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Based upon observation, the required building separations are not maintained to afford the designated hourly rated barriers. Failure to maintain building separations can permit fire/smoke conditions to pass from one building to another in the event of a fire emergency.

Findings include:

On 07/30/18 at 1:45 PM while in the company of the FOM, it was observed that the magnetically held-open 4-hour barrier single swing doors at the Lower Concourse level between the Feinburg building and the tunnel to the Lavin building lacked a coordinator to permit the doors to close and latch to comply with 19.1.3.4.1 and NFPA 80-2010, 6.1.4 when one door is opened after both doors are initially closed.

Based on observation, the facility failed to provide a building with an acceptable construction type. This deficient practice could affect patients, staff and visitors if a fire in the deficient area were to compromise the buildings structural integrity during a fire emergency.

Findings include:

On 07/30/18, while accompanied by the SFM, it was observed that support beams lack spray fire proofing. This does not comply with Table 19.1.6.1 and NFPA 220 2012 Ed. Table 4.1.1.

Locations include:

A. At 2:05 PM, the beam by the Stair Exit access of the Chiller Room (17th Floor).

B. At 11:30 AM, the structural beam in the 17th Floor of the Boiler Room.

C. At 2:40 PM, structural beam by the Catwalk Mezzanine (Mechanical Room).

Based on observation, means of egress are not maintained clear of obstructions. Failure to maintain means of egress clear of obstructions can prevent occupants from reaching an exit in the event of a fire/smoke emergency.

Findings include:

A. On 07/31/18 at 9:30 AM while in the company of the FOM, it was observed that housekeeping containers exceeding 32 gal. capacity were stationed in the 4-hour Vestibule L-233A near Office L-328A in noncompliance with 19.2.1 and 7.1.10.1.

B. On 07/31/18 at 11:30 AM while in the company of the FOM, it was observed that furniture in Lounge 1-713 of the Staff Lockers suite obstructed the use of the corridor exit door. This door was also not easily latched to comply with 19.3.6.3.5.

C. On 08/01/18 at 1:30 PM while in the company of the FOM, it was observed that a janitor cart was stationed in the 6th floor exit access "tunnel" corridor leading to Stair D entrance in noncompliance with 19.2.1 and 7.1.10.1.

Based on observation and interview, the facility failed to maintain Egress Doors. This deficient practice could affect patients, staff and visitors if the egress doors did not function properly during an emergency. Failure to install locking devices in accordance with requirements can prevent or cause undue delay in exiting or evacuation procedures when required.

Findings include:

A. While in the company of the FOM, it was observed that locking systems which prevent egress from occupied spaces are not in compliance with 19.2.2.2.4 and 7.2.1.5.3. Chain & padlocks were used in noncompliance with 7.2.1.5.3. These locks were in addition to the gate latch lock. The provisions for two locks on a means of egress door does not comply with 19.2.2.2.6(2) and 7.2.1.5.10.2.

Locations include:

1. On 07/30/18 at 2:15 PM - L-727 Vac Lock-up (Tina's cage)
2. On 07/30/18 at 2:20 PM - L-718 cage
3. On 07/31/18 at 9:45 AM - L-516 Vending cage at Food Storage room

B. While in the company of the FOM, it was observed that locking systems which employ magnetic locking devices were installed on egress doors which were not in full compliance with 19.2.2.2.4. Per interview, the locking systems are normally inactive during the business day and are actively locked after 4 PM by the security system. The provisions of 7.2.1.6.1.1(4) Delayed Egress locks were not met due to the lack of signage indicating the 15 second delay. The provisions of 7.2.1.6.2(1) Access Controlled Egress were not met due to the lack of sensors to unlock the magnets. Doors observed to lack full compliance with the requirements include the following locations:

1. On 07/30/18 at 3:05 PM - The outer cross corridor doors at corridor L-704 leading to Pharmacy, lack signage for Delayed Egress or sensors for Access Controlled Egress. Manual operation of the doors exceeds the 15 lbf force permitted by 7.2.1.4.5 to open the doors.

