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LEWISGALE MEDICAL CENTER
No Description Available
Tag No.: K0011
Based on observation and interview it was determined that the facility failed to maintain the 2-hour fire barrier between this building and the Hospital building.
Findings include:
On 11/30/11 at approximately 2:42 pm it was observed that the door in the 2 hour separation (that crosses in front of the Anesthesia Work Room) does not appear to have the proper rating for this use.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0011
Based on observation and interview it was determined that the facility failed to maintain the separation between the Hospital and MOB-East.
Findings include:
On 12/5/11 at approximately 11:30 am it was observed that there are unsealed penetrations to the 2 hour fire barrier separating the hospital from MOB-East by conduit and piping on the 2nd floor.
On 12/13/11 at approximately 9:30 am it was observed that there are unprotected penetrations by wires/conduit/piping in the 2 hour barrier separating the Hospital and "A Building" on the ground floor.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0011
Based on observation and interview it was determined that the facility failed to maintain the fire barrier separating this building from the Hospital Building.
Findings include:
On 12/01/11 at approximately 10:00 am it was observed that the 2 hour fire barrier is not completely sealed to the deck at the rear exit.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0012
Based on observation and interview it was determined that the facility failed to maintain the construction type for this building.
Findings include:
On 11/30/11 at approximately 2:47 pm it was observed that required fireproofing material was missing from structural steel above the ceiling in the Oncology electrical/telephone room.
On 11/30/11 at approximately 2:50 pm it was observed that required fireproofing material was missing from structural steel in the Oncology mechanical room.
On 11/30/11 at approximately 3:09 pm it was observed that combustible firestopping is being used to seal penetrations of rated construction in the Oncology Communications Closet.
On 11/30/11 at approximately 3:55 pm it was observed that required fireproofing material is missing from structural steel in the lobby between the two Oncology departments.
On 12/01/11 at approximately 9:00 am it was observed that required fireproofing material is missing from structural steel in the corridor of Oncology near at the nurses' station.
On 12/01/11 at approximately 9:59 am it was observed that required fireproofing material is missing from structural beams above the ceiling in Elevator 8 Lobby.
On 12/01/11 at approximately 10:14 am it was observed that required fireproofing material is missing from structural beams above the ceiling at the rear exit.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0012
Based on observation and interview it was determined that the facility failed to maintain the construction type of the building.
Findings include:
On 11/15/11 and 11/16/11 between approximately 9:30 am and 4:30 pm it was observed that the 2 hour fire separation between floors was modified from its original approved construction. The Plans Review Engineer for the State Fire Marshal's Office, on January 24, 1975, agreed that in lieu of the 2-1/2 slab required by UL Design G202, the facility could use 2 inch concrete slabs provided that the remaining requirements of the Design were followed, to include, no insulation in the area, requirements for spacing and number of recessed lights, tenting of lights, and hold-down clips. Changes have been made to the lighting and ceiling so that the required separation between floors does not meet the approved design.
On 11/15/11 at approximately 11:31 am it was observed that there are unprotected penetrations by conduit to the floor/ceiling assembly by 2 pipes, in the corridor at "Break Room Staff".
On 11/15/11 at approximately 11:39 am it was observed that there are three unprotected penetrations to the floor/ceiling assembly above the ceiling at the entrance to the Cosmetology area by conduit..
On 11/15/11 at approximately 11:44 am it was observed that there is an unprotected penetration to the floor/ceiling assembly by piping above the ceiling in the lobby of the Neurology area.
On 11/15/11 at approximately 11:46 am it was observed that there are unprotected penetrations to the floor/ceiling assembly by piping in corridor area #76.
On 11/15/11 at approximately 1:45 pm it was observed that the ceiling at Space 10 on the 2nd floor, has been changed from the UL-G202 Design that was approved for this building.
On 11/15/11 at approximately 2:35 pm it was observed that an intake area was constructed of wood and is attached to the building.
On 11/16/11 at approximately 1:00 pm it was observed that plywood sheets were placed in the ceiling above the ITU Quiet Room.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0012
Based on observation and interview it was determined that the facility failed to maintain the construction type of the building.
Findings include:
On 11/30/11 at approximately 2:45 PM it was observed that supporting wire for the suspended ceiling had been cut at the separation between OR floor in MOB-West and the hospital.
On 12/1/11 at approximately 10:20 am it was observed that required fireproofing material is missing from structural steel in the corridor at Stair 1, 6th floor.
On 12/1/11 at approximately 10:23 am it was observed that required fireproofing material is missing from structural steel in Room 652.
On 12/1/11 at approximately 10:26 am it was observed that required fireproofing material is missing from structural steel outside of the Soiled Utility Room at Room 647.
On 12/1/11 at approximately 10:28 am it was observed that required fireproofing material is missing from structural steel in the Supply Room close to Room 645.
On 12/1/11 at approximately 10:29 am it was observed that required fireproofing material is missing from structural steel in Room 647.
On 12/1/11 at approximately 10:45 am it was observed that required fireproofing material is missing from structural steel in Room 633.
On 12/1/11 at approximately 10:49 am it was observed that required fireproofing material is missing from structural steel in the Wound Office on the 6th floor.
On 12/1/11 at approximately 10:56 am it was observed that required fireproofing material is missing from structural steel in the storage room located next to Stair 3 on the 6th floor.
On 12/1/11 at approximately 11:06 am it was observed that required fireproofing material is missing from structural steel in the Whirlpool Room on the 6th floor.
On 12/1/11 at approximately 11:20 am it was observed that required fireproofing material is missing from structural steel in the Clean Supply Room on the 6th floor (near the whirlpool room).
On 12/1/11 at approximately 11:27 am it was observed that required fireproofing material is missing from structural steel in the soiled utility room on 6E.
On 12/1/11 at approximately 11:32 am it was observed that required fireproofing material is missing from structural steel in the Director's Office on 6E.
On 12/1/11 at approximately 11:45 am it was observed that required fireproofing material is missing from structural steel across from Stair #5 on 6E.
On 12/1/11 at approximately 12:55 pm it was observed that wood has been used in the ceiling for construction at Stair #5 on 5E.
On 12/1/11 at approximately 12:55 pm it was observed that required fireproofing material is missing from structural steel at Stair #5 on 5E.
On 12/1/11 at approximately 1:04 pm it was observed that required fireproofing material is missing from structural steel in the Storage Room beside Room 532.
On 12/1/11 at approximately 1:04 pm it was observed that combustible foam has been used as a firestop material for the floor/ceiling assembly in the Storage Room beside Room 532.
On 12/1/11 at approximately 1:16 pm it was observed that in the back storage room located in the Soiled Utility Room on 5E, required fireproofing material is missing from structural steel.
On 12/1/11 at approximately 1:16 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the back storage room located inside the Soiled Utility Room on 5E.
On 12/1/11 at approximately 1:16 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Soiled Utility Room on 5E.
On 12/1/11 at approximately 1:18 pm it was observed that required fireproofing material is missing from structural steel at the Nurses' Station on 5E.
On 12/1/11 at approximately 1:19 pm it was observed that required fireproofing material is missing from structural steel in Room 502.
On 12/1/11 at approximately 1:26 pm it was observed that required fireproofing material is missing from structural steel in Room 500.
On 12/1/11 at approximately 1:40 pm it was observed that required fireproofing material is missing from structural steel in the Respiratory Therapy Locker Room on 5E.
On 12/1/11 at approximately 1:45 pm it was observed that required fireproofing material is missing from structural steel in Room 534.
On 12/1/11 at approximately 2:27 pm it was observed that required fireproofing material is missing from structural steel beams in the Soiled Utility Room across from Room 500.
On 12/1/11 at approximately 2:28 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Soiled Utility Room across from Room 500.
On 12/1/11 at approximately 2:30 pm it was observed that required fireproofing material is missing from structural steel in the Storage Room across from Stair 1 on 5W.
On 12/1/11 at approximately 2:35 pm it was observed that required fireproofing material is missing from structural steel in the corridor of 4W Rehab.
On 12/1/11 at approximately 2:37 pm it was observed that required fireproofing material is missing from structural steel in the corridor near the fire barrier on 4W.
On 12/1/11 at approximately 2:40 pm it was observed that required fireproofing material is missing from structural steel in Room D on 4W.
On 12/1/11 at approximately 2:46 pm it was observed that required fireproofing material is missing from structural steel at the ADL Room on 4W.
On 12/1/11 at approximately 2:48 pm it was observed that required fireproofing material is missing from structural steel in Room 446.
On 12/1/11 at approximately 2:54 pm it was observed that required fireproofing material is missing from structural steel in Room 433.
On 12/1/11 at approximately 3:01 pm it was observed that required fireproofing material is missing from structural steel in the H4A Closet (IS Closet).
On 12/1/11 at approximately 3:07 pm it was observed that required fireproofing material is missing from structural steel at Room 400.
On 12/1/11 at approximately 3:09 pm it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room on 4E.
On 12/1/11 at approximately 3:09 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Soiled Utility Room on 4E.
On 12/1/11 at approximately 3:14 pm it was observed that required fireproofing material is missing from structural steel at the smoke barrier outside of the Soiled Utility Room on 4E.
On 12/1/11 at approximately 3:21 pm it was observed that required fireproofing material is missing from structural steel at Stair #5 on 4E.
On 12/1/11 at approximately 3:21 pm it was observed that wood has been used in the building construction at Stair #5 on 4E.
On 12/5/11 at approximately 9:34 am it was observed that required fireproofing material is missing from structural steel at Stair #1, 3rd floor.
On 12/5/11 at approximately 9:40 am it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room on 3W.
On 12/5/11 at approximately 9:40 am it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Soiled Utility Room on 3W.
On 12/5/11 at approximately 9:42 am it was observed that required fireproofing material is missing from structural steel in the Clean Linen Room on 3W.
On 12/5/11 at approximately 9:50 am it was observed that required fireproofing material is missing from structural steel in Cardiac Rehab on the 3rd floor.
On 12/5/11 at approximately 10:00 am it was observed that required fireproofing material is missing from structural steel outside of Cardiac Rehab at the smoke barrier wall in the corridor of the 3rd floor.
On 12/5/11 at approximately 10:12 am it was observed that required fireproofing material is missing from structural steel at Room 301.
On 12/5/11 at approximately 10:13 am it was observed that required fireproofing material is missing from structural steel in the elevator lobby for elevators 4 and 5 on the 3rd floor.
On 12/5/11 at approximately 10:47 am it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room on 3E.
On 12/5/11 at approximately 10:47 am it was observed that there are unprotected openings in the floor/ceiling assembly in the Soiled Utility Room on 3E.
On 12/5/11 at approximately 10:45 am it was observed that required fireproofing material is missing from structural steel in the corridor leading into the CCU area on the 3rd floor.
On 12/5/11 at approximately 10:45 am it was observed that required fireproofing material is missing from structural steel in the corridor near the fire barrier at Case Management on 3E.
On 12/5/11 at approximately 11:07 am it was observed that required fireproofing material is missing from structural steel in CCU Medical Equipment Room on 3E.
On 12/5/11 at approximately 11:30 am it was observed that required fireproofing material is missing from structural steel at the building separation leading into MOB-East at the 2 hour fire barrier on the 2nd floor.
On 12/5/11 at approximately 2:29 pm it was observed that required fireproofing material is missing from structural steel in the Supply Room in the EP Lab on the 2nd floor.
On 12/5/11 at approximately 2:35 pm it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room in Cardiac Holding on the 2nd floor.
On 12/5/11 at approximately 2:42 pm it was observed that the fire barrier at Stair 5, 2nd floor, does not appear to be sealed to the deck.
On 12/5/11 at approximately 2:50 pm it was observed that required fireproofing material is missing from structural steel in the Storage Room between OR 21 and OR 22 on the 2nd floor.
On 12/5/11 at approximately 3:02 pm it was observed that required fireproofing material is missing from structural steel in the back hall outside of Central Sterile on the 2nd floor.
On 12/7/11 at approximately 9:35 am it was observed that required fireproofing material is missing from structural steel at the smoke barrier outside of Room 234.
On 12/7/11 at approximately 9:40 am it was observed that there is an unprotected penetration of the floor/ceiling assembly above the ceiling in Room 234.
On 12/7/11 at approximately 9:55 am it was observed that required fireproofing material is missing from structural steel in the Storage Room on 2W at the Nurses' Station.
On 12/7/11 at approximately 10:00 am it was observed that required fireproofing material is missing from structural steel in Storage Room 24 beside Room 260.
On 12/7/11 at approximately 10:07 am it was observed that required fireproofing is missing from structural steel in the Lactation Hall on the 2nd floor.
On 12/7/11 at approximately 10:18 am it was observed that required fireproofing material is missing from structural steel in the area of the separation of the hospital to MOB East, Building A.
On 12/7/11 at approximately 10:27 am it was observed that required fireproofing is missing from structural steel in the Storage Room in the Medical Intensive Care Department.
On 12/7/11 at approximately 10:57 am it was observed that required fireproofing material is missing from structural steel in the Lab Office.
On 12/7/11 at approximately 10:57 am it was observed that the Office in the Lab has combustible paper on the insulation above the ceiling.
On 12/7/11 at approximately 11:03 am it was observed that the required fireproofing material is missing from structural steel in the Blood Bank in the Lab.
On 12/7/11 at approximately 11:04 am it was observed that the required fireproofing material is missing from structural steel in the Lab Library.
On 12/7/11 at approximately 11:07 am it was observed that required fireproofing material is missing from structural steel in the Lab Break Room.
On 12/7/11 at approximately 11:13 am it was observed that there is wood used for construction in the wall of the corridor at the Lab Break Room.
On 12/7/11 at approximately 11:13 am it was observed that required fireproofing material is missing from structural steel in the corridor at the Lab Break Room.
On 12/7/11 at approximately 11:16 am it was observed that required fireproofing material is missing from structural steel in the Lab Supervisor's Office.
On 12/7/11 at approximately 11:16 am it was observed that there is wood used for construction in the wall of the Lab Supervisor's Office.
On 12/7/11 at approximately 11:22 am it was observed that required fireproofing material is missing from structural steel in the Lab.
On 12/7/11 at approximately 11:39 am it was observed that at the double doors for the Lab, where the 1 hour rated wall turns, fireproofing material is missing from structural steel.
On 12/7/11 at approximately 11:39 am it was observed that required fireproofing material is missing from structural steel where the 1 hour rated wall turns in the Lab.
On 12/7/11 at approximately 11:51 am it was observed that required fireproofing material is missing from structural steel in the Waiting Room (Wireless Access) on the 1st floor.
On 12/7/11 at approximately 11:53 am it was observed that there are unprotected penetrations at the exit area of Bio-Hazard Medical Engineering to the 2 hour barrier.
On 12/7/11 at approximately 1:46 it was observed that required fireproofing material is missing from structural steel in the Pharmacy Staffing Office.
On 12/7/11 at approximately 1:50 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the corridor outside of the Pharmacy Mechanical Room.
On 12/7/11 at approximately 2:46 pm it was observed that there required fireproofing material is missing from structural steel in the Storage Room outside of Endoscopy.
On 12/7/11 at approximately 3:05 pm it was observed that required fireproofing material is missing from structural steel in M51.
On 12/7/11 at approximately 3:06 pm it was observed that required fireproofing is missing from structural steel outside of the Blueprint Room on the 1st floor.
On 12/7/11 at approximately 3:11 pm it was observed that required fireproofing material is missing from structural steel in the EVS corridor on the 1st floor.
On 12/12/11 at approximately 9:30 am it was observed that required fireproofing material is missing from structural steel in the Trash Chute Room on 1E.
On 12/12/11 at approximately 9:35 am it was observed that required fireproofing is missing from structural steel in the Linen Chute Room on 1E.
On 12/12/11 at approximately 9:30 am it was observed that required fireproofing material was missing from structural steel in the Private Office across from Pharmacy Storage on the 1st floor.
On 12/12/11 at approximately 9:41 am it was observed that required fireproofing material is missing from structural steel in the Private Office storage room across from Pharmacy Storage on the 1st floor.
On 12/12/11 at approximately 10:07 am it was observed that required fireproofing material is missing from structural steel in the large storage room across from the Mail Room on the 1st floor.
On 12/12/11 at approximately 10:35 am it was observed that required fireproofing material is missing from structural steel in an Engineering office (#1) on the 1st floor.
On 12/12/11 at approximately 10:37 am it was observed that required fireproofing material is missing from structural steel in the Engineering restroom on the 1st floor.
On 12/12/11 at approximately 11:13 am it was observed that required fireproofing material is missing from structural steel in the Tel Com Room, 1st floor.
On 12/12/11 at approximately 11:19 am it was observed that required fireproofing material is missing from structural steel at TR1-1.
On 12/12/11 at approximately 11:26 am it was observed that required fireproofing material is missing from structural steel in Security Central on the 1st floor.
On 12/12/11 at approximately 11:28 am it was observed that required fireproofing material is missing from structural steel in the Clean Linen Chute Room on 1W.
On 12/12/11 at approximately 11:32 am it was observed that required fireproofing material is missing from structural steel at the entrance to the Cafeteria on 1W.
On 12/12/11 at approximately 11:38 am it was observed that required fireproofing material is missing from structural steel above the ceiling at the double doors near the ATM on 1W.
On 12/12/11 at approximately 11:40 am it was observed that required fireproofing material is missing from structural steel in the IT Closet at the ATM on 1W.
On 12/12/11 at approximately 1:28 pm it was observed that required fireproofing material is missing from structural steel in the Business Office/Cashier on 1W.
On 12/12/11 at approximately 1:35 pm it was observed that required fireproofing material is missing from structural steel in the Hyperbaric Room on the 1st floor.
On 12/12/11 at approximately 1:49 pm it was observed that required fireproofing material is missing from structural steel in the Advanced Wound Center on the 1st floor.
On 12/12/11 at approximately 1:50 pm it was observed that required fireproofing material is missing from structural steel in the Main Lobby on the 1st floor.
On 12/12/11 at approximately 2:03 pm it was observed that required fireproofing material is missing from structural steel at Exam Room 3 in Pre-Admission Testing on the 1st floor.
On 12/12/11 at approximately 2:05 pm it was observed that required fireproofing material is missing from structural steel in the Supply Room near the entrance to the Cafeteria.
On 12/12/11 at approximately 2:10 pm it was observed that required fireproofing material is missing from structural steel in the dining area of the Cafeteria near the vending machines.
On 12/12/11 at approximately 2:10 pm it was observed that there is a wood stud used for construction material in the dining area of the Cafeteria at the vending machines.
On 12/12/11 at approximately 2:38 pm it was observed that required fireproofing material is missing from structural steel in the Janitor's Closet in Dietary.
On 12/12/11 at approximately 2:45 pm it was observed that required fireproofing material is missing from structural steel in the kitchen work area.
On 12/13/11 at approximately 9:15 am it was observed that required fireproofing material is missing from structural steel in Mechanical Room 4B.
On 12/13/11 at approximately 9:30 am it was observed that required fireproofing material is missing from structural steel at the 2 hour barrier separating the Hospital and "A Building" on the ground floor.
On 12/13/11 at approximately 9:42 am it was observed that required fireproofing material is missing from structural steel in the Lobby of Radiology Registration.
On 12/13/11 at approximately 9:49 am it was observed that required fireproofing material is missing from structural steel outside of the CT Scan area in Radiology.
On 12/13/11 at approximately 9:55 am it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room outside of the CT Scan area in Radiology.
On 12/13/11 at approximately 10:00 am it was observed that required fireproofing is missing from structural steel in the Storage Room behind the elevator room on the ground floor.
On 12/13/11 at approximately 11:12 am it was observed that required fireproofing is missing from structural steel outside of the elevator room on the ground floor.
On 12/13/11 at approximately 10:18 am it was observed that required fireproofing material is missing from structural steel in the electrical closet at the separation between the Hospital and OR on the ground floor.
On 12/13/11 at approximately 10:18 am it was observed that required fireproofing material is missing from structural steel in the IT Closet behind the electrical closet at the separation between the Hospital and OR on the ground floor.
On 12/13/11 at approximately 10:33 am it was observed that required fireproofing is missing from structural steel in the Nuclear Medicine Suite on the ground floor.
On 12/13/11 at approximately 10:35 am it was observed that required fireproofing is missing from structural steel in the corridor outside of the Nuclear Medicine Suite.
On 12/13/11 at approximately 11:00 am it was observed that required fireproofing material is missing from structural steel in the corridor at the Interventional Holding area.
On 12/13/11 at approximately 11:18 am it was observed that required fireproofing is missing from structural steel at the 2 hour fire barrier between the Hospital and "A Building".
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0012
Based on observation and interview it was determined that the facility failed to maintain the type of building construction.
