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Based on observation, spaces/areas were open to the exit access corridor.

1st Floor-South Building

A. The receptionist area near the inpatient endoscopy suites is not staffed on a 24/7 basis. On off hours, a rolling grill separates the reception area from the exit access corridor.

B. A dutch door from the reception area to the exit access corridor is undercut by approximately 6"-8" and is not smoke tight when the door is shut.



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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:

C. The North Building First Floor (Northwest Wing) Cashier's Booths were observed to constitute staff work areas, open to the smoke compartment corridors, which lack smoke detectors required by Subpart (c) of Exception 1. to 19.3.6.1.

Based on random observation and staff interview, doors to the exit access corridor did not latch.

Basement-North Building

A. Pharmacy door to the corridor was equipped with an electric strike. Staff could not verify whether the electric strike latched in the secure position upon activation of the fire alarm system.

Basement-West Building

B. The back door from the kitchen to the corridor was equipped with a latching device that would not self latch.

C. The cafeteria tray return is located in the corridor and is equipped with a fire rated shutter that does not release upon activation of a local smoke detector or the fire alarm. Through interview with hospital staff, it was determined the shutter is closed manually when the cafeteria is closed



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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.

Findings include:

D. The door to the North Building Third Floor (East) Locker Room was observed to not be positive latching as required by 19.3.6.3.2.
E. The manual flush bolt at the door to North Building Second Floor (Northwest Wing) Nuclear Medicine Room N235 was observed to not be engaged; thus the door assembly was not positive latching as required by 19.3.6.3.2.

F. The room-side face of the door to the North Building Fifth Floor Dialysis Unit was observed to be delaminating; the door is thus not resistant to the passage of smoke as required by 19.3.6.3.1.

G. A throw bolt was observed at the inactive leaf of a pair of doors serving a Closet adjacent to the North Building Second Floor (Southwest Wing) Staff lounge; the door is thus not positive latching as required by 19.3.6.3.2.

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

Findings include:

A. High pressure ducts serving induction units, typically located below exterior windows in Patient Sleeping Rooms and in other rooms located on the perimeter of the building, were observed which are not sealed against the passage of smoke and fire as they exit the related shaft enclosures as required by 8.2.3.2.4.2. and 8.3.6.1. During an interview held in a Sixth Floor Northwest Wing Patient Sleeping Room on the afternoon of January 3, 2011, the provider's Director of Facilities confirmed that this condition likely exists at all induction units installed on the Fifth, Fourth, and Third Floors of the North Building.

B. High pressure ductwork was also observed, serving the Seventh Floor perimeter induction units, which is not sealed against the passage of smoke and fire as it passes through the Seventh Floor slab as required by 8.2.3.2.4.2. and 8.3.6.1. During an interview held in a Seventh Floor North Building Conference Room on the morning of January 4, 2011, the provider's Director of Facilities confirmed that this condition likely exists at all induction units installed on the Seventh Floor of the North Building.

C. Doors or access panels were observed at ventilation or other shafts which are 4 or more stories in height were observed that do not carry a fire resistance rating of at least 1-1/2 hours as required by 8.2.3.2.3.1(1). Locations observed include (all North Building):

1. Ventilation shaft east of Elevators:

a. Fifth Floor.

b. Fourth Floor. There is also a steel plate covering an opening in the ventilation shaft wall which lacks the required fire resistance rating.

c. Third Floor.

2. Ventilation shaft shaft west of Elevators:

a. Fifth Floor.

b. Fourth Floor.

c. Third Floor.

D. The access panel in the 2 hour fire rated floor assembly of the North Building Ninth Floor Elevator Penthouse was observed to not carry a fire resistance rating of at least 1-1/2 hours as required by 8.2.3.2.3.1.(1).

E. A (pneumatic tube) pipe penetration, through 2 hour fire rated floor assembly above the North Building Fifth Floor (East) Telemetry Equipment Room was observed to not be sealed against the passage of fire in accordance with 8.2.3.2.4.2.

Based upon observation, hazardous areas are not properly protected.

Basement-North Building

A. The coordinator for the double doors to the Central Supply Department from the exit access corridor did not operate properly and the double doors could not close correctly.

1st Floor South ED

B. The fire rated doors to the emergency department supply are not self closing.


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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:

C. Hazardous areas not covered by a sprinkler system were observed at which doors do not carry a minimum fire resistance rating of 3/4 hour as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include (all North Building):

1. Fifth Floor (West) Supply Room, 2 doors.

2. Fourth Floor (West) Supply Room, 2 doors.

3. Fourth Floor (East) Supply Room, 1 door.

4. Third Floor (West) Old Hydrotherapy Room (now used for storage), 1 door.

5. Second Floor (Northwest Wing) Storage Room across from Room N237, 1 door.

6. Second Floor (West) Medical Records Suite, 1 door (at north side).

Based on direct observation, fire doors are not properly installed and operated.

1st & 2nd Floors

A. The fire rated double doors enclosing the 2 story area at the entrance to the building were equipped with non-approved hold-open devices (foot pegs) and closers that do not release upon activation of a local smoke detector and/or fire alarm.

Based on observation, exits are not readily available for use.