2. On 07/31/18 at 9:35 AM - The Materials Management L-323 doors have a sensor for Access Controlled Egress but always requires wall push-button activation to release & open the door(s).

3. On 07/31/18 at 10:35 AM - The ED northwest exit doors lack signage for Delayed Egress or sensors for Access Controlled Egress. The provisions of 19.2.2.2.5.2 are not otherwise met.

4. On 07/31/18 at 12:45 PM - The cross corridor exit doors, east and west, from the Staff Elevators on the Mezzanine level have magnetic locks not signed as Delayed Egress. These doors have sensors but the functional operation of the locks after hours could not be tested to confirmed locking system operation.

5. On 07/31/18 at 2:45 PM - The cross corridor exit doors east of the Staff Elevators on the 3rd floor lacked signage for Delayed Egress or sensors for Access Controlled Egress.

6. On 08/01/18 at 10:55 AM - The 5th floor PACU suite doors (both at the west corridor to Galter & the east doors to Corridor 5-303) lack signage for Delayed Egress or sensors for Access Controlled Egress.

7. On 08/01/18 at 10:58 AM - The 5th floor doors from the restricted corridor of Feinberg to the non-restricted corridors of Galter lack signage for Delayed Egress or sensors for Access Controlled Egress.

C. While in the company of the FOM, it was observed that marked exit access doors have locking systems which prevent egress which does not comply with 19.2.2.2.4.

Locations include:

1. On 07/31/18 at 2:47 PM - The marked exit access door for the 3rd floor corridor T3080, directed thru the Executive Administration reception office area 3-706, is locked from the corridor egress side.

2. On 08/01/18 at 9:30 AM - The marked exit access door from Waiting 4-302 to Corridor 4-303 is locked from the egress side.


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D. On 07/31/18 at 9:00 AM, while accompanied by CPM, it was determined that on the 13th floor, Public Corridor, West Medical Unit, 15-second delayed egress doors when tested, reset automatically. This does not comply with 19.2.2.2.4 and 7.2.1.6.1.1(3)(d).

Based on observation, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

On 07/30/2018 at 9:50 AM while accompanied by the SFM, a pair of entry doors were observed having a manual flush bolt which was not engaged. Upon closing the doors, the surveyor was able to push on one door which opened both. Upon closing the doors again, they did not latch in order to comply with 19.3.2.1 and 8.4.1.

Locations include:

1. Lower Level floor - pair of corridor entry doors at Mail Center (#2322).

2. Lower Level floor - pair of corridor entry doors at Materials Management.

Based on observation, not all stairways are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, the ability to exit the building under emergency conditions could be compromised if the stairways are not properly constructed and maintained.

Finding include:

A. On 07/31/18 at 9:15 AM while accompanied by the ACE, observation determined that Fourth Floor Exit Corridor T0472 is being used for storing large quantities of combustible material ranging from trash, cardboard boxes, and a trash trolley, blocking the egress path in a manner prohibited by 7.1.3.2.3.


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B. On 07/30/18 at 2:43 PM while accompanied by the PMCPO, the First Floor Northwest Exit Passageway was observed to house paint cans, scaffolds, and other equipment as prohibited by 7.1.3.2.3.

C. On 07/30/18, at 3:09 PM while accompanied by the PMCPO, the First Floor Northwest Exit Passageway was observed to contain the following items or functions, causing the Exit Passageway to serve an alternate purpose as prohibited by 7.1.3.2.3:
1. A security desk.

2. A waiting area.

Based on observation, fire barrier doors are not maintained to provide separation of building areas. Failure to provide required separations can contribute to the spread of fire & smoke beyond the compartment of fire origin and compromise the safety of building occupants in adjacent compartments.

Findings include:

A. While in the company of the FOM, it was observed that the fire barrier doors did not self-close to a latched condition to comply with 8.3.3, 8.3.4 and NFPA 80-2010, 6.1.4.

Locations include:

1. On 07/31/18 at 8:45 AM, the 2-hour barrier cross corridor doors near EVS L-500 did not self-close to a latched condition.