Findings include:
On 11/30/11 at approximately 10:05 am it was observed that required fireproofing material is missing from structural steel in the ER Mediation Room.
On 11/30/11 at approximately 10:32 am it was observed that required fireproofing material is missing from structural steel in ER Fast Track.
On 11/30/11 at approximately 10:44 am it was observed that required fireproofing material is missing from structural steel in the ER-EMS room.
On 11/30/11 at approximately 10:40 am it was observed that required fireproofing material is missing from structural steel above the ceiling at the ER Desk Tech.
On 11/30/11, at approximately 11:47 am it was observed that required fireproofing material is missing from structural steel in the ER Electrical Room.
On 11/30/11 at approximately 12:59 pm it was observed that required fireproofing material is missing for structural steel above the doors across from the elevators (1st floor).
On 11/30/11 at approximately 1:03 pm it was observed that required fireproofing material is missing from structural steel above the lay-in ceiling in the old Orthopaedic Clinic.
On 11/30/11 at approximately 1:05 pm it was observed that required fireproofing material is missing from structural steel in the Mechanical Room on the 1st floor.
On 11/30/11 at approximately 1:10 pm it was observed that required fireproofing material is missing from structural steel in the Electrical Closet on the 1st floor.
On 11/30/11 at approximately 1:12 pm it was observed that required fireproofing material is missing from structural steel in the "Jefferson Surgical Center" area.
On 11/30/11 at approximately 1:15 pm it was observed that required fireproofing material is missing from structural steel in the Western VA OBGYN lobby area.
On 11/30/11 at approximately 1:17 pm it was observed that required fireproofing material is missing from structural steel in the Western VA OBGYN corridor near Exam Room 4.
On 11/30/11 at approximately 1:25 pm it was observed that fireproofing material is missing from structural steel in the stairwell near the OBGYN entrance.
On 11/30/11 at approximately 1:30 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Lobby area of the Lewis Gale OBGYN Suite.
On 11/30/11 at approximately 1:30 pm it was observed that required fireproofing material is missing from structural steel in the Lobby area of the Lewis Gale OBGYN office.
On 11/30/11 at approximately 1:32 pm it was observed that required fireproofing material is missing from structural steel in the corridor area of the Lewis Gale OBGYN suite.
On 11/30/11 at approximately 1:35 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly at the separation between the OR and the Hospital.
On 11/30/11 at approximately 1:35 pm it was observed that required fireproofing is missing from structural steel above the ceiling at the separation between the OR and the Hospital.
On 11/30/11 at approximately 1:39 pm it was observed that required fireproofing material is missing from structural steel above the ceiling at the Medication Room on the OR floor.
On 11/30/11 at approximately 1:42 pm it was observed that required fireproofing material is missing from structural steel above the ceiling at the Janitor's Closet on the OR floor.
On 11/30/11 at approximately 2:05 pm it was observed that required fireproofing material is missing above the ceiling in PACU on the OR floor.
On 11/30/11 at approximately 2:12 pm it was observed that required fireproofing material is missing from structural steel at OR 8.
On 11/30/11 at approximately 2:14 pm it was observed that required fireproofing material is missing from structural steel in the equipment room on the OR floor.
On 11/30/11 at approximately 2:15 and 2:30 pm it was observed that required fireproofing material is missing from structural steel in the Core Storage Room of the OR.
On 11/30/11 at approximately 2:33 pm it was observed that required fireproofing material is missing from structural steel in the Communications Closet in the OR.
On 11/30/11 at approximately 2:40 pm it was observed that required fireproofing material is missing from structural steel above the ceiling outside of OR 5.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0014
Based on observation and interview it was determined that the facility failed to ensure that flame spread ratings are Class A or Class B.
Findings include:
On 12/7/11 at approximately 11:55 am it was observed that there is plywood used on the exterior wall of the Bio-Hazard Room.
On 12/12/11 at approximately 1:23 pm it was observed that wood has been used on the wall outside of EDS on 1W and is over 4' in height from the bottom of the wall.
The above was confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0015
Based on observation and interview it was determined that the interior finish for the gym area does not appear to have the required flame spread rating.
Findings include:
On 11/16/11 at approximately 3:30 pm it was observed that a wood climbing wall was added to the Gym wall. Documentation was not available to show the flame spread rating for this material.
The above was witnessed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0017
Based on observation and interview it was determined that the facility failed to maintain smoke tight corridors. Corridors are required to be smoke tight partitions to the deck above because of the use of a plenum above the lay in ceiling.
Findings include:
On 11/16/11 at approximately 1:35 pm it was observed that there are unsealed penetrations to the smoke partition at the Emergency Equipment Room.
On 11/16/11 at approximately 3:05 pm it was observed that there are unsealed penetrations to the smoke partition in the AAU (Adult Unit 1) corridor at Room 204.
On 11/16/11 at approximately 3:07 pm it was observed that there are unsealed penetrations to the smoke partition in the AAU corridor at Room 202.
On 11/16/11 at approximately 3:10 pm it was observed that there are unsealed penetrations to the smoke partition in the AAU corridor at Room 111.
On 11/16/11 at approximately 3:42 pm it was observed that there are unsealed penetrations to the smoke partition in the Cafeteria corridor by wires and conduit.
On 11/16/11 at approximately 3:50 pm it was observed that there are unsealed penetrations to the Health Information Management corridor by conduit, pipes, and wires.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0018
Based on observation and interview it was determined that the facility failed to ensure that corridor doors are smoke tight.
Findings include:
On 12/1/11 at approximately 10:33 am it was observed that the door to patient Room 636 is not equipped with a means to keep the door closed.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0018
Based on observation and interview it was determined that the facility failed to maintain corridor openings to resist the passage of smoke.
Findings include:
On 11/15/11 at approximately 2:50 pm it was observed that corridor doors 311 & 312 are not smoke tight as they are not equipped with a means suitable for keeping them closed.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0020
Based on observation and interview it was determined that the facility failed to maintain stairways with a one hour fire resistance rating.
Findings include:
On 11/30/11 at approximately 1:25 pm it was observed that there are unprotected penetrations by sprinkler piping/conduit to the stairwell near the OBGYN entrance.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0020
Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating of elevator shafts.
Findings include:
On 12/01/11 at approximately 3:10 pm it was observed that there are unprotected penetrations by conduit/wires to the elevator shaft wall in the Elevator Lobby.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0020
Based on observation and interview it was determined that the facility failed to maintain the required fire resistance rating of shafts.
Findings include:
On 11/16/11 at approximately 1:17 pm it was observed that there are two unprotected penetrations by conduit to the 2nd floor elevator shaft.
On 11/16/11 at approximately 1:25 pm it was observed that the shaft (where elevator was moved) has unprotected penetrations by sprinkler piping and wires on the 2nd floor.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0021
Based on observation and interview it was determined that the facility failed to maintain fire doors that they will close automatically.
Findings include:
On 11/15/11 at approximately 11:08 am it was observed that the door to Stair 1, 1st floor is being held open by unapproved means. Further, this door is not automatically latching in the closed position.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0025
Based on observation and interview it was determined that the facility failed to maintain the construction of smoke barrier walls.
Findings include:
On 11/30/11 at approximately 9:10 am it was observed that combustible foam is being used to seal penetrations to the smoke barrier in the lobby of ER Triage.
On 11/30/11 at approximately 9:12 am it was observed that combustible foam is being used to seal penetrations to the smoke barrier in the ER Meditation Room.
On 11/30/11 at approximately 9:20 am it was observed that there are unsealed penetrations in the corridor of ER Triage by conduit/piping.
On 11/30/11 at approximately 9:42 am it was observed that there are unsealed penetrations in the corridor at ER Super Track by conduit/piping.
On 11/30/11 at approximately 10:14 am it was observed that there are unsealed penetrations to ER Super Track room by conduit.
On 11/30/11 at approximately 10:32 am it was observed that there are unsealed penetrations to ER Fast Track by conduit/wiring.
On 11/30/11 at approximately 10:41 am it was observed that combustible foam is being used for sealing the smoke barrier in the ER Ambulatory Lobby entrance.
On 11/30/11 at approximately 10:45 am it was observed that combustible foam is being used for sealing the smoke barrier in the ER-EMS room.
On 11/30/11 at approximately 2:42 pm it was observed that there are unsealed penetrations to the barrier wall above the ceiling at the Anesthesia Work Room.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0025
Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating of smoke barriers.
Findings include:
On 12/1/11 at approximately 10:23 am it was observed that there are unsealed penetrations to the smoke barrier by wires and conduit in Room 652.
On 12/1/11 at approximately 10:45 am it was observed that the smoke barrier in Room 633 does not appear to be properly sealed to the deck.
On 12/1/11 at approximately 10:45 am it was observed that there are unsealed penetrations to the smoke barrier in Room 633 by conduit/wires.
On 12/1/11 at approximately 11:06 am it was observed that there are unsealed penetrations to the smoke barrier in the Whirlpool Room on the 6th floor by conduit.
On 12/1/11 at approximately 1:19 pm it was observed that combustible foam was used to seal around a penetration in the smoke barrier wall in Room 502.
On 12/1/11 at approximately 2:15 pm it was observed that penetrations to the smoke barrier in Room 550 appear to have been sealed with combustible (green) foam.
On 12/1/11 at approximately 3:07 pm it was observed that there are unsealed penetrations by conduit/piping to the smoke barrier at Room 400.
On 12/1/11 at approximately 3:15 pm it was observed that there are unsealed penetrations by conduit in the smoke barrier wall near the Soiled Utility Room on 4E.
On 12/5/11 at approximately 9:50 am it was observed that there are unsealed penetrations to the smoke barrier by conduit in Cardiac Rehab on the 3rd floor.
On 12/5/11 at approximately 10:12 am it was observed that there are unsealed penetrations to the smoke barrier in Room 301 (Staff Lounge) by conduit.
On 12/5/11 at approximately 10:14 am it was observed that there is combustible foam used as a sealant in the smoke barrier in Room 301.
On 12/5/11 at approximately 10:47 am it was observed that there are unsealed penetrations by conduit to the smoke barrier in the Soiled Utility Room on 3E.
On 12/5/11 at approximately 10:53 am it was observed that there are unsealed penetrations by conduit to the smoke barrier at CCU on 3E.
On 12/5/11 at approximately 10:53 am it was observed that combustible foam has been used as a sealant in the smoke barrier at CCU on 3E.
On 12/5/11 at approximately 2:42 pm it was observed that there are unsealed penetrations to the smoke barrier wall at Stair 5, 2nd floor.
On 12/7/11 at approximately 9:35 am it was observed that there are unsealed penetrations to the smoke barrier at Room 234 by wires.
On 12/7/11 at approximately 9:40 am it was observed that there are unsealed penetrations to the smoke barrier in Room 234 by conduit and piping.
On 12/7/11 at approximately 3:00 pm it was observed that there are unsealed penetrations to the smoke barrier outside the back of Endoscopy.
On 12/12/11 at approximately 11:02 am it was observed that there are unsealed penetrations to the smoke barrier at PPX on the 1st floor. Also, the smoke barrier wall is not complete in the same area.
On 12/12/11 at approximately 11:17 am it was observed that there is an unsealed penetration to the smoke barrier wall - the right wall in M2-1.
On 12/12/11 at approximately 11:17 am it was observed that there are unsealed penetrations to the smoke barrier wall in the corridor at M2-1.
On 12/12/11 at approximately 11:32 am it was observed that there are unsealed penetrations to the barrier at the entrance to the Cafeteria on 1W.
On 12/12/11 at approximately 11:38 am it was observed that there are unsealed penetrations to the smoke barrier above the double doors near the ATM on 1W.
On 12/13/11 at approximately 9:49 am it was observed that there are unsealed penetrations to the smoke barrier wall outside of the CT Scan area in Radiology and around the corner from the room.
On 12/13/11 at approximately 9:49 am it was observed that the smoke barrier is not sealed to the deck outside of the CT Scan area (around the corner) in Radiology.
On 12/13/11 at approximately 10:20 am it was observed that there are unsealed penetrations to the smoke barrier in the corridor at the Educator Office on the ground floor.
On 12/13/11 at approximately 10:28 am it was observed that the smoke barrier is not sealed to the deck above the double doors (B7) on the ground floor.
On 12/13/11 at approximately 10:33 am it was observed that there are unsealed penetrations to the Nuclear Medicine Suite by conduit/wires (part of the smoke barrier).
On 12/13/11 at approximately 10:35 am it was observed that the smoke barrier wall is not sealed to the deck in the corridor outside Nuclear Medicine Suite on the ground floor.
On 12/13/11 at approximately 10:35 am it was observed that there are unsealed penetrations to the smoke barrier outside of Nuclear Medicine Suite on the ground floor.
On 12/13/11 at approximately 10:45 am it was observed that there are unsealed penetrations to the smoke barrier at the rear of Interventional Holding on the ground floor.
On 12/13/11 at approximately 11:09 am it was observed that there are unsealed penetrations to the smoke barrier at B12.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0025
Based on observation and interview it was determined that the facility failed to properly construct and maintain smoke barriers.
Findings include:
On 11/15/11 at approximately 9:55 am it was observed that the smoke barrier wall near the elevator equipment room does not extend to the deck above.
On 11/15/11 at approximately 10:25 am it was observed that there are unsealed penetrations to the smoke barrier between the men's restroom and a private office.
On 11/15/11 at approximately 10:30 am it was observed that there are unsealed penetrations to the smoke barrier in "Private Office".
On 11/15/11 at approximately 10:37 am it was observed that there are unsealed penetrations to the smoke barrier inside the men's restroom.
On 11/15/11 at approximately 10:47 am it was observed that the smoke barrier wall is not complete from the corner of the women's restroom to the stairwell.
On 11/15/11 at approximately 1:56 pm it was observed that combustible foam was used to seal penetrations above the barrier doors leading to ITU (Adult Unit 3).
On 11/15/11 at approximately 1:58 pm it was observed that there are unsealed penetrations to the barrier wall leading to ITU (Adult Unit 3) by wires/conduit.
On 11/15/11 at approximately 2:05 pm it was observed that there are unsealed penetrations to the barrier wall in Area 7, ID staff room by piping and conduit.
On 11/15/11 at approximately 2:11 pm it was observed that there is an unsealed opening in the barrier wall above the double doors at the Storage Room on the 2nd floor created by a bundle of wires.
On 11/15/11 at approximately 3:00 pm it was observed that combustible foam was used and covered with a thin coating of firestopping material above the smoke barrier doors leading to the Children's Unit to seal penetrations of the barrier wall.
On 11/15/11 at approximately 3:10 pm it was observed that there are unsealed penetrations to the smoke barrier at Room 220.
On 11/16/11 at approximately 1:00 pm it was observed that the barrier wall in the ITU Quiet Room is not constructed properly (this wall was changed during a renovation).
On 11/16/11 at approximately 1:55 pm it was observed that there are unsealed penetrations to the smoke barrier above the double doors at the Physician's Consult Room.
On 11/16/11 at approximately 2:07 pm it was observed that there are unsealed penetrations to the barrier wall at the room by AAU.
On 11/16/11 at approximately 2:29 pm it was observed that there is an unsealed penetration to the smoke barrier above the door to Room 217 at the entrance to the Doctor's Office on the 2nd floor.
On 11/16/11 at approximately 2:40 pm it was observed that there are unsealed penetrations to the barrier wall in the room beside the Behavioral Health Director.
On 11/16/11 at approximately 2:50 pm it was observed that there are unsealed penetrations by conduit to the barrier wall, on the Doctor's Office side of the door, at Dr. L's office.
On 11/16/11 at approximately 2:55 pm it was observed that there are unsealed penetrations by conduit to the smoke barrier at the Children's Lounge.
On 11/16/11 at approximately 3:35 pm it was observed that there are unsealed penetrations by conduit to the barrier wall at the entrance to the Gym.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0027
Based on observation and interview it was determined that the facility failed to maintain door openings in smoke barriers.
Findings include:
On 11/30/11 at approximately 2:55 pm it was observed that the dutch fire doors in the barrier wall at Blue Ridge Oncology are not automatically closing when the fire alarm is activated. One door in the reception area had the opposite leaf propped open. An additional door at the reception area was obstructed from closing by shelving.
On 11/30/11 and 12/1/11 at approximately 3:27 pm and 9:30 am it was observed that the two rated doors in the barrier wall across from Exam Room 4 in Blue Ridge Oncology were being held open with a door stop.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0027
Based on observation and interview it was determined that the facility failed to maintain smoke tight and self-closing doors in the smoke barrier.
Findings include:
On 11/15/11 at approximately 9:45 am it was observed that the door between the Pavilion Administrator and the Private Office which is located in the smoke barrier, is not equipped with a closer.
On 11/15/11 at approximately 9:47 am it was observed that the door at the rear of the reception desk which is part of the smoke barrier, is not equipped with a closer.
On 11/16/11 at approximately 2:25 pm it was observed that there is an unapproved sweep on the rated doors at Room 206.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0029
Based on observation and interview it was determined that the facility failed to maintain identified hazardous areas separated by required construction with properly rated doors that remain self-closing.
Findings include:
On 11/16/11 at approximately 1:34 pm it was observed that the old pharmacy area was changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 11/16/11 at approximately 1:35 pm it was observed that the old exam room was changed to storage and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 11/16/11 at approximately 3:25 pm it was observed that the office in the Gym was changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 11/16/11 at approximately 3:27 pm it was observed that an additional office in the Gym was changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 11/16/11 at approximately 3:30 pm it was observed that the door to Storage Room A in the Gym is not self-closing.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0029
Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating of hazardous areas.
Findings include:
On 12/01/11 at approximately 9:57 am it was observed that the rated construction was not properly sealed to the deck in the Oncology soiled utility room.
On 12/01/11 at approximately 9:57 am it was observed that there is a penetration by conduit to the rated construction in the Oncology soiled utility room
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0029
Based on observation and interview it was determined that the facility failed to maintain the required fire resistance rating for identified hazardous areas.
Findings include:
On 11/30/11 at approximately 2:14 pm it was observed that there are unprotected penetrations by piping/conduit of 1 hour rated construction in the equipment room on the OR floor.
On 11/30/11 at approximately 2:15 pm it was observed that there are unprotected penetrations to rated construction by conduit and piping in the Core Storage Room of the OR.
On 11/30/11 at approximately 2:33 pm it was observed that there are penetrations to 1 hour rated construction in the Communications Closet in the OR by conduit.
On 11/30/11 at approximately 2:35 pm it was observed that there are unprotected penetrations by conduit/piping to rated construction in the storage room beside OR 11.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0029
Based on observation and interview it was determined that the facility failed to properly protect identified hazardous areas.
Findings include:
On 12/1/11 at approximately 10:56 am it was observed that the door closer has been removed from the Storage Room door located next to Stair 3 on the 6th floor.
On 12/1/11 at approximately 10:56 am it was observed that there are unprotected penetrations in the Storage Room located next to Stair 3 on the 6th floor by conduit and piping that are not sealed with an approved firestop material.
On 12/1/11 at approximately 10:56 am it was observed that the Storage Room located next to Stair 3 on the 6th floor is not properly sealed to the deck.
On 12/1/11 at approximately 11:30 am it was observed that a shower room on 6E has been converted to a clean linen room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 1:04 pm it was observed that there are unprotected penetrations in one wall in the Storage Room beside Room 532 by pipes/conduit.
On 12/1/11 at approximately 1:04 pm it was observed that the door to the Storage Room beside Room 532 is not rated.
On 12/1/11 at approximately 1:16 pm it was observed that there are unprotected penetrations to the wall of the back storage room located in the Soiled Utility Room on 5E.
On 12/1/11 at approximately 1:16 pm it was observed that there are unprotected penetrations to the wall (corridor side) in the Soiled Utility Room on 5E.
On 12/1/11 at approximately 1:26 pm it was observed that Room 500 has been converted to a combustible storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 1:40 pm it was observed that the Respiratory Therapy Locker Room on 5E has been converted to a combustible storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 1:45 pm it was observed that the Respiratory Therapy Break Room has been converted to a storage room and the door is not listed for this use.
On 12/1/11 at approximately 1:45 pm it was observed that Room 534 has been converted to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 2:30 pm it was observed that the Storage Room across from Stair 1 on 5W is not separated in accordance with the construction requirements for hazardous areas.
On 12/1/11 at approximately 2:48 pm it was observed that Patient Room 446 has been converted to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 2:55 pm it was observed that Room 434 has been changed to a storage roomand is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 3:09 pm it was observed that there are unprotected penetrations by conduit to the wall in the Soiled Utility Room on 4E.
On 12/5/11 at approximately 11:07 am it was observed that there are unprotected penetrations by conduit and IT wiring to the rated wall in CCU Medical Equipment Room on 3E.
