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

Findings include:

A. Steel angles supporting knock-out floor panels in future Elevator Shafts were observed which are not covered by fire proofing materials in accordance with the building's designated construction type. This condition was observed in the 1970 Building at 2 future Elevator Shafts, with the angles supporting knock-out floor panels serving at least the Sixth through Third Floors.

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 Second Floor Surgical Department Holding Bays were observed to constitute patient treatment rooms which are not separated from exit access corridors as required by 19.3.6.1.

B. Staff work areas which were observed to be open to corridors were observed to lack smoke detectors required by Exception 1. [subpart (c)] to 19.3.6.1. Locations observed include (all First Floor):

1. 2000 Building Radiology Department staff cubicles.

2. 1970 Building Quality Management staff cubicles near the Urgent Care Unit.

C. The First Floor 1920 Building Rest Stop, which constitutes a waiting area which is open to the corridor but not visible from a constantly attended station, was observed to not be provided with a smoke detector as required by Exception 2. to 19.3.6.1.

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:

A. A series of nurse server units were observed on the Sixth, Fifth, Fourth, Third, and Second Floors of the 1970 Building. These nurse server units were observed to be installed in pairs between Patient Sleeping Rooms. Many of the (corridor side) doors to these nurse server units were observed to not be functioning properly; therefore those doors are not positive latching as required by 19.3.6.3.2.

B. Doors in exit access corridors were observed at which manual flush bolts were not engaged as required by 19.3.6.3.2. Locations observed include (all Third Floor):

1. 1929/1961 Building Cardio-Vascular Unit, all Patient Room doors.
2. 1970 Building Acute Dialysis Unit.
C. The pair of aluminum doors to the Second Floor 1961 Building Endoscopy Unit (a designated suite) were observed to not be 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. During an interview held at the site on the morning of July 15, 2010, the provider's Compliance Specialist was not able to verify compliance of the 2-story communicating space, serving the First and Second Floors of the building, with 8.2.5.5. because:

1. The entire floor area of the communicating space was observed to not be open and unobstructed, such that a fire in any part of the space will be readily obvious to all occupants of the space, as required by Subpart (3) 8.2.5.5.

2. The communicating space is not separated from there remainder of the building by an enclosure which is resistant to the passage of smoke, as required by Subpart (4) to 8.2.5.5., because:
a. Doors in the First Floor walls of the enclosure which were held open by unapproved devices (door wedges).
b. Cased openings and pass-through openings were observed in the First Floor enclosure walls.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3.

Findings include:

A. Fifth Floor: Cable wirings near the EMS Office were observed that pass through a required smoke barrier wall that are not sealed against smoke to comply with 8.3.6.1.

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. 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:

1. Fourth Floor: Medical File Room ( larger than 100 square feet) door is not labeled.

2. First Floor: Unoocupied Operating Rooms (Non Sprinklered Rooms).

3. Third Floor: Storage Room 321 door is not labeled.

4. Second Floor: Storage Room 231, Storage Room 235, Central File Room and Storage Room 236 doors are not rated and labeled.

B. First Floor: The Core Room for the unoccupied OR's being used as Storage does not have a positive latching hardware.

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. At the First Floor level of 1982 Building Exit Stair 9, windows were observed in the east exterior wall which are not protected in accordance with 7.2.2.5.2. because there is an exterior door with glass lites and transoms in the south wall of the adjacent 1994 Building.

B. At the First Floor level of 1994 Building Exit Stair 10, a door was observed which opens into the Stair from the adjacent Emergency Generator Room, which is not a normally occupied room, as prohibited by 7.1.3.2.1(d).

C. The following deficiencies were observed at the Basement level Exit Passageway serving Exit Stairs 3 and 7 (within the 1929, 1961, and 2000 Buildings):

1. The steps at the base of Exit Stair 3 (within the Exit Passageway in the 1961 Building) were observed to lack handrails required by 7.2.2.4.2.

2. A door was observed which opens into the Exit Passageway from the adjacent 1961 Building Pharmacy Storage Room, which is not a normally occupied room, as prohibited by 7.1.3.2.1(d).