2. On 07/31/18 at 9:30 AM, the power operated doors in the 4-hour barrier between Feinberg & Galter Pavilions near L-306 did not self-close to a latched condition.

3. On 07/31/18 at 9:32 AM, the 4-hour barrier pair of doors near L-323A did not self-close to a latched condition.

4. On 07/31/18 at 9:35 AM, the single door in the 4-hour barrier near L-328A did not self-close to a latched condition.

5. On 8/1/18 at 11:00 AM the 5th floor cross corridor doors in the 2-hour fire/smoke barrier at the SW corner of the restricted surgery corridor did not self-close to a latched condition due to friction between door leaves.


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B. On 8/1/18 at 9:37 AM, while accompanied by CPM it was determined that on the 8th floor, East Unit, 2-hour rated double doors contained deficient door hardware and the north door leaf was damaged. This does not comply with 19.2.5.7.1.2. and NFPA 80, 5.1.5.1.

C. On 8/1/18 at 9:43 AM, while accompanied by CPM it was determined that on the 8th floor, East Unit, 2-hour rated double doors adjacent to room 8-825 contained a gap between the door edges that exceeded the 1/8" minimum requirement. This does not comply with NFPA 80, 6.3.1.7.1.

Based on observation, not all building stories or fire compartments are provided with at least two remote exits. This deficient practice could affect patients, staff, and visitors in the building because they could be prevented from exiting the building under emergency conditions if an insufficient number of exits is provided.

Findings include:

On 07/31/18, while accompanied by the PMCPO, observation determined that building stories exist at which the required exits are not remote from each other, in accordance with 7.5.1.3.1, as required by 19.2.4.2.

Locations include:

A. 1:28 PM: Fourth Floor.

B. 1:30 PM: Third Floor.

C. 1:40 PM: Second Floor.

Based on observation, dead end corridors exist in excess of Code permitted lengths. Failure to restrict egress movements in corridors without access to exits can prevent occupants from reaching an exit or place of refuge during a fire/smoke event.

Findings include:

On 08/01/18 at 1:37 PM while in the company of the FOM, it was observed that corridor 6-109 leading to Mechanical room 6-518 has a dead end condition in excess of 50' in noncompliance with 19.2.5.2.

Based on observation, not all corridors have at least two means of egress identified. Failure to identify required alternate exit paths can prevent occupants from reaching an available exit during an emergency.

Findings include:

A. On 07/30/18 at 1:47 PM while in the company of the FOM, it was observed that corridor L-734F leading from the tunnel from the Lavin building lacked an identified 2nd means of egress to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

B. On 07/30/18 at 2:20 PM while in the company of the FOM, it was observed that the corridor serving L-178 lacked an identified 2nd means of egress to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

C. On 07/31/18 at 2:48 PM while in the company of the FOM, it was observed that exit access corridor 3-717, serving the Administration Offices and Banquet Hall 3-514, lacked an identified 2nd means of egress to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

D. On 07/31/18 at 3:10 PM while in the company of the FOM, it was observed that the exit access corridor 3-207A, serving the Hospital Operators Service 3-210 & General Office 3-143, lacked an identified 2nd means of egress to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

E. On 08/01/18 at 10:00 AM while in the company of the FOM, it was observed that exit signage, at the corridor intersection near 4-727 looking north, was not provided to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

F. On 08/01/18 at 10:01 AM while in the company of the FOM, it was observed that exit signage, at the corridor intersection near IR #6 looking east, was not provided to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

Based on observation, designated suites lack compliant number of exits. This deficiency could affect any staff, patients and visitors from exiting those areas in a timely manner under emergency conditions.

Findings include:

On 07/31/2018 at 11:20 AM while accompanied by the SFM, due to surrounding construction, the 5th floor MRI suite, a non-sleeping patient care suite of approximately 4,000 s.f., contained one means of egress to an exit. This condition does not comply with 19.2.5.5.2, 19.2.5.7.3.2 (A) and (C) due to the following:

1. The second means of egress is through a pair of cross corridor doors which are completely covered with white visqueen and tape. The surveyor questioned staff about emergency exiting, they were not aware of the Facility's Interim Life Safety Measures which included tearing off the taped visqueen and passing through the doors. This does not comply with 7.2.1.1.2 for an obvious, direct path of egress.