On 12/5/11 at approximately 1:57 pm it was observed that the door for the Pixis Room in SICU (storage room) has been removed. There are unsealed penetrations to the walls by conduit and part of the wall is not complete.
On 12/5/11 at approximately 2:00 pm it was observed that the storage room in SICU on 2E is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/5/11 at approximately 2:12 pm it was observed that there are unprotected penetrations to the wall of the Soiled Utility Room in the Cath Lab on the 2nd floor by conduit and piping.
On 12/5/11 at approximately 2:12 pm it was observed that the wall in the Soiled Utility Room in the Cath Lab on the 2nd floor is not properly sealed to the deck.
On 12/5/11 at approximately 2:18 pm it was observed that the Storage Room in Cath Lab A on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas.
On 12/5/11 at approximately 2:29 pm it was observed that the Supply Room in the EP Lab on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas.
On 12/5/11 at approximately 2:35 pm it was observed that the Soiled Utility Room in Cardiac Holding on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas.
On 12/5/11 at approximately 2:50 pm it was observed that the Storage Room between OR 21 and OR 22 on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas
On 12/5/11 at approximately 3:08 pm it was observed that the old OR ' s 1, 2, and 3 on the 2nd floor have been converted to storage rooms and are not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/5/11 at approximately 3:17 pm it was observed that the room across from OR 32 in PACU 2 has been converted to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/5/11 at approximately 3:20 pm it was observed that Central Sterile on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas. In addition, there are unprotected penetrations to the wall by conduit and piping. Part of the wall is completely missing and the existing wall is not sealed to the deck. Some of the doors are not rated, are not self-closing, and will not latch automatically.
On 12/7/11 at approximately 9:45 am it was observed that there are unprotected penetrations in the Clean Utility Room on 2W. The tube system is sealed with fire caulk applied to newspaper.
On 12/7/11 at approximately 9:45 am it was observed that the door to the Clean Utility Room on 2W is not rated to properly separate this room with approved construction.
On 12/7/11 at approximately 9:45 am it was observed that the dumb waiter in the Clean Utility Room on 2W is no longer being used and is not sealed with approved construction.
On 12/7/11 at approximately 9:55 am it was observed that there are unprotected penetrations to the Storage Room on 2W at the Nurses' Station by conduit and piping.
On 12/7/11 at approximately 10:00 am it was observed that there are unprotected penetrations to Storage Room 24 beside Room 260 by conduit.
On 12/7/11 at approximately 10:27 am it was observed that there are unprotected penetrations to the wall of the Storage Room in the Medical Intensive Care Department by conduit.
On 12/7/11 at approximately 10:40 am it was observed that one leaf of the rated doors leading into the Lab is not self-latching.
On 12/7/11 at approximately 10:50 am it was observed that there are unprotected penetrations to the 1 hour rated wall leading into the Lab.
On 12/7/11 at approximately 10:55 am it was observed that there are unprotected penetrations to the 1 hour rated wall inside the Blood Bank Supervisor's Office in the Lab.
On 12/7/11 at approximately 10:59 am it was observed that the 1 hour rated wall in the Lab, Blood Bank Supervisor's Office, does not appear to be sealed to the deck.
On 12/7/11 at approximately 11:03 am it was observed that there are unprotected penetrations to the 1 hour rated wall by conduit/wires in the Blood Bank in the Lab.
On 12/7/11 at approximately 11:04 am it was observed that there are unprotected penetrations by conduit/piping in the 1 hour wall at the rear of the Lab Library.
On 12/7/11 at approximately 11:07 am it was observed that flex duct penetrates the 1 hour rated wall between the Break Room and the Pharmacy and is not equipped with a duct.
On 12/7/11 at approximately 11:13 am it was observed that there are unprotected penetrations to the 1 hour rated wall in the corridor at the Lab Break Room.
On 12/7/11 at approximately 11:16 am it was observed that there are unprotected penetrations by conduit/wires in the 1 hour rated wall in back of the Lab Supervisor's Office.
On 12/7/11 at approximately 11:39 am it was observed that there are unprotected penetrations at the double doors for the Lab, where the 1 hour rated wall turns.
On 12/7/11 at approximately 11:44 am it was observed that there are 7 unprotected penetrations by conduit/pipes at the entrance to the wall of the Lab across from the water fountain.
On 12/7/11 at approximately 11:44 am it was observed that the door to the Lab across from the water fountain is not properly rated in accordance with the construction requirements for hazardous areas.
On 12/7/11 at approximately 1:14 pm it was observed that the door closer was removed from the office/storage room in the Pharmacy.
On 12/7/11 at approximately 1:21 pm it was observed that there are unprotected penetrations to the rated wall of the Pharmacy Sterile Compounding Ante Room.
On 12/7/11 at approximately 1:38 pm it was observed that the rated wall is not complete at the rear of the Pharmacy in accordance with the construction requirements for hazardous areas. There are also unprotected penetrations in the existing wall.
On 12/7/11 at approximately 2:00 pm it was observed that there are unprotected penetrations in the rated wall of the Pharmacy (in corridor leading to the Morgue). Also, the wall is not complete in accordance with the construction requirements for hazardous areas.
On 12/7/11 at approximately 2:50 it was observed that Endoscopy Room 8 has been changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/7/11 at approximately 3:05 pm it was observed that there are unprotected penetrations to the Blueprint Storage Room on the 1st floor.
On 12/12/11 at approximately 1:00 pm it was observed that there are unprotected penetrations to the rated wall in the Cart room in the EVS hallway. Also, the wall is not sealed to the deck.
On 12/12/11 at approximately 1:00 pm it was observed that there are unprotected penetrations to the rated wall in the Clean Linen Room, 1st floor in the EVS hallway.
On 12/7/11 at approximately 10:50 am it was observed that there are unprotected penetrations to the 1 hour rated wall leading into the Lab on the 1st floor.
On 12/7/11 at approximately 10:55 am it was observed that flexible duct penetrates the 1 hour wall in the Lab, Blood Bank Supervisor's Office, and is not equipped with a damper.
On 12/12/11 at approximately 9:41 am it was observed that the door to the storage room in the Private Office across from Pharmacy Storage on the 1st floor has a 20 minute rating.
On 12/12/11 at approximately 10:01 am it was observed that the storage room in the "Private Office" office across from Endoscopy on the 1st floor is not being maintained in accordance with the construction requirements for hazardous areas.
On 12/12/11 at approximately 10:20 am it was observed that there are unsealed penetrations to the rated wall in Engineering on the 1st floor.
On 12/12/11 at approximately 10:20 am it was observed that the double doors leading into Engineering on the 1st floor are rated for 20 minutes.
On 12/12/11 at approximately 10:37 am it was observed that there are penetrations to the rated wall in the Engineering Restroom on the 1st floor.
On 12/12/11 at approximately 10:38 am it was observed that there is a penetration by a pipe sleeve to the rated wall above the sink in the Engineering Department on the 1st floor.
On 12/12/11 at approximately 10:46 am it was observed that there is an unprotected penetration to the rated wall over the exit door from the Engineering Department on the 1st floor.
On 12/12/11 at approximately 10:46 am it was observed that the rated wall is not sealed to the deck above the exit door from the Engineering Department on the 1st floor.
On 12/12/11 at approximately 10:57 am it was observed that the Spill Response Room on the 1st floor is not being maintained in accordance with the construction requirements for hazardous areas. Also, the door is not self-closing.
On 12/12/11 at approximately 1:12 pm it was observed that the EDS Supply Room on 1W is not sealed to the deck. There are also unprotected penetrations to the rated wall.
On 12/12/11 at approximately 1:34 pm it was observed that the Supply Room door is not latching in the Advanced Wound Center on the 1st floor.
On 12/12/11 at approximately 2:05 pm it was observed that the Supply Room near the entrance to the Cafeteria is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/12/11 at approximately 2:14 pm it was observed that the large storage room for Dietary is not separated inaccordance with the construction requirements for hazardous areas.
On 12/12/11 at approximately 2:15 pm it was observed that there are unprotected penetrations to the 1 hour rated wall of the Dry Storage Room in Dietary.
On 12/13/11 at approximately 9:15 am it was observed that the Mechanical Room 4B is not properly protected (door not rated) in Radiology.
On 12/13/11 at approximately 9:45 am it was observed that there is no closer on the Storage Room door in the CT Scan area of Radiology.
On 12/13/11 at approximately 9:55 am it was observed that the Soiled Utility Room outside of the CT Scan area in Radiology is not separated in accordance with the construction requirements for hazardous areas.
On 12/13/11 at approximately 9:55 am it was observed that flex duct penetrates the wall of the Soiled Utility Room outside of the CT Scan area in Radiology and is not equipped with a damper.
On 12/13/11 at approximately 10:00 am it was observed that there are unprotected penetrations by conduit to the Storage Room behind the elevator room on the ground floor. Also, one penetration has been improperly sealed with cardboard and mineral wool.
On 12/13/11 at approximately 10:42 am it was observed that the Soiled Utility Room in the small corridor at the rear of Interventional Holding on the ground floor is not separated in accordance with the construction requirements for hazardous areas.
On 12/13/11 at approximately 11:10 am it was observed that the top leaf of the dutch doors for the X-Ray File Storage Room was not latching.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0033
Based on observation and interview it was determined that the facility failed to maintain stairways with a fire resistance rating.
Findings include:
On 12/13/11 at approximately 10:47 am it was observed that the door to Stair 5, Floor G is not latching.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0033
Based on observation and interview it was determined that the facility failed to maintain stairways with at least a 1 hour fire resistance rating.
Findings include:
On 11/15/11 at approximately 10:58 am it was observed that there is a penetration to stairwell 2, 1st floor, by conduit and wiring running through the same unprotected opening.
On 11/15/11 at approximately 11:15 am it was observed that there are unprotected penetrations to Stairwell 1, 1st floor, by sprinkler piping.
On 11/15/11 at approximately 11:20 am it was observed that there are unprotected penetrations to Stairwell 1, 2nd floor, by fire alarm wire and conduit.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0038
Based on observation and interview it was determined that the facility failed to maintain exits readily accessible.
Findings include:
On 12/1/11 at approximately 2:50 pm it was observed that egress from Room 438 was partially obstructed by furniture.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0038
Based on observation and interview it was determined that the facility failed to provide approved locking arrangements.
Findings include:
On 11/30/11 at approximately 10:42 am it was observed that the ER Ambulatory Lobby doors were locked in an unapproved manner.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0039
Based on observation and interview it was determined that the facility failed to maintain corridors free and clear of obstructions.
On 12/12/11 at approximately 1:10 pm it was observed that there was combustible storage in the EVS hallway outside of the Clean Linen and Cart Room.
On 12/7/11 at approximately 2:47 pm it was observed that there is a significant amount of housekeeping storage in the EVS corridor outside of the rear of Endoscopy.
The above was observed and confirmed by the Director of Engineering and the Safety Director.
No Description Available
Tag No.: K0039
Based on observation and interview it was determined that the facility failed to maintain exit corridors clear and unobstructed.
Findings include:
On 11/30/11 at approximately 3:22 pm it was observed that the exit corridor leading to the rear exit of Blue Ridge Oncology was obstructed by storage.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0044
Based on observation and interview it was determined that the facility failed to maintain horizontal exits.
Findings include:
On 12/5/11 at approximately 10:53 am it was observed that the closer for the rated door at the CCU Waiting Room on 3E was removed. This corridor is part of a horizontal exit.
On 12/13/11 at approximately 10:15 am it was observed that the door in the horizontal exit from Radiology to OR (2 hour barrier) was "dogged down" and not self-latching on the ground floor.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0052
Based on observation and interview the facility failed to install the fire alarm system in accordance with NFPA 72.
On 12/13/11 at approximately 10:15 am it was observed that there are no fire alarm pull stations on either side of the 2 hour barrier (Horizontal Exit from Radiology to OR) on the ground floor.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0054
Based on observation and interview the facility failed to maintain smoke detectors as required.
On 12/12/11 at approximately 1:30 pm it was observed that a smoke detector in an ante-room off the office in the Business office on 1W appears to be too close to the air diffuser. (NFPA 72, 2-3.5.1)
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0056
Based on observation and interview it was determined that the facility failed to install a complete automatic sprinkler system in accordance with NFPA 13.
Findings include:
On 11/15/11 at approximately 11:48 am it was observed that sprinklers appear to be installed improperly (too close together). (NFPA 13, Section 5-6.3.4)
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0056
Based on observation and interview it was determined that the facility failed to install the sprinkler system in accordance with NFPA 13.
Findings include:
On 12/5/11 at approximately 9:33 am it was observed that there is no sprinkler protection for the Waiting Area on the 3rd floor where the new partition was added.
On 12/5/11 at approximately 2:44 pm it was observed that the pendant sprinklers do not appear to be installed in accordance with the manufacturer's installation instructions in OR 21 and OR 22.
On 12/5/11 at approximately 3:22 pm it was observed that there is no sprinkler coverage in the Sub-Sterilizer Room in Central Sterile on the 2nd floor.
On 12/7/11 at approximately 10:28 am it was observed that recessed sprinklers do not appear to be installed in accordance with the manufacturer's installation instructions in the MICD Storage Room.
On 12/7/11 at approximately 2:46 pm it was observed that sprinkler piping was being supported by a steam line at the Medical Director Outpatient Oncology Office. (NFPA 13, Section 6-1.1.5)
On 12/12/11 at approximately 11:39 am it was observed that a sprinkler valve at the exit door located across from the ATM on 1W does not appear to be supervised.
(NFPA 13, Section 5-14.1.1.3)
On 12/12/11 at approximately 1:54 pm it was observed that a sprinkler appears to be located too close to the restroom wall in the Surgical Services Suite on the 1st floor.
On 12/12/11 at approximately 1:54 pm it was observed that there is no sprinkler protection in a second restroom of the Surgical Services Suite on the 1st floor.
On 12/12/11 at approximately 2:00 pm it was observed that there is no sprinkler protection in the restroom of Pre-Admission Testing on the 1st floor.
On 12/12/11 at approximately 2:05 pm it was observed that the sprinklers in the Supply Room near the entrance to the Cafeteria are located too close to each other. (NFPA 13, Section 5-6.3.4)
On 12/12/11 at approximately 2:14 pm it was observed that the sprinklers for the Dietary loading dock do not appear to be tied into the sprinkler system.
On 12/12/11 at approximately 2:30 pm it was observed that two different (standard & quick response) types of sprinklers are installed in the large Storage Room of Dietary. (NFPA 13, Section 5-3.1.5.2)
On 12/12/11 at approximately 3:30 pm it was observed that the front canopy at the main entrance to the hospital is not sprinklered and cars stop and park under the canopy. (NFPA 13, Sections 5-13.8.1 & 5-13.8.2; see explanation in Appendix)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0056
Based on observation and interview it was determined that the facility failed to provide a complete sprinkler system.
Findings include:
On 11/30/11 at approximately 10:45 am it was observed that the EMS canopy is not sprinklered and ambulances park under this canopy. (NFPA 13, Sections 5-13.8.1 & 5-13.8.2; see explanation in Appendix)
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0062
Based on observation and interview it was determined that the facility failed to continuously maintain the sprinkler system in a reliable operating condition..
Findings include:
On 11/30/11 at approximately 10:40 am it was observed that sprinkler covers are painted(recessed sprinklers) in ER Fast Track. (NFPA 13, Section 3-2.6.3)
On 11/30/11 at approximately 1:37 pm it was observed that there is an escutcheon missing from a sprinkler in the Janitor's Closet on the OR floor. (NFPA 13, Section 3-2.7.2)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0062
Based on observation and interview it was determined that the facility failed to maintain the required automatic sprinkler systems in a reliable operating condition.
Findings include:
On 12/1/11 at approximately 10:32 am it was observed that an escutcheon is missing from the sprinkler in Room 645. (NFPA 13, Section 3-2.7.2)
On 12/1/11 at approximately 1:17 pm it was observed that there is an escutcheon missing from the sprinkler in the Pixis Room on 5E. (NFPA 13, Section 3-2.7.2)
On 12/1/11 at approximately 1:18 pm it was observed that there is an escutcheon missing from the sprinkler in the Dictation Room on 5E. (NFPA 13, Section 3-2.7.2)
On 12/1/11 at approximately 2:20 pm it was observed that an escutcheon is missing from a sprinkler in Room 566. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 12:42 am it was observed that there is an escutcheon missing from a sprinkler in the Med Room on 3E at the Nurses' Station. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 10:12 am it was observed that a sprinkler is obstructed by a sign on 3 Center. (NFPA 25, Section 2-2.1.2)
On 12/5/11 at approximately 10:45 am it was observed that the ceiling grid is supported by sprinkler piping in the corridor on 3E leading to the CCU area. (NFPA 13, Section 6-1.1.5)
On 12/5/11 at approximately 10:45 am it was observed that wiring is attached to sprinkler piping in the corridor on 3E leading to the CCU area. (NFPA 13, Section 6-1.1.5)
On 12/5/11 at approximately 11:07 am it was observed that wire is attached to sprinkler piping in CCU Medical Equipment Room on 3E. (NFPA 13, Section 6-1.1.5)
On 12/5/11 at approximately 1:50 pm it was observed that an escutcheon is missing from a sprinkler in restroom E5 in SICU. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 2:12 pm it was observed that an escutcheon is missing from a sprinkler in the Soiled Utility Room in the Cath Lab on the 2nd floor. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 10:12 am it was observed that data wiring is being supported by sprinkler piping at Room 301. (NFPA 13, Section 6-1.1.5)
On 12/5/11 at approximately 3:15 pm it was observed that an escutcheon was missing from the sprinkler in the restroom in PACU 2. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 3:17 pm it was observed that an escutcheon is missing from a sprinkler in OR-32, C-Section Room on the 2nd floor. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 3:40 pm it was observed that an escutcheon is missing from a sprinkler in the Soiled Utility Room in ASU on the 2nd floor. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 10:16 am it was observed that a wall has been removed creating sprinklers that are not properly spaced at the Vending Area and corridor at Maternity Family Waiting. (NFPA 13, Section 5.6.3.4)
On 12/7/11 at approximately 10:18 am it was observed that there are wires being supported by sprinkler piping at the separation of the hospital to MOB East, Building A. (NFPA 13, Section 6-1.1.5)
On 12/7/11 at approximately 11:39 am it was observed that wires are wrapped around sprinkler hangers are used where the 1 hour rated wall turns in the Lab. (NFPA 13, Section 6-1.1.5)
On 12/7/11 at approximately 11:51 am it was observed that there are 2 escutcheons missing from sprinklers in the Waiting Room (Wireless Access) on the 1st floor. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 1:25 pm it was observed that an escutcheon is missing from a sprinkler in the rear of the small hallway leading out of the Pharmacy. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 1:37 pm it was observed that an escutcheon is missing from a sprinkler in the closet of the Pharmacy Quality Coordinator. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 2:00 pm it was observed that an escutcheon is missing from a sprinkler in the Morgue Shower Room. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 2:25 pm it was observed that a sprinkler valve is not labeled in Stair 5, Floor 1. (NFPA 13, Section 3-8.3)
On 12/7/11 at approximately 2:27 pm it was observed that a sprinkler has "mud" on the deflector outside of Bio-Medical Engineering on the 1st floor. (NFPA 25, Section 2-2.1.1)
On 12/7/11 at approximately 2:40 pm it was observed that an escutcheon is missing from a sprinkler in the Endoscopy Dressing Room. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 2:40 pm it was observed that an escutcheon is missing from a sprinkler in Endoscopy Recovery Room 3. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 3:08 pm it was observed that an escutcheon is missing from a sprinkler in the EVS corridor Housekeeping Closet #2 on the 1st floor. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 3:09 pm it was observed that an escutcheon is missing from a sprinkler in the EVS corridor Housekeeping Closet #3 on the 1st floor. (NFPA 13, Section 3-2.7.2)
On 12/12/11 at approximately 9:35 am it was observed that a sprinkler is damaged in the Linen Chute Room on 1E. (NFPA 25, Section 2-2.1.1)
On 12/12/11 at approximately 10:20 am it was observed that the sprinkler piping is supporting wires in Engineering on the 1st floor. (NFPA 13, Section 6-1.1.5)
On 12/12/11 at approximately 10:41 am it was observed that storage is not being maintained at least 18 " below sprinkler deflectors in the Engineering Department on the 1st floor. (NFPA 25, Section 2-2.1.1)
On 12/12/11 at approximately 2:07 pm it was observed that an escutcheon is missing from a sprinkler in the dining area of the Cafeteria. (NFPA 13, Section 3-2.7.2)
On 12/12/11 at approximately 2:13 pm it was observed that an escutcheon is missing from the sprinkler over the refrigerator in the kitchen of Dietary. (NFPA 13, Section 3-2.7.2)
On 12/12/11 at approximately 2:15 pm it was observed that a sprinkler deflector is damaged in the Dry Storage Room of Dietary. (NFPA 25, Section 2-2.1.1)
On 12/12/11 at approximately 2:36 pm it was observed that ceiling tiles are missing above the Pastry Freezer in Dietary on the 1st floor.