3. A time clock was observed, directly east of the exterior door serving the Exit Passageway within the 2000 Building, as prohibited by 7.1.3.2.1(e) and 7.1.3.2.3.
D. A series of doors from rooms which are not normally occupied were observed which open into the Basement level Exit Passsageway serving Exit Stairs 4 and 5 (within the 1929 and 1961 Buildings): Rooms with doors which open into the Exit Passageway include (all 1929 Building):
1. The Housekeeping Storage Room.

2. The Mechanical Room.

E. A series of doors from rooms which are not normally occupied were observed which open into the Basement level Exit Passsageway serving Exit Stair 6 (within the 1952 Building): Rooms with doors which open into the Exit Passageway include:
1. The Janitor's Closet.
2. The Toilet Room.

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

Findings include:

A. Chairs were observed, at a series of (Third Floor Surgery Center) Surgical Corridor work stations, which obstruct the Corridor in a manner prohibited by 19.2.3.3. and 7.1.10.2.1.

Based on random observation during the survey walk-through and document review, not all designated suites are provided with exits in accordance with 19.2.5.2.

Findings include:

A. The Second Floor 1994 Building Intensive Care Unit suite was observed to be shown on facility life safety master plans as being in excess of 5,000 square feet in area, as prohibited by 19.2.5.6.

Based on random observation during the survey walk-through and document review, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. Designated 2 hour rated fire separation walls at the First Floor Level near the Old Day Surgery Waiting have double egress doors that are not labeled as to their fire resistance rating.

Based on random observation during the survey walk-through and staff interview, 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 19.2.8.

Findings include:

A. During an interview held at the site on the afternoon of July 14, 2010, the provider's Compliance Specialist confirmed that there is no emergency lighting, required by 19.2.8. and 7.8.1.1., within the First Floor Courtyard bounded by the 1961, 1970, and 1972 Buildings.

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:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include (all First Floor):

1. The egress path from the Courtyard formed by the 1961, 1970, and 1982 Buildings.

2. The north end of the 1929 Building (former Administration) Corridor.

Based on document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During a review of the facility's fire protection plan documents, it was determined that the facility has not accurately maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical elements of these systems not shown accurately on the facility's Life Safety Master Plans include:

1. Not all existing Ventilation shaft are identified on the Life Safety master Plan. Example: Sixth Floor-Ventilation Shafts on the West Side.

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. Fire alarm pull stations were observed which are not located within 5'-0" of the door as required by NFPA 72 1999 2-8.2.2. Locations observed include (all 1961 Building Fourth Floor):

1. At Exit Stair 3.

2. At Exit Stair 4.

Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6.

Findings include:

A. Through document review, it was determined that the sensitivity of smoke detectors is not calibrated at least every other year as required by NFPA 72 1999 7-3.2.1. During an interview, held in the Office of the Administrative Director of Facility Support Services and Safety on the morning of July 15, 2010, the provider's Compliance Specialist confirmed this finding.

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.

Findings include:

A. The exterior canopy for the First Floor Emergency Department Ambulance Bay, under which combustible materials (including storage bins and vehicles) were observed being stored, was observed to lack sprinkler heads required by NFPA 13 1999 5-13.8.2. During an interview held at the site on the morning of July 14, 2010, the provider's Compliance Specialist confirmed that the parking of ambulances within the Bay is a common occurrence.

B. An Electrical Room, located in the First Floor 1994 Building, adjacent to the Laboratory, was observed at which no ceiling is present, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1. because the room is thus open to the ceiling cavities of all adjacent rooms.

A. Based on direct observation not all water supply valves are electronically supervised for the fire protection system.

1. The city service supply valve to the fire pump is not fitted with electronic tamper protection.

A. 1970 Building Ninth Floor Elevator equipment room:

1. By direct observation the surveyor finds the preaction fire protection system does not derive its source of electricity from the essential electrical system. (NFPA 99, 1999, 3-4.2.2.3 NFPA 13, 1999, 4-2.6 and 4-4)

B. Annual fire pump testing documents do not indicate test was performed on emergency power. (NFPA 25, 1998, 5-3.3.4)

Based on document review and staff interview, not all portable fire extinguishers in the facility are installed and maintained in accordance with 19.3.5.6., 9.7.4.1., and NFPA 10.