2. The temporary exit sign taped on the visqueen covered doors does not comply with 7.10.3 for legibility.

3. The second means of egress out of the suite was through a construction zone which does not comply with 19.3.2.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

A. On 07/31/18, at 9:09 AM while accompanied by the ACE, observation determined that directional exit signs are not installed at Fourth Floor Exit Corridor T4072 south end as required by 7.10.3.1.


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B. On 07/31/18, while accompanied by the PMCPO, observation determined that signs exist which read "STAIR" and not "EXIT" as required by 7.10.3.1.

Locations include:

1. At 8:57 AM: Mezzanine landing, Exit Stair 4.

2. At 9:07 AM: Mezzanine landing, Exit Stair 3.

Based on observation, vertical openings between floors are not protected in accordance with Code requirements. Failure to protect vertical openings between floor can permit fire/smoke conditions to migrate to other floor levels during an emergency situation.

Findings include:

A. On 07/30/18 at 1:50 PM while in the company of the FOM, it could not be confirmed that four 4" conduits through the floor were sealed at IT/Storage room L-734D to prevent the passage of smoke to the floor above to comply with 19.3.1.1 and 8.6.3(1).

B. On 08/01/18 at 1:00 PM while in the company of the FOM, it was observed that the corridor door to Mechanical room 6-714 (which forms a part of the shaft enclosure) is not provided with positive latching hardware to comply with 8.3.3 and 8.3.4. The manual flush bolt for the inactive door was not functional and in the open position.

C. On 08/01/18 at 1:15 PM while in the company of the FOM, it was observed that the east corridor door at Mechanical room 6-516 (which forms a part of the shaft enclosure) was not self-closing to a latched condition to comply with 8.3.3 and 8.3.4.

D. On 08/01/18 at 1:35 PM while in the company of the FOM, it was observed that the east corridor door at Mechanical room 6-518 (which forms a part of the shaft enclosure) was not positive latching to comply with 8.3.3 and 8.3.4 due to unlatched manual flush bolts.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency.

Findings include:

On 07/31/18 while accompanied by the ACE, observation determined that storage rooms contain sufficient combustible material to constitute high hazard areas. These room doors were observed to not be positive latching due to damaged doors, which does not comply with 39.3.2.1.

Locations include:

A. At 10:00 AM: Fourth Floor Fresenius Medical Care Storage room.

B. At 10:10 AM: Fourth Floor Storage room 4-259.

Based on observation, the the facility failed to provide for all piped-in medical gas systems to be installed and maintained code compliant. This condition could hinder the efficient shut off of any system in an emergency which will affect patients and staff within the immediate location.

Findings include:

A. On 08/01/2018 at 2:30 PM while accompanied by the SFM, the location of the medical gas shut off valve for an Operating Room (OR) was observed to also serve the adjacent NICU Pod. This condition does not comply with NFPA 99, 2010, 5.1.4.8.7 and 5.1.4.8.7.2.

Locations include:

1. 10th floor med gas shut off valve on wall of corridor #T10039 adjacent to OR #1088

B. On 08/01/2018 at 1:30 PM while accompanied by the SFM, medical gas shut off valves serving patient rooms were observed to lack labeling of all rooms served. The identifying graphic located adjacent to each shut off valve does not reflect current conditions and does not comply with NFPA 99, 2010, 5.1.4.8.8 and 5.1.11.2.

Locations include:

1. 4th floor - ZVB 4.1.2.1(adjacent to infusion area)

2. 11th floor - ZVB 11.4.3.1, ZVB 11.1.3.1 and ZVB 11.2.3.1

Based on observation, not all fire alarm initiation devices are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, the fire alarm could fail to activate under emergency conditions.