On 12/12/11 at approximately 2:37 pm it was observed that the sprinkler in the Pastry Freezer in Dietary appears to be leaking. (NFPA 25, Section 2-2.1.1)
On 12/12/11 at approximately 2:38 pm it was observed that an escutcheon is missing from a sprinkler close to the Janitor ' s Closet in Dietary. (NFPA 13, Section 3-2.7.2)
On 12/12/11 at approximately 2:44 pm it was observed that a sprinkler deflector is damaged in the sink wash area of the kitchen work area on the 1st floor. (NFPA 25, Section 2-2.1.1)
On 12/13/11 at approximately 11:00 am it was observed that there are wires attached to sprinkler piping in the corridor at the Interventional Holding area. (NFPA 13, Section 6-1.1.5)
On 12/13/11 at approximately 11:18 am it was observed that a bundle of white wires are attached to sprinkler piping in the corridor at the 2 hour fire barrier between the Hospital and "A Building". (NFPA 13, Section 6-1.1.5)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0062
Based on observation and interview it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.
Findings include:
On 11/15/11 at approximately 10:47 am it was observed that there was ceiling tile lying on sprinkler piping at the women's restroom. (NFPA 13, Section 6-1.1.5)
On 11/15/11 at approximately 11:15 am it was observed that sprinkler piping does not appear to be secured properly in Stairwell 1, 1st floor.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0062
Based on observation and interview it was determined that the facility failed to properly maintain the sprinkler system.
Findings include:
On 11/30/11 at approximately 3:10 pm it was observed that an escutcheon is missing from a sprinkler in the Oncology Mold Room. (NFPA 13, Section 3-2.7.2)
On 12/01/11 at approximately 9:05 am it was observed that there are wires attached to and being supported by sprinkler piping and hangers in the corridor of Oncology at the nurses' station. (NFPA 13, Section 6-1.1.5)
On 12/01/11 at approximately 9:58 am it was observed that sprinkler valves are not permanently identified in the stairwell on the 2nd floor. (NFPA 13, Section 3-8.3)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0067
Based on observation and interview it was determined that the facility failed to maintain the HVAC system.
Findings include:
On 12/5/11 at approximately 3:45 pm it was observed that no damper was provided for the flex duct that runs into the lounge in Central Sterile on the 2nd floor. (two hour barrier)
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0067
Based on observation and interview it was determined that the facility failed to maintain the HVAC system.
On 11/15/11 at approximately 9:30 am it was observed that the corridor is being used as a return air plenum.
On 11/15/11 at approximately 9:45 am it was observed that the corridor is being used as a plenum and corridors do not extend to the deck above as a smoke partition.
On 11/15/11 at approximately 10:09 am it was observed that there is wood in the plenum ceiling near the elevator equipment room.
On 11/15/11 at approximately 10:11am it was observed that documentation could not be provided to show that wiring in the plenum is rated for plenum use.
On 11/15/11 at approximately 10:20 am it was observed that there is a plastic drip pan in the plenum at the coffee station.
On 11/15/11 at approximately 10:30 am it was observed that the facing for insulation in "Private Office" is flammable and is exposed to the plenum area.
On 11/15/11 at approximately 11:46 am it was observed that there is a combustible drip pan in the plenum in corridor area #76.
On 11/15/11 at approximately 2:58 pm it was observed that there are wood furring strips above the smoke barrier doors, in the plenum, leading to the Children's Unit.
On 11/16/11 at approximately 1:32 pm it was observed that there is wiring in the plenum for the locking system that does not appear to be plenum rated.
On 11/16/11 at approximately 1:50 pm it was observed that documentation was not available to show that the wireless router is rated for plenum use at the Emergency Equipment Room.
On 11/16/11 at approximately 2:00 pm it was observed that a fan coil unit is tented above the office next to the old pharmacy in the plenum.
On 11/16/11 at approximately 2:11 pm it was observed that there is a duct penetration to the 2 hour fire barrier at the Nursing Supervisor's office that does not appear to be equipped with a damper. (NFPA 90A - Section 3-3.1.1)
On 11/16/11 at approximately 3:50 pm it was observed that dampers are not marked at the Health Information Management Office. (NFPA 90A, Section 2-3.4.2)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0067
Based on observation and interview it was determined that the facility failed to properly mark the location of fire/smoke dampers.
Findings include:
On 11/30/11 at approximately 2:14 pm it was observed that the location of dampers is not marked in the equipment room on the OR floor. [NFPA 90A, Section 2-3.4.2)
On 11/30/11 at approximately 2:15 pm it was observed that the location of dampers is not marked in the Core Storage Room of the OR. [NFPA 90A, Section 2-3.4.2)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0069
Based on observation and interview it was determined that the facility failed to maintain kitchen hoods systems.
Findings include:
On 12/12/11 at approximately 2:12 pm it was observed that the kitchen range hood system in Dietary is not provided with a grease drip pan.
On 12/12/11 at approximately 2:12 pm it was observed that the filters for the kitchen range hood system in Dietary are not properly installed.
On 12/12/11 at approximately 2:41 pm it was observed that the kitchen range hood system in the kitchen work area has a damaged filter. There are also gaps between the filters.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0071
Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating for the walls of the linen and trash chutes.
Findings include:
On 12/12/11 at approximately 9:30 am it was observed that there are unprotected penetrations to the rated walls of the Trash Chute Room on 1E.
On 12/12/11 at approximately 9:35 am it was observed that there are unprotected penetrations of the front and rear wall of the Linen Chute Room on 1E.
On 12/12/11 at approximately 11:28 am it was observed that there is an unprotected penetration at the corner of Trash Chute Room on 1W.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0072
Based on observation and interview it was determined that the facility failed to maintain exits free of all obstructions.
Findings include:
On 12/5/11 at approximately 10:20 am it was observed that beds were being stored in the elevator lobby for elevators 6 and 7 on 3E.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0073
Based on observation and interview it was determined that the facility failed to ensure that all decorative material is flame retardant.
Findings include:
On 12/1/11 at approximately 1:50 pm it was observed that in the area of Room 539 and continuing down the corridor, a significant amount of flammable material is affixed to the walls.
On 12/1/11 at approximately 1:59 pm it was observed that documentation was not available to show that the large poster affixed to the wall is flame retardant at Room 543.
On 12/5/11 at approximately 10:05 am it was observed that documentation was not available to show that the plastic shoe holders are flame retardant (on 3 middle) in the area open to the corridor.
On 12/5/11 at approximately 3:41 pm it was observed that black plastic was hung over the windows to the PAT call nurse office.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0073
Based on observation and interview it was determined that the facility failed to ensure that no decorations are highly flammable.
Findings include:
On 11/30/11 at approximately 2:45 pm it was observed that there was no documentation available to show that the material over the window for the Oncology Staff Lounge is flame retardant.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0073
Based on observation and interview it was determined that the facility failed to maintain the building so that no highly flammable decorations or furnishings are used.
Findings include:
On 11/15/11 at approximately 2:25 pm it was observed that there was no documentation available to show that the paper window blinds covering the patient room windows are flame retardant.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0074
Based on observation and interview it was determined that the facility failed to maintain flame retardant drapes and curtains.
Findings include:
On 12/1/11 at approximately 3:02 pm it was observed that documentation was not available to verify that the drapes in the Conference Room on 4E are flame retardant.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0075
Based on observation and interview it was determined that the facility failed to properly store trash and soiled linen containers that exceed 32 gallons.
Findings include:
On 12/7/11 at approximately 2:03 pm it was observed that four 44 gallon containers are being stored in the corridor at the Morgue.
On 12/12/11 at approximately 9:39 am it was observed that a trash container over 32 gallons capacity was being used in the Private Office across from Pharmacy Storage.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0075
Based on observation and interview it was determined that the facility failed to properly store trash collection receptacles exceeding 32 gallons.
Findings include:
On 11/30/11 at approximately 10:37 it was observed that trash cans greater than 32 gallons are improperly stored in ER Triage.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0078
Based on observation and interview it was determined that the facility failed to label oxygen shut-off valves.
Findings include:
On 11/30/11 at approximately 11:43 am it was observed that there is no labeled oxygen shut-off for Suites A & B in ER. [NFPA 99, Section 4.3.1.2.3(n)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0130
Based on observation and interview it was determined that the facility failed to maintain horizontal sliding doors.
Findings include:
On 12/5/11 at approximately 2:37 pm it was observed that the horizontal sliding doors leading into Cardiac Holding on the 2nd floor are not functioning properly with respect to the breakaway function. (Section 7-2.1.4)
Based on observation and interview it was determined that the facility failed to construct ramps in accordance with the regulations.
Findings include:
On 12/7/11 at approximately 2:20 pm it was observed that the ramp leading from the exit near the Morgue does not appear to meet the requirements of the code.
(Sections 19.2.2.6, 7.2.5, and Table 7.2.5.2(b) for Existing Ramps)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0130
Based on observation and interview it was determined that the facility failed to maintain the elevator machine room with the required fire resistance rating and without storage.
Findings include:
On 11/15/11 at approximately 9:52 am it was observed that the elevator equipment room near the main lobby is not equipped with a closer. (ASME A17.1, Section 101.1a)
On 11/15/11 at approximately 9:52 am it was observed that the elevator equipment room near the main lobby is being used for combustible storage. (ASME A17.1, Section 101.2)
On 11/15/11 at approximately 9:55 am it was observed that the elevator equipment room near the main lobby is not completely separated by construction to provide a 1 hour rating. (ASME A17.1, Section 101.1a)
On 11/15/11 at approximately 11:25 am it was observed that there are unprotected penetrations to the elevator room across from the Business Office. (ASME A17.1, Section 101.1a)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0147
Based on observation and interview it was determined that the facility failed to comply with the electrical requirements of NFPA 70.
Findings include:
On 11/30/11 at approximately 11:45 am it was observed that an approved cover is not provided for an electrical junction box in the Electrical Room of ER. [NFPA 70, Section 370-28(b)]
On 11/30/11 at approximately 1:35 pm it was observed that an approved cover is not provided for a junction box above the ceiling at the fire barrier on the OR floor. [NFPA 70, Section 370-28(b)]
On 11/30/11 at approximately 2:09 pm it was observed that an approved cover is not provided for an electrical junction box at OR 2. [NFPA 70, Section 370-28(b)]
On 11/30/11 at approximately 2:35 pm it was observed that an approved cover is not provided for an electrical junction box above the ceiling in the storage room beside OR 11.
[NFPA 70, Section 370-28(b)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0147
Based on observation and interview it was determined that the facility failed to ensure that the requirements of NFPA 70 were met.
Findings include:
On 12/1/11 at approximately 10:22 am it was observed that a power strip is plugged to an extension cord for permanent wiring in the Clinical Oncology Educator's Office on the 6th floor. [NFPA 70, Section 400-7(b)]
On 12/1/11 at approximately 10:50 am it was observed that there are 3 power strips used in a series in the Chaplain's Office on the 6th floor. [NFPA 70, Section 400-7(b)]
On 12/1/11 at approximately 11:26 am it was observed that 2 power strips are being used in a series in the Case Manager's Office on the 6th floor. [NFPA 70, Section 400-7(b)]
On 12/1/11 at approximately 11:32 am it was observed that an approved cover plate is missing from an electrical outlet in the Director's Office on 6E. [NFPA 70, Section 370-28(c)]
On 12/1/11 at approximately 11:45 am it was observed that an approved cover is not provided for an electrical junction box above the ceiling across from Stair #5 on 6E. [NFPA 70, Section 370-28(b)]
On 12/1/11 at approximately 1:19 pm it was observed that an approved cover is not provided for the electrical junction box above the ceiling at Stair 4 on 5E. [NFPA 70, Section 370-28(b)]
On 12/1/11 at approximately 2:52 pm it was observed that 2 power strips are being used in a series in Room 435. [NFPA 70, Section 400-7(b)]
On 12/1/11 at approximately 2:54 pm it was observed that an unapproved multi-plug device was being used for permanent wiring in Room 433. [NFPA 70, Section 305-6(a)]
On 12/5/11 at approximately 10:00 am it was observed that an approved cover is not provided for an electrical junction box above the ceiling outside of Cardiac Rehab on the 3rd floor. [NFPA 70, Section 370-28(b)]
On 12/5/11 at approximately 10:14 am it was observed that approved covers are not provided for 2 electrical junction boxes on 3E in the front and rear corridors. [NFPA 70, Section 370-28(b)]
On 12/5/11 at approximately 10:47 am it was observed that temporary wiring was left above the ceiling in the Soiled Utility Room on 3E. [NFPA 70, Section 305-2(d)]
On 12/5/11 at approximately 2:42 pm it was observed that an approved cover is not provided for the electrical junction box above the ceiling in the corridor at Stair 5, 2nd floor. [NFPA 70, Section 370-28(b)]
On 12/5/11 at approximately 2:44 pm it was observed that there appears to be "home made" extension cords being used in OR 21 on the 2nd floor. [NFPA 70, Section 400-7(b)]
On 12/5/11 at approximately 3:00 pm it was observed that unapproved multi-plug devices are being used for permanent wiring in OR 22 on the 2nd floor. [NFPA 70, Section 400-8]
On 12/7/11 at approximately 9:40 am it was observed that an approved cover is not provided for an electrical junction box above the ceiling in Room 234. [NFPA 70, Section 370-28(b)]
On 12/7/11 at approximately 9:48 am it was observed that there is a damaged electrical cord to the ice machine. [NFPA 70, Section 110.12(c)]
On 12/7/11 at approximately 10:21 am it was observed that there are 2 power strips used in a series in the Volunteer Office area. [NFPA 70, Section 400-7(b)]
On 12/7/11 at approximately 11:13 am it was observed that an approved cover is not provided for an electrical junction box located above the ceiling in the corridor at the Lab Break Room. [NFPA 70, Section 370-28(b)]
On 12/7/11 at approximately 11:16 am it was observed that there is exposed wiring above the ceiling in the Lab Supervisor ' s Office at the back wall. [NFPA 70, Section 305-2(d)]
On 12/7/11 at approximately 11:20 am it was observed that there are 3 power strips used in series in the Lab, Pathology Processing area. [NFPA70, Section 400-7(b)]
On 12/7/11 at approximately 3:11 pm it was observed that an approved cover plate is not provided for an electrical junction box above the ceiling in the EVS corridor on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/12/11 at approximately 9:30 am it was observed that temporary wiring has been left above the ceiling in the Trash Chute Room on 1E. [NFPA 70, Section 305-2(d)]
On 12/12/11 at approximately 9:37 am it was observed that there was an unapproved multiplug device being used in the Anesthesiologist Offices, 1st floor, at the rear desk on the right. [NFPA 70, Section 305-6(a)]
On 12/12/11 at approximately 9:45 am it was observed that an approved cover plate is not provided for an electrical junction box in the IS Room off of the "cold room" on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/12/11 at approximately 9:50 am it was observed that approved covers are not provided for 3 electrical junction boxes in the Private Break Room across from Endoscopy on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/12/11 at approximately 10:20 am it was observed that temporary wiring was left above the ceiling in Engineering on the 1st floor. [NFPA 70, Section 305-2(d)]
On 12/12/11 at approximately 10:37 am it was observed that an approved cover is not provided for an electrical junction box in the Engineering Restroom on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/12/11 at approximately 11:35 am it was observed that power strips are being used in series in the Credit Union on 1W. [NFPA 70, Section 400-7(b)]
On 12/12/11 at approximately 2:05 pm it was observed that an electrical receptacle is not provided with an approved cover in the Supply Room near the entrance to the Cafeteria. [NFPA 70, 370-28.3(c)]
On 12/12/11 at approximately 2:44 pm it was observed that an approved cover plate is not provided for an electrical junction box above the ceiling in the kitchen work area on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/13/11 at approximately 9:15 am it was observed that there is unprotected exposed wiring in Mechanical Room 4B. [NFPA 70, Section 305-2(d)]
On 12/13/11 at approximately 9:30 am it was observed that there is unprotected exposed wiring above the ceiling at the 2 hour barrier separating the Hospital and "A Building" on the ground floor. [NFPA 70, Section 305-2(d)]
On 12/13/11 at approximately 9:55 am it was observed that an approved cover is not provided for an electrical junction box in the Soiled Utility Room outside of the CT Scan area in Radiology. [NFPA 70, Section 370-28(b)]
On 12/13/11 at approximately 10:20 am it was observed that an approved cover is not provided for an electrical junction box in the corridor at the Educator Office on the ground floor. [NFPA 70, Section 370-28(b)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0147
Based on observation and interview it was determined that the facility failed to install and maintain electrical equipment in accordance with NFPA 70.
Findings include:
On 11/15/11 at approximately 9:52 am it was observed that an unapproved multi-plug device is being used for permanent wiring in the elevator equipment room. [NFPA 70, Section 305-6(a)]
On 11/15/11 at approximately 10:09 am it was observed that temporary wiring was left above the ceiling near the elevator equipment room. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 10:11 pm it was observed that there is exposed wiring above the ceiling in the plenum. [NFPA 70, Section 305.2(d)]
On 11/15/11 at approximately 10:37 am it was observed that 2 electrical junction boxes above the ceiling of the Men's Restroom are not provided with approved covers. [NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 10:37 am it was observed that temporary wiring was left above the ceiling in the Men's Restroom. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 11:00 am it was observed that temporary wiring was left above the ceiling in Stairwell 2, 2nd floor. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 11:00 am it was observed that there are two electrical junction boxes in the elevator lobby on the 1st floor that are not provided with approved covers. [NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 11:15 am it was observed that temporary wiring was left above the ceiling in Stair 1, 1st floor. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 11:20 am it was observed that temporary wiring was left above the ceiling at Stair 1, 2nd floor. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 1:45 pm it was observed that temporary wiring was left above the ceiling on the 2nd floor, Space 10. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 1:57 pm it was observed that an approved cover is not provided for an electrical junction box above the doors leading to ITU (Adult Unit 3). [NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 2:08 pm it was observed that an electrical junction box above the ceiling in Area 7 ID staff room is not provided with an approved cover. [NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 2:58 pm it was observed that an electrical junction box above the smoke barrier doors leading to the Children ' s Unit is not equipped with an approved cover.
[NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 3:10 pm it was observed that temporary wiring was left above the ceiling at Room 220. [NFPA 70, Section 302-2(d)]
On 1/16/11 at approximately 2:07 pm it was observed that an electrical junction box above the ceiling is not equipped with an approved cover at the room by AAU. [NFPA 70, Section 370-28(b)]
On 11/16/11 at approximately 2:11 pm it was observed that an electrical junction box is not equipped with an approved cover above the ceiling at the Nursing Supervisor ' s office. [NFPA 70, Section 370-28(b)]
On 11/16/11 at approximately 2:29 pm it was observed that temporary wiring was left above the ceiling at Room 217. [NFPA 70, Section 302-2(d)]
On 11/16/11 at approximately 2:50 pm it was observed that temporary wiring was left above the ceiling at the 2 hour barrier at a Dr. L's office door. [NFPA 70, Section 302-2(d)]
On 11/16/11 at approximately 2:58 pm it was observed that temporary wiring was left above the ceiling in Room 218. [NFPA 70, Section 302-2(d)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
No Description Available
Tag No.: K0147
Based on observation and interview it was determined that the facility failed to maintain the electrical systems in accordance with the requirements of NFPA 70.
Findings include:
On 11/30/11 at approximately 2:53 pm it was observed that there is an unapproved multi-plug adapter being used in the Oncology Darkroom. [NFPA 70, Section 305-6(a)]
On 11/30/11 at approximately 4:00 pm it was observed that temporary wiring was left above the ceiling in the lobby between the two Oncology departments. [NFPA 70, Section 305-2(d)]
On 12/01/11 at approximately 9:30 am it was observed that temporary wiring was left above the ceiling at the Oncology clean utility room. [NFPA 70, Section 305-2(d)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
Means of Egress - General
Tag No.: K0211
Based on observation and interview it was determined that the facility failed to install ABHR's in accordance with all requirements.
Findings include:
On 12/1/11 at approximately 11:27 am it was observed that an alcohol based hand rub dispenser is positioned over a light switch in the Soiled Utility Room on 6E.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0011
Based on observation and interview it was determined that the facility failed to maintain the 2-hour fire barrier between this building and the Hospital building.