1st Floor

A. The back exit stair was found to have the following items stored in the exit, under the stair:
ladder, ceiling tile, bucket, boxes of Christmas decorations.

1st & 2nd Floor

B. The exit path from Suite 100 was found to have obstructions (chair & scale) in the path of egress.

Base on observation, the fire barriers in the building are not fully protected.

1st Floor South ED

A. On Tuesday (01/04/10) at approximately 10:30 am, the door to the financial counselor's office, which is part of a fire separation was found to be wedged open with a non approved hold-open device.

Basement

B. The fire door in the separation wall near the linen chute room appears to have a door sill clearance greater than 3/4" permitted per code.

Based on random observation, emergency lighting to illumionate the path of egress was not provided;

1st Floor-North Building

A. No two sources of emergency lighting were found at the exit discharge of Stair #8

5th Floor-South Building

B. At the egress path across the roof to an adjacent exit stair, the path along the roof did not have 2 sources of emergency lighting.

1st Floor West Building

C. Two sources of emergency lighting were not provided at the exit discharge of Stair #3.



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D. By document review the surveyor finds the battery operated emergency lighting is not tested for 30 seconds at 30 day intervals and that the required annual test of 1 1/2 hours is not being conducted. NFPA 101, 2000, 7.9.3

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Based on random observations, exit signs were not illuminated to direct occupants to an exit.

6th Floor

A. The exit sign in the corridor of the on-call rooms was not lit.

2nd Floor

B. The exit sign in the vestibule of the building separation to the west building, near Exam Room #5, was not lit.

Basement

C. The path of exit was designated by a sign the reas "STAIRWAY" only.



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Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

D. The egress path toward the southwest, in the North Building First Floor Northeast Wing, was observed to not be identified by an exit sign as required by 7.10.1.1.

Based on staff interview, fire drills are not held in accordance with 19.7.1.2.

Findings include:

A. During an interview held in the Service Building Conference Room on the morning of January 5, 2011, the provider's Director of Facilities confirmed that fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on direct observation and staff interview, the fire alarm system is not functioning properly.

1st Floor

A. On Wednesday, January 5, 2011 at approximately 9:30 am, the fire alarm panel at the facility had the following indicator lights illuminated: AC power, system alarm, and system trouble. The provider indicated this was an indication of a low battery.

Based upon observation, sprinkler systems are compromised.

Basement-West Building

A. The kitchen storage room adjacent to the Sister's dining room was found to have ceiling tiles out of place, thus compromising the sprinkler system.

B. Hospital systems piping was observed which penetrates the ceiling system in the corridor, near the cafeteria tray return. The opening in the ceiling are too large and will compromise smoke detection in the area.

Based on random observation, portable fire extinguishers are not checked on a monthly basis.

Elevator Penthouse-West Building

A. The inspection tag on the portable FE was dated 11/10.

Basement-West Building

B. The monthly inspection tag on the portable fire extinguisher in compactor room was last signed on February, 2010.

Based on random observation, portable fire extinguishers are not checked on a monthly basis.

4th Floor-West Building

C. Three portable FE's located in the mechanical room were last checked in August of 2010.

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

Findings include:

A. High pressure ductwork which passes through 2 hour fire rated floor assemblies was observed to lack fire dampers required by NFPA 90A 1999 3-3.2. During an interview held in a Sixth Floor Northwest Wing Patient Sleeping Room on the afternoon of January 3, 2011, the provider's Director of Facilities confirmed that this condition likely exists at all locations in the North Building where ductwork serving induction units on the floors below passes through the Sixth Floor slab.

A. By direct observation the surveyor find the facility failed to provide instructional signage for the use of the type K fire extinguishers located by the grease hoods in the kitchen in compliance with NFPA 10, 1998, 2-3.2.1. These extinguishers are located in close proximity to other dry chemical extinguishers that should not be used for the grease hoods.

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Based on random observation, oxygen tanks are not properly stored.

Basement-North Building

A. The oxygen tank storage room contained approximately 100 small oxygen tanks and 12 large oxygen tanks. No form of ventilation for this room could be identified.

Based on random observation, medical shut off valves are not properly identified.

1st Floor

A. The identification labeling for medical shutoff valves is not located in a permanent location. It is located on the frangible valve box cover, which can become lost or misplaced on another valve box. Locations identified include:

1. 1st floor West Building Radiology

2. 1st Floor South Building ED



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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:

B. The North Building Second Floor Surgical Department was observed to constitute a vital support area which is not provided with a medical gas Area Alarm Panel as required by NFPA 99 1999 4-3.1.2.2(c)(1).

Based on observation, electrical installation is not properly grounded.

1st Floor

A. The grounding cable connected to the water piping does not have a jumper across the water meter.

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.

A. By direct observation the surveyor finds the facility failed to provide eye wash stations in the Laboratory in compliance with the above NFPA standard and ANSI Z358-1. The eye wash stations observed did not have a means for pressure and temperature control.

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

Findings include:

A. The North Building Second Floor PACU Stage I Recovery Bays were observed to constitute critical care patient beds at which electrical receptacles served by the building emergency electrical system are not labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a).