Findings includes:

A. On 07/31/18 while accompanied by the ACE, observation determined that fire alarm initiating devices (smoke detectors) are located so that airflow from supply air diffusers within 3'-0" of them, prevent their operation as prohibited by NFPA 72 2010 17.7.4.1.

Locations include:

1. At 8:50 AM: Public elevator lobby - 2 devices.

2. At 9:18 AM: Storage room ( Fresenius Medical Care) -1 device.

3. At 9:35 AM: Storage room 4.259 - 1 device.


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B. On 07/31/18 while accompanied by the PMCPO, observation determined that fire alarm initiating devices (smoke detectors) are located so that airflow from supply air diffusers within 3'-0" of them, prevent their operation as prohibited by NFPA 72 2010 17.7.4.1.

Locations include:

1. At 8:52 AM: Mezzanine Laboratory M220, 2 devices.

2. At 8:57 AM: Mezzanine Laboratory M230, 1 device.

3. At 9:01 AM: Mezzanine Laboratory M530, 1 device.

Based on observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required.

Findings include:

On 08/01/18, while accompanied by the PMCPO, observation determined that the breaker serving the Fire Alarm Control Unit is not labeled "FIRE ALARM," as required by NFPA 72 2010 10.5.2.2, and that the breaker serving the Fire Alarm Control Unit is not provided with red marking, as required by NFPA 72 2010 10.5.2.3.

Locations include:

A. 10:40 AM: The Life Safety Panel located in Thirteenth Floor Electrical Closet A-1.

B. 10:42 AM: The Life Safety Panel located in Thirteenth Floor Electrical Closet A-2.

C. 1:29 PM: The Life Safety Panel located in Tenth Floor Electrical Closet A-2.

D. 2:08 PM: The Life Safety Panel located in Ninth Floor Electrical Closet A-2.

Based on document review and interview, the facility failed to provide a properly functioning fire alarm system. This deficient practice could affect patients, staff and visitors if the fire alarm system failed to function properly during a fire event.

Findings include:

On 08/01/18 between 11:30 AM - 1:00 PM document review of the fire alarm system testing identified that 46 fire alarm batteries failed during the last annual testing. An interview with CPM indicated that the batteries have not been replaced at the time of this survey. This does not comply with NFPA 72, 10.5.7.1.

Based on observation, the facility failed to provide a complete automatic sprinkler system. This deficient practice could affect patients, staff, and visitors in the building because the automatic sprinkler system may fail to extinguish a fire if it is not properly installed.

Findings include:

A. On 07/31/18 while accompanied by the ACE, observation determined that the sprinkler heads at the following locations are not installed as required.

1. At 9:55 AM: At the Fourth Floor Fresenius Medical Care Storage Room, escutcheon rings were observed to be missing from three pendent sprinkler heads to comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011 5.2.1.1.2(3).

2. At 9:58 AM: At the Fourth Floor Fresenius Medical Care Storage Room, storage boxes stacked on the shelves to less than 18 inches from the sprinkler heads as prohibited by NFPA 13-2010, 8.5.6.1.

Based on observation and interview, the facility failed to inspect and maintain the facility's fire protection sprinkler system. This deficient practice could affect patients, staff and visitors if the sprinkler system did not perform properly during a fire event due to a lack of proper maintenance.

Findings include:

A. On 07/30/18 at 2:15 PM while in the company of the FOM, it was observed at Bed Storage L-724 that a sprinkler head escutcheon was missing and not in compliance with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

B. On 07/31/18 at 1:35 PM while in the company of the FOM, it was observed that ceiling tile was missing at the IT room M-530A adjacent Stair D to comply with NFPA 13-2010, 8.6.4.

C. On 08/01/18 at 2:30 PM while in the company of the FOM, it was observed outside the 6th floor CSS ETO rooms that a sprinkler escutcheon was missing and not in compliance with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).