Findings include:
On 11/30/11 at approximately 2:42 pm it was observed that the door in the 2 hour separation (that crosses in front of the Anesthesia Work Room) does not appear to have the proper rating for this use.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0011
Based on observation and interview it was determined that the facility failed to maintain the separation between the Hospital and MOB-East.
Findings include:
On 12/5/11 at approximately 11:30 am it was observed that there are unsealed penetrations to the 2 hour fire barrier separating the hospital from MOB-East by conduit and piping on the 2nd floor.
On 12/13/11 at approximately 9:30 am it was observed that there are unprotected penetrations by wires/conduit/piping in the 2 hour barrier separating the Hospital and "A Building" on the ground floor.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0011
Based on observation and interview it was determined that the facility failed to maintain the fire barrier separating this building from the Hospital Building.
Findings include:
On 12/01/11 at approximately 10:00 am it was observed that the 2 hour fire barrier is not completely sealed to the deck at the rear exit.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0012
Based on observation and interview it was determined that the facility failed to maintain the construction type for this building.
Findings include:
On 11/30/11 at approximately 2:47 pm it was observed that required fireproofing material was missing from structural steel above the ceiling in the Oncology electrical/telephone room.
On 11/30/11 at approximately 2:50 pm it was observed that required fireproofing material was missing from structural steel in the Oncology mechanical room.
On 11/30/11 at approximately 3:09 pm it was observed that combustible firestopping is being used to seal penetrations of rated construction in the Oncology Communications Closet.
On 11/30/11 at approximately 3:55 pm it was observed that required fireproofing material is missing from structural steel in the lobby between the two Oncology departments.
On 12/01/11 at approximately 9:00 am it was observed that required fireproofing material is missing from structural steel in the corridor of Oncology near at the nurses' station.
On 12/01/11 at approximately 9:59 am it was observed that required fireproofing material is missing from structural beams above the ceiling in Elevator 8 Lobby.
On 12/01/11 at approximately 10:14 am it was observed that required fireproofing material is missing from structural beams above the ceiling at the rear exit.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0012
Based on observation and interview it was determined that the facility failed to maintain the construction type of the building.
Findings include:
On 11/15/11 and 11/16/11 between approximately 9:30 am and 4:30 pm it was observed that the 2 hour fire separation between floors was modified from its original approved construction. The Plans Review Engineer for the State Fire Marshal's Office, on January 24, 1975, agreed that in lieu of the 2-1/2 slab required by UL Design G202, the facility could use 2 inch concrete slabs provided that the remaining requirements of the Design were followed, to include, no insulation in the area, requirements for spacing and number of recessed lights, tenting of lights, and hold-down clips. Changes have been made to the lighting and ceiling so that the required separation between floors does not meet the approved design.
On 11/15/11 at approximately 11:31 am it was observed that there are unprotected penetrations by conduit to the floor/ceiling assembly by 2 pipes, in the corridor at "Break Room Staff".
On 11/15/11 at approximately 11:39 am it was observed that there are three unprotected penetrations to the floor/ceiling assembly above the ceiling at the entrance to the Cosmetology area by conduit..
On 11/15/11 at approximately 11:44 am it was observed that there is an unprotected penetration to the floor/ceiling assembly by piping above the ceiling in the lobby of the Neurology area.
On 11/15/11 at approximately 11:46 am it was observed that there are unprotected penetrations to the floor/ceiling assembly by piping in corridor area #76.
On 11/15/11 at approximately 1:45 pm it was observed that the ceiling at Space 10 on the 2nd floor, has been changed from the UL-G202 Design that was approved for this building.
On 11/15/11 at approximately 2:35 pm it was observed that an intake area was constructed of wood and is attached to the building.
On 11/16/11 at approximately 1:00 pm it was observed that plywood sheets were placed in the ceiling above the ITU Quiet Room.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0012
Based on observation and interview it was determined that the facility failed to maintain the construction type of the building.
Findings include:
On 11/30/11 at approximately 2:45 PM it was observed that supporting wire for the suspended ceiling had been cut at the separation between OR floor in MOB-West and the hospital.
On 12/1/11 at approximately 10:20 am it was observed that required fireproofing material is missing from structural steel in the corridor at Stair 1, 6th floor.
On 12/1/11 at approximately 10:23 am it was observed that required fireproofing material is missing from structural steel in Room 652.
On 12/1/11 at approximately 10:26 am it was observed that required fireproofing material is missing from structural steel outside of the Soiled Utility Room at Room 647.
On 12/1/11 at approximately 10:28 am it was observed that required fireproofing material is missing from structural steel in the Supply Room close to Room 645.
On 12/1/11 at approximately 10:29 am it was observed that required fireproofing material is missing from structural steel in Room 647.
On 12/1/11 at approximately 10:45 am it was observed that required fireproofing material is missing from structural steel in Room 633.
On 12/1/11 at approximately 10:49 am it was observed that required fireproofing material is missing from structural steel in the Wound Office on the 6th floor.
On 12/1/11 at approximately 10:56 am it was observed that required fireproofing material is missing from structural steel in the storage room located next to Stair 3 on the 6th floor.
On 12/1/11 at approximately 11:06 am it was observed that required fireproofing material is missing from structural steel in the Whirlpool Room on the 6th floor.
On 12/1/11 at approximately 11:20 am it was observed that required fireproofing material is missing from structural steel in the Clean Supply Room on the 6th floor (near the whirlpool room).
On 12/1/11 at approximately 11:27 am it was observed that required fireproofing material is missing from structural steel in the soiled utility room on 6E.
On 12/1/11 at approximately 11:32 am it was observed that required fireproofing material is missing from structural steel in the Director's Office on 6E.
On 12/1/11 at approximately 11:45 am it was observed that required fireproofing material is missing from structural steel across from Stair #5 on 6E.
On 12/1/11 at approximately 12:55 pm it was observed that wood has been used in the ceiling for construction at Stair #5 on 5E.
On 12/1/11 at approximately 12:55 pm it was observed that required fireproofing material is missing from structural steel at Stair #5 on 5E.
On 12/1/11 at approximately 1:04 pm it was observed that required fireproofing material is missing from structural steel in the Storage Room beside Room 532.
On 12/1/11 at approximately 1:04 pm it was observed that combustible foam has been used as a firestop material for the floor/ceiling assembly in the Storage Room beside Room 532.
On 12/1/11 at approximately 1:16 pm it was observed that in the back storage room located in the Soiled Utility Room on 5E, required fireproofing material is missing from structural steel.
On 12/1/11 at approximately 1:16 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the back storage room located inside the Soiled Utility Room on 5E.
On 12/1/11 at approximately 1:16 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Soiled Utility Room on 5E.
On 12/1/11 at approximately 1:18 pm it was observed that required fireproofing material is missing from structural steel at the Nurses' Station on 5E.
On 12/1/11 at approximately 1:19 pm it was observed that required fireproofing material is missing from structural steel in Room 502.
On 12/1/11 at approximately 1:26 pm it was observed that required fireproofing material is missing from structural steel in Room 500.
On 12/1/11 at approximately 1:40 pm it was observed that required fireproofing material is missing from structural steel in the Respiratory Therapy Locker Room on 5E.
On 12/1/11 at approximately 1:45 pm it was observed that required fireproofing material is missing from structural steel in Room 534.
On 12/1/11 at approximately 2:27 pm it was observed that required fireproofing material is missing from structural steel beams in the Soiled Utility Room across from Room 500.
On 12/1/11 at approximately 2:28 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Soiled Utility Room across from Room 500.
On 12/1/11 at approximately 2:30 pm it was observed that required fireproofing material is missing from structural steel in the Storage Room across from Stair 1 on 5W.
On 12/1/11 at approximately 2:35 pm it was observed that required fireproofing material is missing from structural steel in the corridor of 4W Rehab.
On 12/1/11 at approximately 2:37 pm it was observed that required fireproofing material is missing from structural steel in the corridor near the fire barrier on 4W.
On 12/1/11 at approximately 2:40 pm it was observed that required fireproofing material is missing from structural steel in Room D on 4W.
On 12/1/11 at approximately 2:46 pm it was observed that required fireproofing material is missing from structural steel at the ADL Room on 4W.
On 12/1/11 at approximately 2:48 pm it was observed that required fireproofing material is missing from structural steel in Room 446.
On 12/1/11 at approximately 2:54 pm it was observed that required fireproofing material is missing from structural steel in Room 433.
On 12/1/11 at approximately 3:01 pm it was observed that required fireproofing material is missing from structural steel in the H4A Closet (IS Closet).
On 12/1/11 at approximately 3:07 pm it was observed that required fireproofing material is missing from structural steel at Room 400.
On 12/1/11 at approximately 3:09 pm it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room on 4E.
On 12/1/11 at approximately 3:09 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Soiled Utility Room on 4E.
On 12/1/11 at approximately 3:14 pm it was observed that required fireproofing material is missing from structural steel at the smoke barrier outside of the Soiled Utility Room on 4E.
On 12/1/11 at approximately 3:21 pm it was observed that required fireproofing material is missing from structural steel at Stair #5 on 4E.
On 12/1/11 at approximately 3:21 pm it was observed that wood has been used in the building construction at Stair #5 on 4E.
On 12/5/11 at approximately 9:34 am it was observed that required fireproofing material is missing from structural steel at Stair #1, 3rd floor.
On 12/5/11 at approximately 9:40 am it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room on 3W.
On 12/5/11 at approximately 9:40 am it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Soiled Utility Room on 3W.
On 12/5/11 at approximately 9:42 am it was observed that required fireproofing material is missing from structural steel in the Clean Linen Room on 3W.
On 12/5/11 at approximately 9:50 am it was observed that required fireproofing material is missing from structural steel in Cardiac Rehab on the 3rd floor.
On 12/5/11 at approximately 10:00 am it was observed that required fireproofing material is missing from structural steel outside of Cardiac Rehab at the smoke barrier wall in the corridor of the 3rd floor.
On 12/5/11 at approximately 10:12 am it was observed that required fireproofing material is missing from structural steel at Room 301.
On 12/5/11 at approximately 10:13 am it was observed that required fireproofing material is missing from structural steel in the elevator lobby for elevators 4 and 5 on the 3rd floor.
On 12/5/11 at approximately 10:47 am it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room on 3E.
On 12/5/11 at approximately 10:47 am it was observed that there are unprotected openings in the floor/ceiling assembly in the Soiled Utility Room on 3E.
On 12/5/11 at approximately 10:45 am it was observed that required fireproofing material is missing from structural steel in the corridor leading into the CCU area on the 3rd floor.
On 12/5/11 at approximately 10:45 am it was observed that required fireproofing material is missing from structural steel in the corridor near the fire barrier at Case Management on 3E.
On 12/5/11 at approximately 11:07 am it was observed that required fireproofing material is missing from structural steel in CCU Medical Equipment Room on 3E.
On 12/5/11 at approximately 11:30 am it was observed that required fireproofing material is missing from structural steel at the building separation leading into MOB-East at the 2 hour fire barrier on the 2nd floor.
On 12/5/11 at approximately 2:29 pm it was observed that required fireproofing material is missing from structural steel in the Supply Room in the EP Lab on the 2nd floor.
On 12/5/11 at approximately 2:35 pm it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room in Cardiac Holding on the 2nd floor.
On 12/5/11 at approximately 2:42 pm it was observed that the fire barrier at Stair 5, 2nd floor, does not appear to be sealed to the deck.
On 12/5/11 at approximately 2:50 pm it was observed that required fireproofing material is missing from structural steel in the Storage Room between OR 21 and OR 22 on the 2nd floor.
On 12/5/11 at approximately 3:02 pm it was observed that required fireproofing material is missing from structural steel in the back hall outside of Central Sterile on the 2nd floor.
On 12/7/11 at approximately 9:35 am it was observed that required fireproofing material is missing from structural steel at the smoke barrier outside of Room 234.
On 12/7/11 at approximately 9:40 am it was observed that there is an unprotected penetration of the floor/ceiling assembly above the ceiling in Room 234.
On 12/7/11 at approximately 9:55 am it was observed that required fireproofing material is missing from structural steel in the Storage Room on 2W at the Nurses' Station.
On 12/7/11 at approximately 10:00 am it was observed that required fireproofing material is missing from structural steel in Storage Room 24 beside Room 260.
On 12/7/11 at approximately 10:07 am it was observed that required fireproofing is missing from structural steel in the Lactation Hall on the 2nd floor.
On 12/7/11 at approximately 10:18 am it was observed that required fireproofing material is missing from structural steel in the area of the separation of the hospital to MOB East, Building A.
On 12/7/11 at approximately 10:27 am it was observed that required fireproofing is missing from structural steel in the Storage Room in the Medical Intensive Care Department.
On 12/7/11 at approximately 10:57 am it was observed that required fireproofing material is missing from structural steel in the Lab Office.
On 12/7/11 at approximately 10:57 am it was observed that the Office in the Lab has combustible paper on the insulation above the ceiling.
On 12/7/11 at approximately 11:03 am it was observed that the required fireproofing material is missing from structural steel in the Blood Bank in the Lab.
On 12/7/11 at approximately 11:04 am it was observed that the required fireproofing material is missing from structural steel in the Lab Library.
On 12/7/11 at approximately 11:07 am it was observed that required fireproofing material is missing from structural steel in the Lab Break Room.
On 12/7/11 at approximately 11:13 am it was observed that there is wood used for construction in the wall of the corridor at the Lab Break Room.
On 12/7/11 at approximately 11:13 am it was observed that required fireproofing material is missing from structural steel in the corridor at the Lab Break Room.
On 12/7/11 at approximately 11:16 am it was observed that required fireproofing material is missing from structural steel in the Lab Supervisor's Office.
On 12/7/11 at approximately 11:16 am it was observed that there is wood used for construction in the wall of the Lab Supervisor's Office.
On 12/7/11 at approximately 11:22 am it was observed that required fireproofing material is missing from structural steel in the Lab.
On 12/7/11 at approximately 11:39 am it was observed that at the double doors for the Lab, where the 1 hour rated wall turns, fireproofing material is missing from structural steel.
On 12/7/11 at approximately 11:39 am it was observed that required fireproofing material is missing from structural steel where the 1 hour rated wall turns in the Lab.
On 12/7/11 at approximately 11:51 am it was observed that required fireproofing material is missing from structural steel in the Waiting Room (Wireless Access) on the 1st floor.
On 12/7/11 at approximately 11:53 am it was observed that there are unprotected penetrations at the exit area of Bio-Hazard Medical Engineering to the 2 hour barrier.
On 12/7/11 at approximately 1:46 it was observed that required fireproofing material is missing from structural steel in the Pharmacy Staffing Office.
On 12/7/11 at approximately 1:50 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the corridor outside of the Pharmacy Mechanical Room.
On 12/7/11 at approximately 2:46 pm it was observed that there required fireproofing material is missing from structural steel in the Storage Room outside of Endoscopy.
On 12/7/11 at approximately 3:05 pm it was observed that required fireproofing material is missing from structural steel in M51.
On 12/7/11 at approximately 3:06 pm it was observed that required fireproofing is missing from structural steel outside of the Blueprint Room on the 1st floor.
On 12/7/11 at approximately 3:11 pm it was observed that required fireproofing material is missing from structural steel in the EVS corridor on the 1st floor.
On 12/12/11 at approximately 9:30 am it was observed that required fireproofing material is missing from structural steel in the Trash Chute Room on 1E.
On 12/12/11 at approximately 9:35 am it was observed that required fireproofing is missing from structural steel in the Linen Chute Room on 1E.
On 12/12/11 at approximately 9:30 am it was observed that required fireproofing material was missing from structural steel in the Private Office across from Pharmacy Storage on the 1st floor.
On 12/12/11 at approximately 9:41 am it was observed that required fireproofing material is missing from structural steel in the Private Office storage room across from Pharmacy Storage on the 1st floor.
On 12/12/11 at approximately 10:07 am it was observed that required fireproofing material is missing from structural steel in the large storage room across from the Mail Room on the 1st floor.
On 12/12/11 at approximately 10:35 am it was observed that required fireproofing material is missing from structural steel in an Engineering office (#1) on the 1st floor.
On 12/12/11 at approximately 10:37 am it was observed that required fireproofing material is missing from structural steel in the Engineering restroom on the 1st floor.
On 12/12/11 at approximately 11:13 am it was observed that required fireproofing material is missing from structural steel in the Tel Com Room, 1st floor.
On 12/12/11 at approximately 11:19 am it was observed that required fireproofing material is missing from structural steel at TR1-1.
On 12/12/11 at approximately 11:26 am it was observed that required fireproofing material is missing from structural steel in Security Central on the 1st floor.
On 12/12/11 at approximately 11:28 am it was observed that required fireproofing material is missing from structural steel in the Clean Linen Chute Room on 1W.
On 12/12/11 at approximately 11:32 am it was observed that required fireproofing material is missing from structural steel at the entrance to the Cafeteria on 1W.
On 12/12/11 at approximately 11:38 am it was observed that required fireproofing material is missing from structural steel above the ceiling at the double doors near the ATM on 1W.
On 12/12/11 at approximately 11:40 am it was observed that required fireproofing material is missing from structural steel in the IT Closet at the ATM on 1W.
On 12/12/11 at approximately 1:28 pm it was observed that required fireproofing material is missing from structural steel in the Business Office/Cashier on 1W.
On 12/12/11 at approximately 1:35 pm it was observed that required fireproofing material is missing from structural steel in the Hyperbaric Room on the 1st floor.
On 12/12/11 at approximately 1:49 pm it was observed that required fireproofing material is missing from structural steel in the Advanced Wound Center on the 1st floor.
On 12/12/11 at approximately 1:50 pm it was observed that required fireproofing material is missing from structural steel in the Main Lobby on the 1st floor.
On 12/12/11 at approximately 2:03 pm it was observed that required fireproofing material is missing from structural steel at Exam Room 3 in Pre-Admission Testing on the 1st floor.
On 12/12/11 at approximately 2:05 pm it was observed that required fireproofing material is missing from structural steel in the Supply Room near the entrance to the Cafeteria.
On 12/12/11 at approximately 2:10 pm it was observed that required fireproofing material is missing from structural steel in the dining area of the Cafeteria near the vending machines.
On 12/12/11 at approximately 2:10 pm it was observed that there is a wood stud used for construction material in the dining area of the Cafeteria at the vending machines.
On 12/12/11 at approximately 2:38 pm it was observed that required fireproofing material is missing from structural steel in the Janitor's Closet in Dietary.
On 12/12/11 at approximately 2:45 pm it was observed that required fireproofing material is missing from structural steel in the kitchen work area.
On 12/13/11 at approximately 9:15 am it was observed that required fireproofing material is missing from structural steel in Mechanical Room 4B.
On 12/13/11 at approximately 9:30 am it was observed that required fireproofing material is missing from structural steel at the 2 hour barrier separating the Hospital and "A Building" on the ground floor.
On 12/13/11 at approximately 9:42 am it was observed that required fireproofing material is missing from structural steel in the Lobby of Radiology Registration.
On 12/13/11 at approximately 9:49 am it was observed that required fireproofing material is missing from structural steel outside of the CT Scan area in Radiology.
On 12/13/11 at approximately 9:55 am it was observed that required fireproofing material is missing from structural steel in the Soiled Utility Room outside of the CT Scan area in Radiology.
On 12/13/11 at approximately 10:00 am it was observed that required fireproofing is missing from structural steel in the Storage Room behind the elevator room on the ground floor.
On 12/13/11 at approximately 11:12 am it was observed that required fireproofing is missing from structural steel outside of the elevator room on the ground floor.
On 12/13/11 at approximately 10:18 am it was observed that required fireproofing material is missing from structural steel in the electrical closet at the separation between the Hospital and OR on the ground floor.
On 12/13/11 at approximately 10:18 am it was observed that required fireproofing material is missing from structural steel in the IT Closet behind the electrical closet at the separation between the Hospital and OR on the ground floor.
On 12/13/11 at approximately 10:33 am it was observed that required fireproofing is missing from structural steel in the Nuclear Medicine Suite on the ground floor.
On 12/13/11 at approximately 10:35 am it was observed that required fireproofing is missing from structural steel in the corridor outside of the Nuclear Medicine Suite.
On 12/13/11 at approximately 11:00 am it was observed that required fireproofing material is missing from structural steel in the corridor at the Interventional Holding area.
On 12/13/11 at approximately 11:18 am it was observed that required fireproofing is missing from structural steel at the 2 hour fire barrier between the Hospital and "A Building".
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0012
Based on observation and interview it was determined that the facility failed to maintain the type of building construction.
Findings include:
On 11/30/11 at approximately 10:05 am it was observed that required fireproofing material is missing from structural steel in the ER Mediation Room.
On 11/30/11 at approximately 10:32 am it was observed that required fireproofing material is missing from structural steel in ER Fast Track.