Findings include:

A. Based on document review, it could not be determined that portable fire extinguishers are inspected and tested annually in accordance with NFPA 10 1998 4-4.1. because no records of such tests had been provided by the vendor responsible for the tests. During an interview, held in the Office of the Administrative Director of Facility Support Services and Safety on the morning of July 15, 2010, the provider's Compliance Specialist confirmed this finding.

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

Findings include:

A. The deficiencies listed below were observed at a series of toilet exhaust ducts throughout the 1970 Building. Surveyor 14290 notes that it appears that the cited conditions exist in at least 8 locations on the Sixth through Second Floors. Deficiencies observed include:
1. The toilet exhaust ducts were observed to not be enclosed in shafts which which carry a minimum 2 hour fire resistance rating, as required by NFPA 90A 1999 3-3.4.1., because the enclosures for the ducts consist of drywall or plaster on the outside of metal studs only and because they do not extend from the ceiling to the underside of the deck above.

2. No fire dampers, required by NFPA 90A 1999 3-3.4.4., were observed where the toilet exhaust ducts penetrate the enclosure walls.

A. Based on direct observation, record review and interview, the facility failed to provide for the Tea Room grease hood system:

1. A connection between the hood suppression system and the fire alarm system. (NFPA 96, 1999, 7-6.2)

2. Monthly system inspections of the hood suppression system as required. (NFPA 17, 1998, 9-2 & 17A, 5-2)

Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed an maintained as fire resistive assemblies.

Findings include:

A. Doors to Linen Chute Service Rooms, serving a chute which is more than 4 or more stories in height, were observed that do not carry a minimum 1-1/2 hour fire resistance rating required by NFPA 82 1999 3-2.4.3. Locations observed include (all 1970 Building):

1. Sixth Floor.
2. Fifth Floor.

3. Fourth Floor.
4. Third Floor.

5. Second Floor.

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 (all Third Floor Surgery Center):

1. The Endoscopy Prep/Recovery Corridor.

2. The Surgical Prep/Stage I Recovery Corridors.

3. The Surgical Unit Corridor.

4. The Corridor between the Endoscopy Unit and the Surgical Prep/Stage I Recovery Unit.

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

Findings include:

A. Medical gas tanks were observed being stored, in sprinklered portions of the building, that are less than 5'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(2). Locations observed include:

1. Sixth Floor:
a. 1970 Building (Skilled Nursing Unit) Medication Room, 9 tanks.

b. 1961 Building Storage Room, 6 tanks.

2. Third Floor 1961 Building CVU Clean Utility Room, 3 tanks.

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. Combustible materials (files) were observed being stored in the Third Floor Surgery Center Medical Gas Manifold Room as prohibited by NFPA 99 1999 4-3.1.1.2(7).

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3.

Findings include:

A. Fifth Floor: The designated smoke barrier wall near the Stair 2 was observed to not form a complete barrier as required by 19.3.7.3. and 8.3.5. because the wall was observed with duct penetrations that are not provided with smoke dampers, this floor is not sprinklered.

B. First Floor: Designated smoke barrier wall leading to Patient Account Offices was observed with a duct penetration that is not smoke dampered (adjacent compartment of the Patient Account Offices is not sprinklered).

D. First Floor: Designated smoke barrier wall was observed that is not complete to provide a smoke tight wall, it has 3 transfer grills on the back side of the Pharmacy.

A. By direct observation the surveyor finds:

1. The facility failed to provide a remote manual emergency stop station for the Boiler House emergency generator. (NFPA 110, 1999, 3-5.5.6)

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 Fourth Floor 1961 Building LDR Rooms 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).

B. Two semi-private Post-Partum Rooms, in the Fourth Floor of the 1970 Building, were observed at which at least 2 duplex electrical receptacles were not provided, as required by NFPA 70 1999 517-18(a) or 517-19(a), for the bassinet locations.

A. 1970 Building Ninth Floor Elevator Penthouse

1. By direct observation the surveyor finds sprinkler protection provided within the elevator equipment room, however heat detectors are not provided or install within 2 feet of each sprinkler head as a means to automatically disconnect the main power supply to elevators prior to the application of water from the activation of sprinklers. (A17.1, 102.2.c.3)

2. By direct observation and staff interview the above condition exists within the remainder of the faculties elevator equipment rooms.