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D. On 07/30/18 at 1:50 & 1:55 PM in the company of the CF/G, it was observed the top of stair sprinkler heads are obstructed by masking tape in noncompliance with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3)/(6) at the following locations:
1. Stair 17D
2. Stair 18B


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E. On 07/31/18 at 9:25 AM, while accompanied by CPM, it was determined that on the 12th floor, East Medical Unit, South Corridor 12-721 contained a sprinkler head in the ceiling that was missing the protective escutcheon plate. This does not comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

F. On 08/01/18 at 9:22 AM, while accompanied by CPM, it was determined that on the 8th floor, East Medical Unit, South Corridor 12-721 contained a sprinkler head in the ceiling that was missing the protective escutcheon plate. This does not comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

G. On 08/01/18 at 10:05 AM, while accompanied by CPM, it was determined that on the 8th floor, East Medical Unit, Southeast Supply room adjacent to door 8-736 contained a sprinkler head in the ceiling that was missing the protective escutcheon plate. This does not comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

H. On 08/01/18 at 10:30 AM, while accompanied by CPM, it was determined that on the 7th floor, East Medical Unit, Stair "C" contained a sprinkler head under the 8th floor landing that was painted. This does not comply with NFPA 25-2011, 5.2.1.1.2(6).

I. On 08/01/18 at 10:35 AM, while accompanied by CPM, it was determined that on the 7th floor, East Medical Unit, Equipment room 7-772 contained a sprinkler head in the ceiling that was missing the protective escutcheon plate. This does not comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

J. On 08/01/18 at 1:39 PM, while accompanied by CPM, it was determined that on the 7th floor, Operating Suite, Sterile Processing room, south row of storage, contained an escutcheon plate that was painted. This does not comply with NFPA 25-2011, 5.2.1.1.2(6).

K. On 08/01/18 at 2:02 PM, while accompanied by CPM, it was determined that on the 7th floor, Specimen Receiving Lab, south side of the room contained an escutcheon plate that was partially imbedded into the ceiling tile. This condition could prevent the proper activation of the sprinkler head. This does not comply with NFPA 25-2011, 5.2.1.1.2(3).

L. On 08/01/18 at 2:10 PM, while accompanied by CPM, it was determined that on the 7th floor, Specimen Receiving Lab, south side of the room contained a damaged ceiling tile adjacent to a sprinkler head. This condition could prevent the proper activation of the sprinkler head. This does not comply with NFPA 13-2010, 8.6.4.1.1.1.

M. On 08/01/18 at 2:15 PM, while accompanied by CPM, it was determined that on the 7th floor, Specimen Receiving Lab, Histology Tissue Lab contained 2 escutcheon plates that were corroded. This does not comply with NFPA 25-2011, 5.2.1.1.2(2).

Based on observation and staff interview, spaces open to the exit access corridor are not provided with protective features in accordance with Code requirements. Failure to provided protective features can compromise the use of the corridor when prompt notification of a fire/smoke event occurring within the space open to the corridor is not provided.

Findings include:

A. On 08/01/18 at 10:10 AM while in the company of the FOM, it was observed that the waiting area open to corridor 4-519A outside Outpatient Radiology at corridor 4-321A was not provided with smoke detection to comply with 19.3.6.1(2)(b).

B. On 08/01/18 at 10:35 AM while in the company of the FOM, it was observed that the waiting area open to corridor at the Visitor elevator lobby reception area 5-500B was not provided with smoke detection to comply with 19.3.6.1(2)(b).

C. On 08/01/18 at 10:38 AM while in the company of the FOM, it was observed that Waiting area 5-507 open to corridor was not provided with smoke detection located at the high ceiling areas to comply with 19.3.6.1(2)(b) and NFPA 72-2010, 17.7.3.2.1. The smoke detectors provided are mounted at the bottom of the headers in the ceiling approximately 18" below the plane of the high ceiling areas.

D. On 08/01/18 at 10:40 AM while in the company of the FOM, it was observed that the table & chair waiting area along corridor 5-301A was not provided with smoke detection to comply with 19.3.6.1(2)(b).

E. On 08/01/18 at 1:50 PM while in the company of the FOM, it was observed that the table & chair waiting area along corridor 6-307 outside the CSS department was not provided with smoke detection to comply with 19.3.6.1(2)(b).