On 11/30/11 at approximately 10:44 am it was observed that required fireproofing material is missing from structural steel in the ER-EMS room.
On 11/30/11 at approximately 10:40 am it was observed that required fireproofing material is missing from structural steel above the ceiling at the ER Desk Tech.
On 11/30/11, at approximately 11:47 am it was observed that required fireproofing material is missing from structural steel in the ER Electrical Room.
On 11/30/11 at approximately 12:59 pm it was observed that required fireproofing material is missing for structural steel above the doors across from the elevators (1st floor).
On 11/30/11 at approximately 1:03 pm it was observed that required fireproofing material is missing from structural steel above the lay-in ceiling in the old Orthopaedic Clinic.
On 11/30/11 at approximately 1:05 pm it was observed that required fireproofing material is missing from structural steel in the Mechanical Room on the 1st floor.
On 11/30/11 at approximately 1:10 pm it was observed that required fireproofing material is missing from structural steel in the Electrical Closet on the 1st floor.
On 11/30/11 at approximately 1:12 pm it was observed that required fireproofing material is missing from structural steel in the "Jefferson Surgical Center" area.
On 11/30/11 at approximately 1:15 pm it was observed that required fireproofing material is missing from structural steel in the Western VA OBGYN lobby area.
On 11/30/11 at approximately 1:17 pm it was observed that required fireproofing material is missing from structural steel in the Western VA OBGYN corridor near Exam Room 4.
On 11/30/11 at approximately 1:25 pm it was observed that fireproofing material is missing from structural steel in the stairwell near the OBGYN entrance.
On 11/30/11 at approximately 1:30 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly in the Lobby area of the Lewis Gale OBGYN Suite.
On 11/30/11 at approximately 1:30 pm it was observed that required fireproofing material is missing from structural steel in the Lobby area of the Lewis Gale OBGYN office.
On 11/30/11 at approximately 1:32 pm it was observed that required fireproofing material is missing from structural steel in the corridor area of the Lewis Gale OBGYN suite.
On 11/30/11 at approximately 1:35 pm it was observed that there are unprotected penetrations to the floor/ceiling assembly at the separation between the OR and the Hospital.
On 11/30/11 at approximately 1:35 pm it was observed that required fireproofing is missing from structural steel above the ceiling at the separation between the OR and the Hospital.
On 11/30/11 at approximately 1:39 pm it was observed that required fireproofing material is missing from structural steel above the ceiling at the Medication Room on the OR floor.
On 11/30/11 at approximately 1:42 pm it was observed that required fireproofing material is missing from structural steel above the ceiling at the Janitor's Closet on the OR floor.
On 11/30/11 at approximately 2:05 pm it was observed that required fireproofing material is missing above the ceiling in PACU on the OR floor.
On 11/30/11 at approximately 2:12 pm it was observed that required fireproofing material is missing from structural steel at OR 8.
On 11/30/11 at approximately 2:14 pm it was observed that required fireproofing material is missing from structural steel in the equipment room on the OR floor.
On 11/30/11 at approximately 2:15 and 2:30 pm it was observed that required fireproofing material is missing from structural steel in the Core Storage Room of the OR.
On 11/30/11 at approximately 2:33 pm it was observed that required fireproofing material is missing from structural steel in the Communications Closet in the OR.
On 11/30/11 at approximately 2:40 pm it was observed that required fireproofing material is missing from structural steel above the ceiling outside of OR 5.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0014
Based on observation and interview it was determined that the facility failed to ensure that flame spread ratings are Class A or Class B.
Findings include:
On 12/7/11 at approximately 11:55 am it was observed that there is plywood used on the exterior wall of the Bio-Hazard Room.
On 12/12/11 at approximately 1:23 pm it was observed that wood has been used on the wall outside of EDS on 1W and is over 4' in height from the bottom of the wall.
The above was confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0015
Based on observation and interview it was determined that the interior finish for the gym area does not appear to have the required flame spread rating.
Findings include:
On 11/16/11 at approximately 3:30 pm it was observed that a wood climbing wall was added to the Gym wall. Documentation was not available to show the flame spread rating for this material.
The above was witnessed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0017
Based on observation and interview it was determined that the facility failed to maintain smoke tight corridors. Corridors are required to be smoke tight partitions to the deck above because of the use of a plenum above the lay in ceiling.
Findings include:
On 11/16/11 at approximately 1:35 pm it was observed that there are unsealed penetrations to the smoke partition at the Emergency Equipment Room.
On 11/16/11 at approximately 3:05 pm it was observed that there are unsealed penetrations to the smoke partition in the AAU (Adult Unit 1) corridor at Room 204.
On 11/16/11 at approximately 3:07 pm it was observed that there are unsealed penetrations to the smoke partition in the AAU corridor at Room 202.
On 11/16/11 at approximately 3:10 pm it was observed that there are unsealed penetrations to the smoke partition in the AAU corridor at Room 111.
On 11/16/11 at approximately 3:42 pm it was observed that there are unsealed penetrations to the smoke partition in the Cafeteria corridor by wires and conduit.
On 11/16/11 at approximately 3:50 pm it was observed that there are unsealed penetrations to the Health Information Management corridor by conduit, pipes, and wires.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0018
Based on observation and interview it was determined that the facility failed to ensure that corridor doors are smoke tight.
Findings include:
On 12/1/11 at approximately 10:33 am it was observed that the door to patient Room 636 is not equipped with a means to keep the door closed.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0018
Based on observation and interview it was determined that the facility failed to maintain corridor openings to resist the passage of smoke.
Findings include:
On 11/15/11 at approximately 2:50 pm it was observed that corridor doors 311 & 312 are not smoke tight as they are not equipped with a means suitable for keeping them closed.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0020
Based on observation and interview it was determined that the facility failed to maintain stairways with a one hour fire resistance rating.
Findings include:
On 11/30/11 at approximately 1:25 pm it was observed that there are unprotected penetrations by sprinkler piping/conduit to the stairwell near the OBGYN entrance.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0020
Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating of elevator shafts.
Findings include:
On 12/01/11 at approximately 3:10 pm it was observed that there are unprotected penetrations by conduit/wires to the elevator shaft wall in the Elevator Lobby.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0020
Based on observation and interview it was determined that the facility failed to maintain the required fire resistance rating of shafts.
Findings include:
On 11/16/11 at approximately 1:17 pm it was observed that there are two unprotected penetrations by conduit to the 2nd floor elevator shaft.
On 11/16/11 at approximately 1:25 pm it was observed that the shaft (where elevator was moved) has unprotected penetrations by sprinkler piping and wires on the 2nd floor.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0021
Based on observation and interview it was determined that the facility failed to maintain fire doors that they will close automatically.
Findings include:
On 11/15/11 at approximately 11:08 am it was observed that the door to Stair 1, 1st floor is being held open by unapproved means. Further, this door is not automatically latching in the closed position.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0025
Based on observation and interview it was determined that the facility failed to maintain the construction of smoke barrier walls.
Findings include:
On 11/30/11 at approximately 9:10 am it was observed that combustible foam is being used to seal penetrations to the smoke barrier in the lobby of ER Triage.
On 11/30/11 at approximately 9:12 am it was observed that combustible foam is being used to seal penetrations to the smoke barrier in the ER Meditation Room.
On 11/30/11 at approximately 9:20 am it was observed that there are unsealed penetrations in the corridor of ER Triage by conduit/piping.
On 11/30/11 at approximately 9:42 am it was observed that there are unsealed penetrations in the corridor at ER Super Track by conduit/piping.
On 11/30/11 at approximately 10:14 am it was observed that there are unsealed penetrations to ER Super Track room by conduit.
On 11/30/11 at approximately 10:32 am it was observed that there are unsealed penetrations to ER Fast Track by conduit/wiring.
On 11/30/11 at approximately 10:41 am it was observed that combustible foam is being used for sealing the smoke barrier in the ER Ambulatory Lobby entrance.
On 11/30/11 at approximately 10:45 am it was observed that combustible foam is being used for sealing the smoke barrier in the ER-EMS room.
On 11/30/11 at approximately 2:42 pm it was observed that there are unsealed penetrations to the barrier wall above the ceiling at the Anesthesia Work Room.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0025
Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating of smoke barriers.
Findings include:
On 12/1/11 at approximately 10:23 am it was observed that there are unsealed penetrations to the smoke barrier by wires and conduit in Room 652.
On 12/1/11 at approximately 10:45 am it was observed that the smoke barrier in Room 633 does not appear to be properly sealed to the deck.
On 12/1/11 at approximately 10:45 am it was observed that there are unsealed penetrations to the smoke barrier in Room 633 by conduit/wires.
On 12/1/11 at approximately 11:06 am it was observed that there are unsealed penetrations to the smoke barrier in the Whirlpool Room on the 6th floor by conduit.
On 12/1/11 at approximately 1:19 pm it was observed that combustible foam was used to seal around a penetration in the smoke barrier wall in Room 502.
On 12/1/11 at approximately 2:15 pm it was observed that penetrations to the smoke barrier in Room 550 appear to have been sealed with combustible (green) foam.
On 12/1/11 at approximately 3:07 pm it was observed that there are unsealed penetrations by conduit/piping to the smoke barrier at Room 400.
On 12/1/11 at approximately 3:15 pm it was observed that there are unsealed penetrations by conduit in the smoke barrier wall near the Soiled Utility Room on 4E.
On 12/5/11 at approximately 9:50 am it was observed that there are unsealed penetrations to the smoke barrier by conduit in Cardiac Rehab on the 3rd floor.
On 12/5/11 at approximately 10:12 am it was observed that there are unsealed penetrations to the smoke barrier in Room 301 (Staff Lounge) by conduit.
On 12/5/11 at approximately 10:14 am it was observed that there is combustible foam used as a sealant in the smoke barrier in Room 301.
On 12/5/11 at approximately 10:47 am it was observed that there are unsealed penetrations by conduit to the smoke barrier in the Soiled Utility Room on 3E.
On 12/5/11 at approximately 10:53 am it was observed that there are unsealed penetrations by conduit to the smoke barrier at CCU on 3E.
On 12/5/11 at approximately 10:53 am it was observed that combustible foam has been used as a sealant in the smoke barrier at CCU on 3E.
On 12/5/11 at approximately 2:42 pm it was observed that there are unsealed penetrations to the smoke barrier wall at Stair 5, 2nd floor.
On 12/7/11 at approximately 9:35 am it was observed that there are unsealed penetrations to the smoke barrier at Room 234 by wires.
On 12/7/11 at approximately 9:40 am it was observed that there are unsealed penetrations to the smoke barrier in Room 234 by conduit and piping.
On 12/7/11 at approximately 3:00 pm it was observed that there are unsealed penetrations to the smoke barrier outside the back of Endoscopy.
On 12/12/11 at approximately 11:02 am it was observed that there are unsealed penetrations to the smoke barrier at PPX on the 1st floor. Also, the smoke barrier wall is not complete in the same area.
On 12/12/11 at approximately 11:17 am it was observed that there is an unsealed penetration to the smoke barrier wall - the right wall in M2-1.
On 12/12/11 at approximately 11:17 am it was observed that there are unsealed penetrations to the smoke barrier wall in the corridor at M2-1.
On 12/12/11 at approximately 11:32 am it was observed that there are unsealed penetrations to the barrier at the entrance to the Cafeteria on 1W.
On 12/12/11 at approximately 11:38 am it was observed that there are unsealed penetrations to the smoke barrier above the double doors near the ATM on 1W.
On 12/13/11 at approximately 9:49 am it was observed that there are unsealed penetrations to the smoke barrier wall outside of the CT Scan area in Radiology and around the corner from the room.
On 12/13/11 at approximately 9:49 am it was observed that the smoke barrier is not sealed to the deck outside of the CT Scan area (around the corner) in Radiology.
On 12/13/11 at approximately 10:20 am it was observed that there are unsealed penetrations to the smoke barrier in the corridor at the Educator Office on the ground floor.
On 12/13/11 at approximately 10:28 am it was observed that the smoke barrier is not sealed to the deck above the double doors (B7) on the ground floor.
On 12/13/11 at approximately 10:33 am it was observed that there are unsealed penetrations to the Nuclear Medicine Suite by conduit/wires (part of the smoke barrier).
On 12/13/11 at approximately 10:35 am it was observed that the smoke barrier wall is not sealed to the deck in the corridor outside Nuclear Medicine Suite on the ground floor.
On 12/13/11 at approximately 10:35 am it was observed that there are unsealed penetrations to the smoke barrier outside of Nuclear Medicine Suite on the ground floor.
On 12/13/11 at approximately 10:45 am it was observed that there are unsealed penetrations to the smoke barrier at the rear of Interventional Holding on the ground floor.
On 12/13/11 at approximately 11:09 am it was observed that there are unsealed penetrations to the smoke barrier at B12.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0025
Based on observation and interview it was determined that the facility failed to properly construct and maintain smoke barriers.
Findings include:
On 11/15/11 at approximately 9:55 am it was observed that the smoke barrier wall near the elevator equipment room does not extend to the deck above.
On 11/15/11 at approximately 10:25 am it was observed that there are unsealed penetrations to the smoke barrier between the men's restroom and a private office.
On 11/15/11 at approximately 10:30 am it was observed that there are unsealed penetrations to the smoke barrier in "Private Office".
On 11/15/11 at approximately 10:37 am it was observed that there are unsealed penetrations to the smoke barrier inside the men's restroom.
On 11/15/11 at approximately 10:47 am it was observed that the smoke barrier wall is not complete from the corner of the women's restroom to the stairwell.
On 11/15/11 at approximately 1:56 pm it was observed that combustible foam was used to seal penetrations above the barrier doors leading to ITU (Adult Unit 3).
On 11/15/11 at approximately 1:58 pm it was observed that there are unsealed penetrations to the barrier wall leading to ITU (Adult Unit 3) by wires/conduit.
On 11/15/11 at approximately 2:05 pm it was observed that there are unsealed penetrations to the barrier wall in Area 7, ID staff room by piping and conduit.
On 11/15/11 at approximately 2:11 pm it was observed that there is an unsealed opening in the barrier wall above the double doors at the Storage Room on the 2nd floor created by a bundle of wires.
On 11/15/11 at approximately 3:00 pm it was observed that combustible foam was used and covered with a thin coating of firestopping material above the smoke barrier doors leading to the Children's Unit to seal penetrations of the barrier wall.
On 11/15/11 at approximately 3:10 pm it was observed that there are unsealed penetrations to the smoke barrier at Room 220.
On 11/16/11 at approximately 1:00 pm it was observed that the barrier wall in the ITU Quiet Room is not constructed properly (this wall was changed during a renovation).
On 11/16/11 at approximately 1:55 pm it was observed that there are unsealed penetrations to the smoke barrier above the double doors at the Physician's Consult Room.
On 11/16/11 at approximately 2:07 pm it was observed that there are unsealed penetrations to the barrier wall at the room by AAU.
On 11/16/11 at approximately 2:29 pm it was observed that there is an unsealed penetration to the smoke barrier above the door to Room 217 at the entrance to the Doctor's Office on the 2nd floor.
On 11/16/11 at approximately 2:40 pm it was observed that there are unsealed penetrations to the barrier wall in the room beside the Behavioral Health Director.
On 11/16/11 at approximately 2:50 pm it was observed that there are unsealed penetrations by conduit to the barrier wall, on the Doctor's Office side of the door, at Dr. L's office.
On 11/16/11 at approximately 2:55 pm it was observed that there are unsealed penetrations by conduit to the smoke barrier at the Children's Lounge.
On 11/16/11 at approximately 3:35 pm it was observed that there are unsealed penetrations by conduit to the barrier wall at the entrance to the Gym.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0027
Based on observation and interview it was determined that the facility failed to maintain door openings in smoke barriers.
Findings include:
On 11/30/11 at approximately 2:55 pm it was observed that the dutch fire doors in the barrier wall at Blue Ridge Oncology are not automatically closing when the fire alarm is activated. One door in the reception area had the opposite leaf propped open. An additional door at the reception area was obstructed from closing by shelving.
On 11/30/11 and 12/1/11 at approximately 3:27 pm and 9:30 am it was observed that the two rated doors in the barrier wall across from Exam Room 4 in Blue Ridge Oncology were being held open with a door stop.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0027
Based on observation and interview it was determined that the facility failed to maintain smoke tight and self-closing doors in the smoke barrier.
Findings include:
On 11/15/11 at approximately 9:45 am it was observed that the door between the Pavilion Administrator and the Private Office which is located in the smoke barrier, is not equipped with a closer.
On 11/15/11 at approximately 9:47 am it was observed that the door at the rear of the reception desk which is part of the smoke barrier, is not equipped with a closer.
On 11/16/11 at approximately 2:25 pm it was observed that there is an unapproved sweep on the rated doors at Room 206.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0029
Based on observation and interview it was determined that the facility failed to maintain identified hazardous areas separated by required construction with properly rated doors that remain self-closing.
Findings include:
On 11/16/11 at approximately 1:34 pm it was observed that the old pharmacy area was changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 11/16/11 at approximately 1:35 pm it was observed that the old exam room was changed to storage and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 11/16/11 at approximately 3:25 pm it was observed that the office in the Gym was changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 11/16/11 at approximately 3:27 pm it was observed that an additional office in the Gym was changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 11/16/11 at approximately 3:30 pm it was observed that the door to Storage Room A in the Gym is not self-closing.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0029
Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating of hazardous areas.
Findings include:
On 12/01/11 at approximately 9:57 am it was observed that the rated construction was not properly sealed to the deck in the Oncology soiled utility room.
On 12/01/11 at approximately 9:57 am it was observed that there is a penetration by conduit to the rated construction in the Oncology soiled utility room
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0029
Based on observation and interview it was determined that the facility failed to maintain the required fire resistance rating for identified hazardous areas.
Findings include:
On 11/30/11 at approximately 2:14 pm it was observed that there are unprotected penetrations by piping/conduit of 1 hour rated construction in the equipment room on the OR floor.
On 11/30/11 at approximately 2:15 pm it was observed that there are unprotected penetrations to rated construction by conduit and piping in the Core Storage Room of the OR.
On 11/30/11 at approximately 2:33 pm it was observed that there are penetrations to 1 hour rated construction in the Communications Closet in the OR by conduit.
On 11/30/11 at approximately 2:35 pm it was observed that there are unprotected penetrations by conduit/piping to rated construction in the storage room beside OR 11.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0029
Based on observation and interview it was determined that the facility failed to properly protect identified hazardous areas.
Findings include:
On 12/1/11 at approximately 10:56 am it was observed that the door closer has been removed from the Storage Room door located next to Stair 3 on the 6th floor.
On 12/1/11 at approximately 10:56 am it was observed that there are unprotected penetrations in the Storage Room located next to Stair 3 on the 6th floor by conduit and piping that are not sealed with an approved firestop material.
On 12/1/11 at approximately 10:56 am it was observed that the Storage Room located next to Stair 3 on the 6th floor is not properly sealed to the deck.
On 12/1/11 at approximately 11:30 am it was observed that a shower room on 6E has been converted to a clean linen room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 1:04 pm it was observed that there are unprotected penetrations in one wall in the Storage Room beside Room 532 by pipes/conduit.
On 12/1/11 at approximately 1:04 pm it was observed that the door to the Storage Room beside Room 532 is not rated.
On 12/1/11 at approximately 1:16 pm it was observed that there are unprotected penetrations to the wall of the back storage room located in the Soiled Utility Room on 5E.
On 12/1/11 at approximately 1:16 pm it was observed that there are unprotected penetrations to the wall (corridor side) in the Soiled Utility Room on 5E.
On 12/1/11 at approximately 1:26 pm it was observed that Room 500 has been converted to a combustible storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 1:40 pm it was observed that the Respiratory Therapy Locker Room on 5E has been converted to a combustible storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 1:45 pm it was observed that the Respiratory Therapy Break Room has been converted to a storage room and the door is not listed for this use.
On 12/1/11 at approximately 1:45 pm it was observed that Room 534 has been converted to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 2:30 pm it was observed that the Storage Room across from Stair 1 on 5W is not separated in accordance with the construction requirements for hazardous areas.
On 12/1/11 at approximately 2:48 pm it was observed that Patient Room 446 has been converted to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 2:55 pm it was observed that Room 434 has been changed to a storage roomand is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/1/11 at approximately 3:09 pm it was observed that there are unprotected penetrations by conduit to the wall in the Soiled Utility Room on 4E.
On 12/5/11 at approximately 11:07 am it was observed that there are unprotected penetrations by conduit and IT wiring to the rated wall in CCU Medical Equipment Room on 3E.
On 12/5/11 at approximately 1:57 pm it was observed that the door for the Pixis Room in SICU (storage room) has been removed. There are unsealed penetrations to the walls by conduit and part of the wall is not complete.
