, medical gas piping in the West Building Ground Floor Storage Room was observed to not be labeled as required by NFPA 99 1999 4-3.1.2.14(a)(2). This deficiency could affect any patients in the facility, as well as any staff and visitors present, because the unlabeled pipes could be inadvertently damaged or cut.
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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.

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B. Components as required by ANSI A17.1, 102.2 and NFPA 72, 1999, 3-9.4.2 for the means to automatically disconnect the main line power supply prior to the application of water from the sprinkler system are installed or installed in non-compliance with the above listed requirements. Elevator car ocuppants risk entrapment and the hazards of a wet electrical environment. Random surveyor observations include the following locations:

1. Afternoon 6/28/11: Elevators 10 & 11 machine room has fire sprinkler protection installed, however the installation of heat detectors within 2 feet of each speinkler head is not provided for automatic disconnect of the main line power supply.

2. Morning 6/29/11: With the assistance of the facility's elevator service technician the surveyor finds the heat detectors installed within the top of the elevator shafts are greater than 2 feet from the sprinkler heads.

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Based on random observationduring the survey walk through, not all emergency power panels are in compliance with NFPA-99 3-4.2.2.2. These deficiencies could affect patients in the 433 bed facility, as well as any staff and visitors present, because the incorrectly connected life safety components cold fail to operate under emergency conditions.

Findings include:

A. Critical panels on all floors in the original part of the hospital were observed to serve systems that are required by the 1999 edition of NFPA-99-3-4.2.2.2(b), and the 1999 edition of NFPA-70-517-32 to be served by the Life Safety panel. Examples observed include:

1. Elevator cab lighting:

a. 10:35 AM June 29, 2011: critical panel in electrical room near southwest stairwell had a breaker serving elevator cab lighting, which is required by the 1999 edition of NFPA-70-517-32(f), and the 1999 edition of NFPA-99-3-4.2.2.2(b)(6) to be served by the life safety panel.

b. 10:50 AM June 29, 2011: Critical panel CRLP3E circuits 40 & 42 were identified as serving elevator cab lights.


2. Fire alarm panels:

a. 10:50 AM June 29, 2011: Critical panel CRLP3E circuit 36 was identified as serving the clean supply room fire alarm panel which is required by the 1999 edition of NFPA-70-517-32(c), and the 1999 edition of NFPA-99-3-4.2.2.2(b)(3) to be served by the life safety panel.

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Based on random observation during the survey walk-through, not all electrical wiring and labeling met the requirements of NFPA 70. These deficiencies could affect patients in the 433 bed facility, as well as any staff and visitors present, because the listed portions of the building electrical system could become compromised.

Findings include:

A. At 12:48 PM on June 28, 2011, an electrical panel was observed, in the First Floor OB/GYN Suite, which is not provided with a minimum 3'-0" clear working space in front of the panel as required by NFPA 70 1999 110-26(a). The electrical panel was observed to be obstructed by the components of a low voltage electrical system.

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B. At 9:30 AM June 29, 2011 the medical gas system did not meet the requirements of NFPA-70 250-104(c). No bonding was observed in the med gas supply room or the utility tunnel, and staff could not identify the location of the system bonding.

C. At 1:30 PM June 29, 2011 it was observed in the penthouse elevator equipment room that the boxes serving elevator cab lighting were not properly labeled as to what panel and circuit they were fed by, as required by NFPA-70-620-53. This was found to be a common deficiency in all elevator equipment rooms.

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A. By direct observation the morning of 6/29/11, the surveyor finds that heat detection, not smoke detection, is installed within the elevator machine rooms. A17.1, 211.4b requires Phase 1 Firefighter's Service to be initiated by smoke detection in the machine rooms as well as those installed in elevator lobbies and hoistways.

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