Based on observation and interview, the facility failed to maintain a smoke-tight corridor door. This deficient practice could affect patients, staff and visitors if smoke from a room located on an egress corridor did not have a door that properly closed to the frame.

Findings include:

On 07/30/18 at 2:15 PM while accompanied by SFM, the 17th floor, Boiler Room Plant Office, 17-22212 egress door was observed to be equipped with an unapproved hold open device (wood peg). This does not comply with 19.3.6.3.2.

Based on observation, corridor wall openings are not maintained to provide protection of the exit access corridor. Failure to protect the exit access corridor from exposure from a fire/smoke event in an adjoining room can compromise the use of the corridor as a means of egress during a fire/smoke event.

Findings include:

On 08/01/18 at 10:30 AM while in the company of the FOM, it was observed, at the OR Pharmacy 5-521 transaction window on the corridor 5-760A side, that the shutter provided did not have smoke detection on either side within 5' to actuate the shutter to close upon detection of smoke to comply with 19.3.6.5.1 and NFPA 72-2010, 17.7.5.6.

Based on observation, not all smoke barriers are constructed and maintained as required. This deficient practice
could affect patients, staff, and visitors in the building because smoke could pass between adjacent smoke compartments if the smoke barriers are not properly constructed.

Findings include:

A. On 08/01/18 at 11:00 AM while accompanied by the ACE,observation determined that conduit sleeves on Eight Floor above the ceiling at the west pair of exit doors are not sealed against the passage of smoke as required by 8.5.6.2.


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B. On 08/01/18 at 9:47 AM while accompanied by the PMCPO, observation determined that conduit sleeves in the smoke barrier wall, above the ceiling in Thirteenth Floor Corridor G13-100, are not sealed against the passage of smoke as required by 8.5.6.2.

Based on observation, not all smoke barrier doors are installed and maintained as required. This deficient practice could affect patients. staff, and visitors in the hospital because smoke could pass between adjacent smoke compartments if smoke barrier doors are not properly installed and maintained.

Findings include:


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On 08/02/18 at 9:37 AM while accompanied by the PMCPO, the cross-corridor doors located just south of Lower Concourse Exit Stair E did not fully close, as required by 19.3.7.8(1), because the latching hardware on the door is out of adjustment.

Based on observation, the facility failed to install its ventilation system in the required manner. This deficient practice could affect patients, staff, and visitors in the hospital because smoke and fire could be permitted to move between building stories and fire compartments if the system is not properly installed.

Findings include:

A. On 08/01/18, at 9:20 AM while accompanied by the ACE, observation determined that Thirteenth Floor ventilation shafts are not protected as required by 8.3.1.2.

Locations include:

1. At the Southeast Ventilation Shaft, the west wall does not extend to the underside of the deck above, leaving a gap of approximately 12 inches for the entire length of the shaft.

2. At the Southwest Ventilation Shaft, the west wall of the shaft enclosure is not verified to be rated.

B. On 08/01/18, at 9:20 AM while accompanied by the ACE, observation determined that duct penetrations at ventilation shafts are not protected as required by 19.3.1.

Locations include:

1. At the the Tenth Floor Southwest Ventilation Shaft, a duct was observed that lacks the retaining angles required for compliance with UL 555, thus not complying with 8.3.5.7 and NFPA 90A-2012, 5.3.4.6.


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C. On 08/01/18 at 9:42 AM, while accompanied by the PMCPO, observation determined that a fire damper at a duct, penetrating the ventilation shaft enclosure located in Thirteenth Floor Room G13-200, are not installed correctly as required by 8.3.5.7, 9.2.1, and NFPA 80-2010, 19.2.1.6.1 because the installation lacks sheet metal angles.


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D. On 08/01/18 at 9:35 AM, while accompanied by CPM ,it was determined that on the 6th floor, A2 Mechanical Room contained combustible storage throughout this room. This does not comply with NFPA 90A-2012, 5.3.4.5.