On 12/5/11 at approximately 2:00 pm it was observed that the storage room in SICU on 2E is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/5/11 at approximately 2:12 pm it was observed that there are unprotected penetrations to the wall of the Soiled Utility Room in the Cath Lab on the 2nd floor by conduit and piping.
On 12/5/11 at approximately 2:12 pm it was observed that the wall in the Soiled Utility Room in the Cath Lab on the 2nd floor is not properly sealed to the deck.
On 12/5/11 at approximately 2:18 pm it was observed that the Storage Room in Cath Lab A on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas.
On 12/5/11 at approximately 2:29 pm it was observed that the Supply Room in the EP Lab on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas.
On 12/5/11 at approximately 2:35 pm it was observed that the Soiled Utility Room in Cardiac Holding on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas.
On 12/5/11 at approximately 2:50 pm it was observed that the Storage Room between OR 21 and OR 22 on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas
On 12/5/11 at approximately 3:08 pm it was observed that the old OR ' s 1, 2, and 3 on the 2nd floor have been converted to storage rooms and are not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/5/11 at approximately 3:17 pm it was observed that the room across from OR 32 in PACU 2 has been converted to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/5/11 at approximately 3:20 pm it was observed that Central Sterile on the 2nd floor is not separated in accordance with the construction requirements for hazardous areas. In addition, there are unprotected penetrations to the wall by conduit and piping. Part of the wall is completely missing and the existing wall is not sealed to the deck. Some of the doors are not rated, are not self-closing, and will not latch automatically.
On 12/7/11 at approximately 9:45 am it was observed that there are unprotected penetrations in the Clean Utility Room on 2W. The tube system is sealed with fire caulk applied to newspaper.
On 12/7/11 at approximately 9:45 am it was observed that the door to the Clean Utility Room on 2W is not rated to properly separate this room with approved construction.
On 12/7/11 at approximately 9:45 am it was observed that the dumb waiter in the Clean Utility Room on 2W is no longer being used and is not sealed with approved construction.
On 12/7/11 at approximately 9:55 am it was observed that there are unprotected penetrations to the Storage Room on 2W at the Nurses' Station by conduit and piping.
On 12/7/11 at approximately 10:00 am it was observed that there are unprotected penetrations to Storage Room 24 beside Room 260 by conduit.
On 12/7/11 at approximately 10:27 am it was observed that there are unprotected penetrations to the wall of the Storage Room in the Medical Intensive Care Department by conduit.
On 12/7/11 at approximately 10:40 am it was observed that one leaf of the rated doors leading into the Lab is not self-latching.
On 12/7/11 at approximately 10:50 am it was observed that there are unprotected penetrations to the 1 hour rated wall leading into the Lab.
On 12/7/11 at approximately 10:55 am it was observed that there are unprotected penetrations to the 1 hour rated wall inside the Blood Bank Supervisor's Office in the Lab.
On 12/7/11 at approximately 10:59 am it was observed that the 1 hour rated wall in the Lab, Blood Bank Supervisor's Office, does not appear to be sealed to the deck.
On 12/7/11 at approximately 11:03 am it was observed that there are unprotected penetrations to the 1 hour rated wall by conduit/wires in the Blood Bank in the Lab.
On 12/7/11 at approximately 11:04 am it was observed that there are unprotected penetrations by conduit/piping in the 1 hour wall at the rear of the Lab Library.
On 12/7/11 at approximately 11:07 am it was observed that flex duct penetrates the 1 hour rated wall between the Break Room and the Pharmacy and is not equipped with a duct.
On 12/7/11 at approximately 11:13 am it was observed that there are unprotected penetrations to the 1 hour rated wall in the corridor at the Lab Break Room.
On 12/7/11 at approximately 11:16 am it was observed that there are unprotected penetrations by conduit/wires in the 1 hour rated wall in back of the Lab Supervisor's Office.
On 12/7/11 at approximately 11:39 am it was observed that there are unprotected penetrations at the double doors for the Lab, where the 1 hour rated wall turns.
On 12/7/11 at approximately 11:44 am it was observed that there are 7 unprotected penetrations by conduit/pipes at the entrance to the wall of the Lab across from the water fountain.
On 12/7/11 at approximately 11:44 am it was observed that the door to the Lab across from the water fountain is not properly rated in accordance with the construction requirements for hazardous areas.
On 12/7/11 at approximately 1:14 pm it was observed that the door closer was removed from the office/storage room in the Pharmacy.
On 12/7/11 at approximately 1:21 pm it was observed that there are unprotected penetrations to the rated wall of the Pharmacy Sterile Compounding Ante Room.
On 12/7/11 at approximately 1:38 pm it was observed that the rated wall is not complete at the rear of the Pharmacy in accordance with the construction requirements for hazardous areas. There are also unprotected penetrations in the existing wall.
On 12/7/11 at approximately 2:00 pm it was observed that there are unprotected penetrations in the rated wall of the Pharmacy (in corridor leading to the Morgue). Also, the wall is not complete in accordance with the construction requirements for hazardous areas.
On 12/7/11 at approximately 2:50 it was observed that Endoscopy Room 8 has been changed to a storage room and is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/7/11 at approximately 3:05 pm it was observed that there are unprotected penetrations to the Blueprint Storage Room on the 1st floor.
On 12/12/11 at approximately 1:00 pm it was observed that there are unprotected penetrations to the rated wall in the Cart room in the EVS hallway. Also, the wall is not sealed to the deck.
On 12/12/11 at approximately 1:00 pm it was observed that there are unprotected penetrations to the rated wall in the Clean Linen Room, 1st floor in the EVS hallway.
On 12/7/11 at approximately 10:50 am it was observed that there are unprotected penetrations to the 1 hour rated wall leading into the Lab on the 1st floor.
On 12/7/11 at approximately 10:55 am it was observed that flexible duct penetrates the 1 hour wall in the Lab, Blood Bank Supervisor's Office, and is not equipped with a damper.
On 12/12/11 at approximately 9:41 am it was observed that the door to the storage room in the Private Office across from Pharmacy Storage on the 1st floor has a 20 minute rating.
On 12/12/11 at approximately 10:01 am it was observed that the storage room in the "Private Office" office across from Endoscopy on the 1st floor is not being maintained in accordance with the construction requirements for hazardous areas.
On 12/12/11 at approximately 10:20 am it was observed that there are unsealed penetrations to the rated wall in Engineering on the 1st floor.
On 12/12/11 at approximately 10:20 am it was observed that the double doors leading into Engineering on the 1st floor are rated for 20 minutes.
On 12/12/11 at approximately 10:37 am it was observed that there are penetrations to the rated wall in the Engineering Restroom on the 1st floor.
On 12/12/11 at approximately 10:38 am it was observed that there is a penetration by a pipe sleeve to the rated wall above the sink in the Engineering Department on the 1st floor.
On 12/12/11 at approximately 10:46 am it was observed that there is an unprotected penetration to the rated wall over the exit door from the Engineering Department on the 1st floor.
On 12/12/11 at approximately 10:46 am it was observed that the rated wall is not sealed to the deck above the exit door from the Engineering Department on the 1st floor.
On 12/12/11 at approximately 10:57 am it was observed that the Spill Response Room on the 1st floor is not being maintained in accordance with the construction requirements for hazardous areas. Also, the door is not self-closing.
On 12/12/11 at approximately 1:12 pm it was observed that the EDS Supply Room on 1W is not sealed to the deck. There are also unprotected penetrations to the rated wall.
On 12/12/11 at approximately 1:34 pm it was observed that the Supply Room door is not latching in the Advanced Wound Center on the 1st floor.
On 12/12/11 at approximately 2:05 pm it was observed that the Supply Room near the entrance to the Cafeteria is not separated in accordance with the construction requirements for hazardous areas. (Section 18-3.2.1)
On 12/12/11 at approximately 2:14 pm it was observed that the large storage room for Dietary is not separated inaccordance with the construction requirements for hazardous areas.
On 12/12/11 at approximately 2:15 pm it was observed that there are unprotected penetrations to the 1 hour rated wall of the Dry Storage Room in Dietary.
On 12/13/11 at approximately 9:15 am it was observed that the Mechanical Room 4B is not properly protected (door not rated) in Radiology.
On 12/13/11 at approximately 9:45 am it was observed that there is no closer on the Storage Room door in the CT Scan area of Radiology.
On 12/13/11 at approximately 9:55 am it was observed that the Soiled Utility Room outside of the CT Scan area in Radiology is not separated in accordance with the construction requirements for hazardous areas.
On 12/13/11 at approximately 9:55 am it was observed that flex duct penetrates the wall of the Soiled Utility Room outside of the CT Scan area in Radiology and is not equipped with a damper.
On 12/13/11 at approximately 10:00 am it was observed that there are unprotected penetrations by conduit to the Storage Room behind the elevator room on the ground floor. Also, one penetration has been improperly sealed with cardboard and mineral wool.
On 12/13/11 at approximately 10:42 am it was observed that the Soiled Utility Room in the small corridor at the rear of Interventional Holding on the ground floor is not separated in accordance with the construction requirements for hazardous areas.
On 12/13/11 at approximately 11:10 am it was observed that the top leaf of the dutch doors for the X-Ray File Storage Room was not latching.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0033
Based on observation and interview it was determined that the facility failed to maintain stairways with a fire resistance rating.
Findings include:
On 12/13/11 at approximately 10:47 am it was observed that the door to Stair 5, Floor G is not latching.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0033
Based on observation and interview it was determined that the facility failed to maintain stairways with at least a 1 hour fire resistance rating.
Findings include:
On 11/15/11 at approximately 10:58 am it was observed that there is a penetration to stairwell 2, 1st floor, by conduit and wiring running through the same unprotected opening.
On 11/15/11 at approximately 11:15 am it was observed that there are unprotected penetrations to Stairwell 1, 1st floor, by sprinkler piping.
On 11/15/11 at approximately 11:20 am it was observed that there are unprotected penetrations to Stairwell 1, 2nd floor, by fire alarm wire and conduit.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0038
Based on observation and interview it was determined that the facility failed to maintain exits readily accessible.
Findings include:
On 12/1/11 at approximately 2:50 pm it was observed that egress from Room 438 was partially obstructed by furniture.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0038
Based on observation and interview it was determined that the facility failed to provide approved locking arrangements.
Findings include:
On 11/30/11 at approximately 10:42 am it was observed that the ER Ambulatory Lobby doors were locked in an unapproved manner.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0039
Based on observation and interview it was determined that the facility failed to maintain corridors free and clear of obstructions.
On 12/12/11 at approximately 1:10 pm it was observed that there was combustible storage in the EVS hallway outside of the Clean Linen and Cart Room.
On 12/7/11 at approximately 2:47 pm it was observed that there is a significant amount of housekeeping storage in the EVS corridor outside of the rear of Endoscopy.
The above was observed and confirmed by the Director of Engineering and the Safety Director.
LIFE SAFETY CODE STANDARD
Tag No.: K0039
Based on observation and interview it was determined that the facility failed to maintain exit corridors clear and unobstructed.
Findings include:
On 11/30/11 at approximately 3:22 pm it was observed that the exit corridor leading to the rear exit of Blue Ridge Oncology was obstructed by storage.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0044
Based on observation and interview it was determined that the facility failed to maintain horizontal exits.
Findings include:
On 12/5/11 at approximately 10:53 am it was observed that the closer for the rated door at the CCU Waiting Room on 3E was removed. This corridor is part of a horizontal exit.
On 12/13/11 at approximately 10:15 am it was observed that the door in the horizontal exit from Radiology to OR (2 hour barrier) was "dogged down" and not self-latching on the ground floor.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0052
Based on observation and interview the facility failed to install the fire alarm system in accordance with NFPA 72.
On 12/13/11 at approximately 10:15 am it was observed that there are no fire alarm pull stations on either side of the 2 hour barrier (Horizontal Exit from Radiology to OR) on the ground floor.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0054
Based on observation and interview the facility failed to maintain smoke detectors as required.
On 12/12/11 at approximately 1:30 pm it was observed that a smoke detector in an ante-room off the office in the Business office on 1W appears to be too close to the air diffuser. (NFPA 72, 2-3.5.1)
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0056
Based on observation and interview it was determined that the facility failed to install a complete automatic sprinkler system in accordance with NFPA 13.
Findings include:
On 11/15/11 at approximately 11:48 am it was observed that sprinklers appear to be installed improperly (too close together). (NFPA 13, Section 5-6.3.4)
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0056
Based on observation and interview it was determined that the facility failed to install the sprinkler system in accordance with NFPA 13.
Findings include:
On 12/5/11 at approximately 9:33 am it was observed that there is no sprinkler protection for the Waiting Area on the 3rd floor where the new partition was added.
On 12/5/11 at approximately 2:44 pm it was observed that the pendant sprinklers do not appear to be installed in accordance with the manufacturer's installation instructions in OR 21 and OR 22.
On 12/5/11 at approximately 3:22 pm it was observed that there is no sprinkler coverage in the Sub-Sterilizer Room in Central Sterile on the 2nd floor.
On 12/7/11 at approximately 10:28 am it was observed that recessed sprinklers do not appear to be installed in accordance with the manufacturer's installation instructions in the MICD Storage Room.
On 12/7/11 at approximately 2:46 pm it was observed that sprinkler piping was being supported by a steam line at the Medical Director Outpatient Oncology Office. (NFPA 13, Section 6-1.1.5)
On 12/12/11 at approximately 11:39 am it was observed that a sprinkler valve at the exit door located across from the ATM on 1W does not appear to be supervised.
(NFPA 13, Section 5-14.1.1.3)
On 12/12/11 at approximately 1:54 pm it was observed that a sprinkler appears to be located too close to the restroom wall in the Surgical Services Suite on the 1st floor.
On 12/12/11 at approximately 1:54 pm it was observed that there is no sprinkler protection in a second restroom of the Surgical Services Suite on the 1st floor.
On 12/12/11 at approximately 2:00 pm it was observed that there is no sprinkler protection in the restroom of Pre-Admission Testing on the 1st floor.
On 12/12/11 at approximately 2:05 pm it was observed that the sprinklers in the Supply Room near the entrance to the Cafeteria are located too close to each other. (NFPA 13, Section 5-6.3.4)
On 12/12/11 at approximately 2:14 pm it was observed that the sprinklers for the Dietary loading dock do not appear to be tied into the sprinkler system.
On 12/12/11 at approximately 2:30 pm it was observed that two different (standard & quick response) types of sprinklers are installed in the large Storage Room of Dietary. (NFPA 13, Section 5-3.1.5.2)
On 12/12/11 at approximately 3:30 pm it was observed that the front canopy at the main entrance to the hospital is not sprinklered and cars stop and park under the canopy. (NFPA 13, Sections 5-13.8.1 & 5-13.8.2; see explanation in Appendix)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0056
Based on observation and interview it was determined that the facility failed to provide a complete sprinkler system.
Findings include:
On 11/30/11 at approximately 10:45 am it was observed that the EMS canopy is not sprinklered and ambulances park under this canopy. (NFPA 13, Sections 5-13.8.1 & 5-13.8.2; see explanation in Appendix)
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0062
Based on observation and interview it was determined that the facility failed to continuously maintain the sprinkler system in a reliable operating condition..
Findings include:
On 11/30/11 at approximately 10:40 am it was observed that sprinkler covers are painted(recessed sprinklers) in ER Fast Track. (NFPA 13, Section 3-2.6.3)
On 11/30/11 at approximately 1:37 pm it was observed that there is an escutcheon missing from a sprinkler in the Janitor's Closet on the OR floor. (NFPA 13, Section 3-2.7.2)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0062
Based on observation and interview it was determined that the facility failed to maintain the required automatic sprinkler systems in a reliable operating condition.
Findings include:
On 12/1/11 at approximately 10:32 am it was observed that an escutcheon is missing from the sprinkler in Room 645. (NFPA 13, Section 3-2.7.2)
On 12/1/11 at approximately 1:17 pm it was observed that there is an escutcheon missing from the sprinkler in the Pixis Room on 5E. (NFPA 13, Section 3-2.7.2)
On 12/1/11 at approximately 1:18 pm it was observed that there is an escutcheon missing from the sprinkler in the Dictation Room on 5E. (NFPA 13, Section 3-2.7.2)
On 12/1/11 at approximately 2:20 pm it was observed that an escutcheon is missing from a sprinkler in Room 566. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 12:42 am it was observed that there is an escutcheon missing from a sprinkler in the Med Room on 3E at the Nurses' Station. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 10:12 am it was observed that a sprinkler is obstructed by a sign on 3 Center. (NFPA 25, Section 2-2.1.2)
On 12/5/11 at approximately 10:45 am it was observed that the ceiling grid is supported by sprinkler piping in the corridor on 3E leading to the CCU area. (NFPA 13, Section 6-1.1.5)
On 12/5/11 at approximately 10:45 am it was observed that wiring is attached to sprinkler piping in the corridor on 3E leading to the CCU area. (NFPA 13, Section 6-1.1.5)
On 12/5/11 at approximately 11:07 am it was observed that wire is attached to sprinkler piping in CCU Medical Equipment Room on 3E. (NFPA 13, Section 6-1.1.5)
On 12/5/11 at approximately 1:50 pm it was observed that an escutcheon is missing from a sprinkler in restroom E5 in SICU. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 2:12 pm it was observed that an escutcheon is missing from a sprinkler in the Soiled Utility Room in the Cath Lab on the 2nd floor. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 10:12 am it was observed that data wiring is being supported by sprinkler piping at Room 301. (NFPA 13, Section 6-1.1.5)
On 12/5/11 at approximately 3:15 pm it was observed that an escutcheon was missing from the sprinkler in the restroom in PACU 2. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 3:17 pm it was observed that an escutcheon is missing from a sprinkler in OR-32, C-Section Room on the 2nd floor. (NFPA 13, Section 3-2.7.2)
On 12/5/11 at approximately 3:40 pm it was observed that an escutcheon is missing from a sprinkler in the Soiled Utility Room in ASU on the 2nd floor. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 10:16 am it was observed that a wall has been removed creating sprinklers that are not properly spaced at the Vending Area and corridor at Maternity Family Waiting. (NFPA 13, Section 5.6.3.4)
On 12/7/11 at approximately 10:18 am it was observed that there are wires being supported by sprinkler piping at the separation of the hospital to MOB East, Building A. (NFPA 13, Section 6-1.1.5)
On 12/7/11 at approximately 11:39 am it was observed that wires are wrapped around sprinkler hangers are used where the 1 hour rated wall turns in the Lab. (NFPA 13, Section 6-1.1.5)
On 12/7/11 at approximately 11:51 am it was observed that there are 2 escutcheons missing from sprinklers in the Waiting Room (Wireless Access) on the 1st floor. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 1:25 pm it was observed that an escutcheon is missing from a sprinkler in the rear of the small hallway leading out of the Pharmacy. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 1:37 pm it was observed that an escutcheon is missing from a sprinkler in the closet of the Pharmacy Quality Coordinator. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 2:00 pm it was observed that an escutcheon is missing from a sprinkler in the Morgue Shower Room. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 2:25 pm it was observed that a sprinkler valve is not labeled in Stair 5, Floor 1. (NFPA 13, Section 3-8.3)
On 12/7/11 at approximately 2:27 pm it was observed that a sprinkler has "mud" on the deflector outside of Bio-Medical Engineering on the 1st floor. (NFPA 25, Section 2-2.1.1)
On 12/7/11 at approximately 2:40 pm it was observed that an escutcheon is missing from a sprinkler in the Endoscopy Dressing Room. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 2:40 pm it was observed that an escutcheon is missing from a sprinkler in Endoscopy Recovery Room 3. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 3:08 pm it was observed that an escutcheon is missing from a sprinkler in the EVS corridor Housekeeping Closet #2 on the 1st floor. (NFPA 13, Section 3-2.7.2)
On 12/7/11 at approximately 3:09 pm it was observed that an escutcheon is missing from a sprinkler in the EVS corridor Housekeeping Closet #3 on the 1st floor. (NFPA 13, Section 3-2.7.2)
On 12/12/11 at approximately 9:35 am it was observed that a sprinkler is damaged in the Linen Chute Room on 1E. (NFPA 25, Section 2-2.1.1)
On 12/12/11 at approximately 10:20 am it was observed that the sprinkler piping is supporting wires in Engineering on the 1st floor. (NFPA 13, Section 6-1.1.5)
On 12/12/11 at approximately 10:41 am it was observed that storage is not being maintained at least 18 " below sprinkler deflectors in the Engineering Department on the 1st floor. (NFPA 25, Section 2-2.1.1)
On 12/12/11 at approximately 2:07 pm it was observed that an escutcheon is missing from a sprinkler in the dining area of the Cafeteria. (NFPA 13, Section 3-2.7.2)
On 12/12/11 at approximately 2:13 pm it was observed that an escutcheon is missing from the sprinkler over the refrigerator in the kitchen of Dietary. (NFPA 13, Section 3-2.7.2)
On 12/12/11 at approximately 2:15 pm it was observed that a sprinkler deflector is damaged in the Dry Storage Room of Dietary. (NFPA 25, Section 2-2.1.1)
On 12/12/11 at approximately 2:36 pm it was observed that ceiling tiles are missing above the Pastry Freezer in Dietary on the 1st floor.