Based on observation, the facility failed to comply with the requirements for a hazardous room with a single designation. By allowing areas/rooms to serve multiple functions the spread of smoke and fire throughout a smoke compartment is increased and the evacuation of patients, staff and visitors is delayed.

The findings are:

A. On 07/31/2018 at 10:10 AM while accompanied by the SFM, Trash Collection room # 00-2226 was observed being used for a purpose other than what the code allows. The room contains a hot water return pump which is not connected to the function/use of the room. This installation does not comply with 19.5.4.4.

B. On 07/31/2018 at 9:06 AM while accompanied by the SFM, Trash collection room # 00-2226, the chute discharge door was observed with trash piled to the bottom of the door and covering the fusible link. This condition does not comply with NFPA 82, 2009, 10.2.1 for a clear and unobstructed door at all times.

Based on observation, the facility failed to provide a compliant Category 1 medical compressed air system. This deficient practice could result in contamination of this patient use system.

Finding includes:

On 07/31/18 at 10:50 AM in the company of the CF/G, it was observed in the 6th Floor Mechanical Room 6-516 that the intake for the patient medical air compressors is installed in the supply side plenum of surgical air handlers which contain electric fan motors in noncompliance with NFPA 99, 2012, 5.1.3.6.3.12.

Based on observation, the facility failed to install and maintain its piped-in medical gas system in the manner required. This deficient practice could affect patients, staff, and visitors in the building because the medical gas piping system could fail to operate when needed if not properly installed and maintained.

Findings include:

On 07/31/18 at 9:17 AM while accompanied by the PMCPO, observation determined that the door to Medical Gas Manifold Room 2-215 is not positive latching as required by Table 8.3.4.2, NFPA 80 2010 6.1.3 and NFPA 99 2012 5.1.3.3.2(4) because the door hardware is out of adjustment.

Based on observation, not all portions of the building piped medical gas system are installed in accordance with Code requirements. Failure to install medical gas systems in accordance with requirements can result in failure of the system to perform without hazard to the occupants.

Findings include:

A. On 07/31/18 at 10:40 AM while in the company of the FOM, it was observed that the medical gas shut off valves for the 1st floor ED West patient bays labeled as serving 12, 14, 16, 18, 20, & 21 are not separated by a wall between the valve and the outlets forming a separate room to comply with NFPA 99-2012, 5.1.4.8(1) & (3).

B. On 07/31/18 at 11:20 AM while in the company of the FOM, it was observed that the shut off valves for patient bay 15 could not be located to comply with NFPA 99-2012, 5.1.4.8.

Based on observation, not all basic electrical components are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical system could fail to operate properly when needed if the electrical components are not properly installed and maintained.

Findings include:

On 08/02/18, while accompanied by the PMCPO, observation determined that electrical switchgear room doors lack panic hardware required by NFPA 70 2011 450.43(C). Locations observed include:

A. 9:38 AM: Lower Concourse Electrical Switchgear Room L310.

B. 9:40 AM: Lower Concourse Electrical Switchgear Room L312.

C. 9:42 AM: Lower Concourse Electrical Switchgear Room L314.

Based on observation, Critical Branch essential electrical system receptacles are not identified in accordance with Code requirements. Failure to identify receptacles can prevent prompt identification of the panel and circuit from which they are fed to perform maintenance or remedy a loss of power condition promptly.

Findings include:

On 08/01/2018 at 2:20 PM while in the company of the SFM, red critical receptacles in the 10th floor OR room #1088, are not labeled to identify the electrical panel and circuit from which they were fed to comply with NFPA 99-2012, 6.4.2.2.6.2(C) and NFPA 70-2011, 517.19(A).

Based on observation, not all electrical power cords and flexible cords are installed and utilized in the required manner. This deficient practice could affect patients, staff, and visitors in the building because the use of these devices could compromise the emergency electrical systems if they are not used properly.

Findings include:

On 08/02/18 at 9:32 AM, while accompanied by the PMCPO, observation determined that two flexible cords are utilized, in Lower Concourse Copy Room L307, as a substitute for fixed wiring as prohibited by NFPA 70 2011 400.8(1).