On 12/12/11 at approximately 2:37 pm it was observed that the sprinkler in the Pastry Freezer in Dietary appears to be leaking. (NFPA 25, Section 2-2.1.1)
On 12/12/11 at approximately 2:38 pm it was observed that an escutcheon is missing from a sprinkler close to the Janitor ' s Closet in Dietary. (NFPA 13, Section 3-2.7.2)
On 12/12/11 at approximately 2:44 pm it was observed that a sprinkler deflector is damaged in the sink wash area of the kitchen work area on the 1st floor. (NFPA 25, Section 2-2.1.1)
On 12/13/11 at approximately 11:00 am it was observed that there are wires attached to sprinkler piping in the corridor at the Interventional Holding area. (NFPA 13, Section 6-1.1.5)
On 12/13/11 at approximately 11:18 am it was observed that a bundle of white wires are attached to sprinkler piping in the corridor at the 2 hour fire barrier between the Hospital and "A Building". (NFPA 13, Section 6-1.1.5)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0062
Based on observation and interview it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.
Findings include:
On 11/15/11 at approximately 10:47 am it was observed that there was ceiling tile lying on sprinkler piping at the women's restroom. (NFPA 13, Section 6-1.1.5)
On 11/15/11 at approximately 11:15 am it was observed that sprinkler piping does not appear to be secured properly in Stairwell 1, 1st floor.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0062
Based on observation and interview it was determined that the facility failed to properly maintain the sprinkler system.
Findings include:
On 11/30/11 at approximately 3:10 pm it was observed that an escutcheon is missing from a sprinkler in the Oncology Mold Room. (NFPA 13, Section 3-2.7.2)
On 12/01/11 at approximately 9:05 am it was observed that there are wires attached to and being supported by sprinkler piping and hangers in the corridor of Oncology at the nurses' station. (NFPA 13, Section 6-1.1.5)
On 12/01/11 at approximately 9:58 am it was observed that sprinkler valves are not permanently identified in the stairwell on the 2nd floor. (NFPA 13, Section 3-8.3)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0067
Based on observation and interview it was determined that the facility failed to maintain the HVAC system.
Findings include:
On 12/5/11 at approximately 3:45 pm it was observed that no damper was provided for the flex duct that runs into the lounge in Central Sterile on the 2nd floor. (two hour barrier)
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0067
Based on observation and interview it was determined that the facility failed to maintain the HVAC system.
On 11/15/11 at approximately 9:30 am it was observed that the corridor is being used as a return air plenum.
On 11/15/11 at approximately 9:45 am it was observed that the corridor is being used as a plenum and corridors do not extend to the deck above as a smoke partition.
On 11/15/11 at approximately 10:09 am it was observed that there is wood in the plenum ceiling near the elevator equipment room.
On 11/15/11 at approximately 10:11am it was observed that documentation could not be provided to show that wiring in the plenum is rated for plenum use.
On 11/15/11 at approximately 10:20 am it was observed that there is a plastic drip pan in the plenum at the coffee station.
On 11/15/11 at approximately 10:30 am it was observed that the facing for insulation in "Private Office" is flammable and is exposed to the plenum area.
On 11/15/11 at approximately 11:46 am it was observed that there is a combustible drip pan in the plenum in corridor area #76.
On 11/15/11 at approximately 2:58 pm it was observed that there are wood furring strips above the smoke barrier doors, in the plenum, leading to the Children's Unit.
On 11/16/11 at approximately 1:32 pm it was observed that there is wiring in the plenum for the locking system that does not appear to be plenum rated.
On 11/16/11 at approximately 1:50 pm it was observed that documentation was not available to show that the wireless router is rated for plenum use at the Emergency Equipment Room.
On 11/16/11 at approximately 2:00 pm it was observed that a fan coil unit is tented above the office next to the old pharmacy in the plenum.
On 11/16/11 at approximately 2:11 pm it was observed that there is a duct penetration to the 2 hour fire barrier at the Nursing Supervisor's office that does not appear to be equipped with a damper. (NFPA 90A - Section 3-3.1.1)
On 11/16/11 at approximately 3:50 pm it was observed that dampers are not marked at the Health Information Management Office. (NFPA 90A, Section 2-3.4.2)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0067
Based on observation and interview it was determined that the facility failed to properly mark the location of fire/smoke dampers.
Findings include:
On 11/30/11 at approximately 2:14 pm it was observed that the location of dampers is not marked in the equipment room on the OR floor. [NFPA 90A, Section 2-3.4.2)
On 11/30/11 at approximately 2:15 pm it was observed that the location of dampers is not marked in the Core Storage Room of the OR. [NFPA 90A, Section 2-3.4.2)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0069
Based on observation and interview it was determined that the facility failed to maintain kitchen hoods systems.
Findings include:
On 12/12/11 at approximately 2:12 pm it was observed that the kitchen range hood system in Dietary is not provided with a grease drip pan.
On 12/12/11 at approximately 2:12 pm it was observed that the filters for the kitchen range hood system in Dietary are not properly installed.
On 12/12/11 at approximately 2:41 pm it was observed that the kitchen range hood system in the kitchen work area has a damaged filter. There are also gaps between the filters.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0071
Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating for the walls of the linen and trash chutes.
Findings include:
On 12/12/11 at approximately 9:30 am it was observed that there are unprotected penetrations to the rated walls of the Trash Chute Room on 1E.
On 12/12/11 at approximately 9:35 am it was observed that there are unprotected penetrations of the front and rear wall of the Linen Chute Room on 1E.
On 12/12/11 at approximately 11:28 am it was observed that there is an unprotected penetration at the corner of Trash Chute Room on 1W.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0072
Based on observation and interview it was determined that the facility failed to maintain exits free of all obstructions.
Findings include:
On 12/5/11 at approximately 10:20 am it was observed that beds were being stored in the elevator lobby for elevators 6 and 7 on 3E.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0073
Based on observation and interview it was determined that the facility failed to ensure that all decorative material is flame retardant.
Findings include:
On 12/1/11 at approximately 1:50 pm it was observed that in the area of Room 539 and continuing down the corridor, a significant amount of flammable material is affixed to the walls.
On 12/1/11 at approximately 1:59 pm it was observed that documentation was not available to show that the large poster affixed to the wall is flame retardant at Room 543.
On 12/5/11 at approximately 10:05 am it was observed that documentation was not available to show that the plastic shoe holders are flame retardant (on 3 middle) in the area open to the corridor.
On 12/5/11 at approximately 3:41 pm it was observed that black plastic was hung over the windows to the PAT call nurse office.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0073
Based on observation and interview it was determined that the facility failed to ensure that no decorations are highly flammable.
Findings include:
On 11/30/11 at approximately 2:45 pm it was observed that there was no documentation available to show that the material over the window for the Oncology Staff Lounge is flame retardant.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0073
Based on observation and interview it was determined that the facility failed to maintain the building so that no highly flammable decorations or furnishings are used.
Findings include:
On 11/15/11 at approximately 2:25 pm it was observed that there was no documentation available to show that the paper window blinds covering the patient room windows are flame retardant.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0074
Based on observation and interview it was determined that the facility failed to maintain flame retardant drapes and curtains.
Findings include:
On 12/1/11 at approximately 3:02 pm it was observed that documentation was not available to verify that the drapes in the Conference Room on 4E are flame retardant.
The above was observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0075
Based on observation and interview it was determined that the facility failed to properly store trash and soiled linen containers that exceed 32 gallons.
Findings include:
On 12/7/11 at approximately 2:03 pm it was observed that four 44 gallon containers are being stored in the corridor at the Morgue.
On 12/12/11 at approximately 9:39 am it was observed that a trash container over 32 gallons capacity was being used in the Private Office across from Pharmacy Storage.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0075
Based on observation and interview it was determined that the facility failed to properly store trash collection receptacles exceeding 32 gallons.
Findings include:
On 11/30/11 at approximately 10:37 it was observed that trash cans greater than 32 gallons are improperly stored in ER Triage.
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0078
Based on observation and interview it was determined that the facility failed to label oxygen shut-off valves.
Findings include:
On 11/30/11 at approximately 11:43 am it was observed that there is no labeled oxygen shut-off for Suites A & B in ER. [NFPA 99, Section 4.3.1.2.3(n)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0130
Based on observation and interview it was determined that the facility failed to maintain horizontal sliding doors.
Findings include:
On 12/5/11 at approximately 2:37 pm it was observed that the horizontal sliding doors leading into Cardiac Holding on the 2nd floor are not functioning properly with respect to the breakaway function. (Section 7-2.1.4)
Based on observation and interview it was determined that the facility failed to construct ramps in accordance with the regulations.
Findings include:
On 12/7/11 at approximately 2:20 pm it was observed that the ramp leading from the exit near the Morgue does not appear to meet the requirements of the code.
(Sections 19.2.2.6, 7.2.5, and Table 7.2.5.2(b) for Existing Ramps)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0130
Based on observation and interview it was determined that the facility failed to maintain the elevator machine room with the required fire resistance rating and without storage.
Findings include:
On 11/15/11 at approximately 9:52 am it was observed that the elevator equipment room near the main lobby is not equipped with a closer. (ASME A17.1, Section 101.1a)
On 11/15/11 at approximately 9:52 am it was observed that the elevator equipment room near the main lobby is being used for combustible storage. (ASME A17.1, Section 101.2)
On 11/15/11 at approximately 9:55 am it was observed that the elevator equipment room near the main lobby is not completely separated by construction to provide a 1 hour rating. (ASME A17.1, Section 101.1a)
On 11/15/11 at approximately 11:25 am it was observed that there are unprotected penetrations to the elevator room across from the Business Office. (ASME A17.1, Section 101.1a)
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0147
Based on observation and interview it was determined that the facility failed to comply with the electrical requirements of NFPA 70.
Findings include:
On 11/30/11 at approximately 11:45 am it was observed that an approved cover is not provided for an electrical junction box in the Electrical Room of ER. [NFPA 70, Section 370-28(b)]
On 11/30/11 at approximately 1:35 pm it was observed that an approved cover is not provided for a junction box above the ceiling at the fire barrier on the OR floor. [NFPA 70, Section 370-28(b)]
On 11/30/11 at approximately 2:09 pm it was observed that an approved cover is not provided for an electrical junction box at OR 2. [NFPA 70, Section 370-28(b)]
On 11/30/11 at approximately 2:35 pm it was observed that an approved cover is not provided for an electrical junction box above the ceiling in the storage room beside OR 11.
[NFPA 70, Section 370-28(b)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0147
Based on observation and interview it was determined that the facility failed to ensure that the requirements of NFPA 70 were met.
Findings include:
On 12/1/11 at approximately 10:22 am it was observed that a power strip is plugged to an extension cord for permanent wiring in the Clinical Oncology Educator's Office on the 6th floor. [NFPA 70, Section 400-7(b)]
On 12/1/11 at approximately 10:50 am it was observed that there are 3 power strips used in a series in the Chaplain's Office on the 6th floor. [NFPA 70, Section 400-7(b)]
On 12/1/11 at approximately 11:26 am it was observed that 2 power strips are being used in a series in the Case Manager's Office on the 6th floor. [NFPA 70, Section 400-7(b)]
On 12/1/11 at approximately 11:32 am it was observed that an approved cover plate is missing from an electrical outlet in the Director's Office on 6E. [NFPA 70, Section 370-28(c)]
On 12/1/11 at approximately 11:45 am it was observed that an approved cover is not provided for an electrical junction box above the ceiling across from Stair #5 on 6E. [NFPA 70, Section 370-28(b)]
On 12/1/11 at approximately 1:19 pm it was observed that an approved cover is not provided for the electrical junction box above the ceiling at Stair 4 on 5E. [NFPA 70, Section 370-28(b)]
On 12/1/11 at approximately 2:52 pm it was observed that 2 power strips are being used in a series in Room 435. [NFPA 70, Section 400-7(b)]
On 12/1/11 at approximately 2:54 pm it was observed that an unapproved multi-plug device was being used for permanent wiring in Room 433. [NFPA 70, Section 305-6(a)]
On 12/5/11 at approximately 10:00 am it was observed that an approved cover is not provided for an electrical junction box above the ceiling outside of Cardiac Rehab on the 3rd floor. [NFPA 70, Section 370-28(b)]
On 12/5/11 at approximately 10:14 am it was observed that approved covers are not provided for 2 electrical junction boxes on 3E in the front and rear corridors. [NFPA 70, Section 370-28(b)]
On 12/5/11 at approximately 10:47 am it was observed that temporary wiring was left above the ceiling in the Soiled Utility Room on 3E. [NFPA 70, Section 305-2(d)]
On 12/5/11 at approximately 2:42 pm it was observed that an approved cover is not provided for the electrical junction box above the ceiling in the corridor at Stair 5, 2nd floor. [NFPA 70, Section 370-28(b)]
On 12/5/11 at approximately 2:44 pm it was observed that there appears to be "home made" extension cords being used in OR 21 on the 2nd floor. [NFPA 70, Section 400-7(b)]
On 12/5/11 at approximately 3:00 pm it was observed that unapproved multi-plug devices are being used for permanent wiring in OR 22 on the 2nd floor. [NFPA 70, Section 400-8]
On 12/7/11 at approximately 9:40 am it was observed that an approved cover is not provided for an electrical junction box above the ceiling in Room 234. [NFPA 70, Section 370-28(b)]
On 12/7/11 at approximately 9:48 am it was observed that there is a damaged electrical cord to the ice machine. [NFPA 70, Section 110.12(c)]
On 12/7/11 at approximately 10:21 am it was observed that there are 2 power strips used in a series in the Volunteer Office area. [NFPA 70, Section 400-7(b)]
On 12/7/11 at approximately 11:13 am it was observed that an approved cover is not provided for an electrical junction box located above the ceiling in the corridor at the Lab Break Room. [NFPA 70, Section 370-28(b)]
On 12/7/11 at approximately 11:16 am it was observed that there is exposed wiring above the ceiling in the Lab Supervisor ' s Office at the back wall. [NFPA 70, Section 305-2(d)]
On 12/7/11 at approximately 11:20 am it was observed that there are 3 power strips used in series in the Lab, Pathology Processing area. [NFPA70, Section 400-7(b)]
On 12/7/11 at approximately 3:11 pm it was observed that an approved cover plate is not provided for an electrical junction box above the ceiling in the EVS corridor on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/12/11 at approximately 9:30 am it was observed that temporary wiring has been left above the ceiling in the Trash Chute Room on 1E. [NFPA 70, Section 305-2(d)]
On 12/12/11 at approximately 9:37 am it was observed that there was an unapproved multiplug device being used in the Anesthesiologist Offices, 1st floor, at the rear desk on the right. [NFPA 70, Section 305-6(a)]
On 12/12/11 at approximately 9:45 am it was observed that an approved cover plate is not provided for an electrical junction box in the IS Room off of the "cold room" on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/12/11 at approximately 9:50 am it was observed that approved covers are not provided for 3 electrical junction boxes in the Private Break Room across from Endoscopy on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/12/11 at approximately 10:20 am it was observed that temporary wiring was left above the ceiling in Engineering on the 1st floor. [NFPA 70, Section 305-2(d)]
On 12/12/11 at approximately 10:37 am it was observed that an approved cover is not provided for an electrical junction box in the Engineering Restroom on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/12/11 at approximately 11:35 am it was observed that power strips are being used in series in the Credit Union on 1W. [NFPA 70, Section 400-7(b)]
On 12/12/11 at approximately 2:05 pm it was observed that an electrical receptacle is not provided with an approved cover in the Supply Room near the entrance to the Cafeteria. [NFPA 70, 370-28.3(c)]
On 12/12/11 at approximately 2:44 pm it was observed that an approved cover plate is not provided for an electrical junction box above the ceiling in the kitchen work area on the 1st floor. [NFPA 70, Section 370-28(b)]
On 12/13/11 at approximately 9:15 am it was observed that there is unprotected exposed wiring in Mechanical Room 4B. [NFPA 70, Section 305-2(d)]
On 12/13/11 at approximately 9:30 am it was observed that there is unprotected exposed wiring above the ceiling at the 2 hour barrier separating the Hospital and "A Building" on the ground floor. [NFPA 70, Section 305-2(d)]
On 12/13/11 at approximately 9:55 am it was observed that an approved cover is not provided for an electrical junction box in the Soiled Utility Room outside of the CT Scan area in Radiology. [NFPA 70, Section 370-28(b)]
On 12/13/11 at approximately 10:20 am it was observed that an approved cover is not provided for an electrical junction box in the corridor at the Educator Office on the ground floor. [NFPA 70, Section 370-28(b)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0147
Based on observation and interview it was determined that the facility failed to install and maintain electrical equipment in accordance with NFPA 70.
Findings include:
On 11/15/11 at approximately 9:52 am it was observed that an unapproved multi-plug device is being used for permanent wiring in the elevator equipment room. [NFPA 70, Section 305-6(a)]
On 11/15/11 at approximately 10:09 am it was observed that temporary wiring was left above the ceiling near the elevator equipment room. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 10:11 pm it was observed that there is exposed wiring above the ceiling in the plenum. [NFPA 70, Section 305.2(d)]
On 11/15/11 at approximately 10:37 am it was observed that 2 electrical junction boxes above the ceiling of the Men's Restroom are not provided with approved covers. [NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 10:37 am it was observed that temporary wiring was left above the ceiling in the Men's Restroom. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 11:00 am it was observed that temporary wiring was left above the ceiling in Stairwell 2, 2nd floor. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 11:00 am it was observed that there are two electrical junction boxes in the elevator lobby on the 1st floor that are not provided with approved covers. [NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 11:15 am it was observed that temporary wiring was left above the ceiling in Stair 1, 1st floor. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 11:20 am it was observed that temporary wiring was left above the ceiling at Stair 1, 2nd floor. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 1:45 pm it was observed that temporary wiring was left above the ceiling on the 2nd floor, Space 10. [NFPA 70, Section 302-2(d)]
On 11/15/11 at approximately 1:57 pm it was observed that an approved cover is not provided for an electrical junction box above the doors leading to ITU (Adult Unit 3). [NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 2:08 pm it was observed that an electrical junction box above the ceiling in Area 7 ID staff room is not provided with an approved cover. [NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 2:58 pm it was observed that an electrical junction box above the smoke barrier doors leading to the Children ' s Unit is not equipped with an approved cover.
[NFPA 70, Section 370-28(b)]
On 11/15/11 at approximately 3:10 pm it was observed that temporary wiring was left above the ceiling at Room 220. [NFPA 70, Section 302-2(d)]
On 1/16/11 at approximately 2:07 pm it was observed that an electrical junction box above the ceiling is not equipped with an approved cover at the room by AAU. [NFPA 70, Section 370-28(b)]
On 11/16/11 at approximately 2:11 pm it was observed that an electrical junction box is not equipped with an approved cover above the ceiling at the Nursing Supervisor ' s office. [NFPA 70, Section 370-28(b)]
On 11/16/11 at approximately 2:29 pm it was observed that temporary wiring was left above the ceiling at Room 217. [NFPA 70, Section 302-2(d)]
On 11/16/11 at approximately 2:50 pm it was observed that temporary wiring was left above the ceiling at the 2 hour barrier at a Dr. L's office door. [NFPA 70, Section 302-2(d)]
On 11/16/11 at approximately 2:58 pm it was observed that temporary wiring was left above the ceiling in Room 218. [NFPA 70, Section 302-2(d)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.
LIFE SAFETY CODE STANDARD
Tag No.: K0147
Based on observation and interview it was determined that the facility failed to maintain the electrical systems in accordance with the requirements of NFPA 70.
Findings include:
On 11/30/11 at approximately 2:53 pm it was observed that there is an unapproved multi-plug adapter being used in the Oncology Darkroom. [NFPA 70, Section 305-6(a)]
On 11/30/11 at approximately 4:00 pm it was observed that temporary wiring was left above the ceiling in the lobby between the two Oncology departments. [NFPA 70, Section 305-2(d)]
On 12/01/11 at approximately 9:30 am it was observed that temporary wiring was left above the ceiling at the Oncology clean utility room. [NFPA 70, Section 305-2(d)]
The above were observed and confirmed by the Director of Engineering and the Safety Officer.