HospitalInspections.org

Based on observation and interview, the facility failed to ensure doors that opened onto corridors with means to keep them closed, kept them closed. This has the potential to affect all patients and visitors to the facility. The census of the facility was 568 patients.

Findings include:

1.On 05/11/16 at 2:50 PM observation of doors to bathrooms 3289 and 3288 revealed them to be open by approximately one inch to corridor. Further observation revealed they had self-closing hardware, that when tested did not completely close the doors.

On 05/11/16 at 2:50 PM in an interview, Staff Q confirmed the finding.

2. On 05/11/16 at 3:12 PM observation of non-cross corridor double doors to room 3280 revealed they were in a one hour barrier, did not have a coordinator, and did not completely close when tested.

On 05/11/16 at 3:12 PM in an interview, Staff R confirmed the finding.

3. On 05/11/16 at 3:40 PM observation of non-cross corridor double doors to room nw3230 revealed they did not close and latch. Further observation revealed nw3230 contained oxygen storage.

On 05/11/16 at 3:40 PM in an interview, Staff Q confirmed the finding.

4. On 05/11/16 at 4:03 PM observation of the corridor doors to the men's and women's bathrooms opposite room NW1354 revealed they were open to the corridor by approximately one to two inches. Further observation revealed they both had self-closing hardware that when tested did not close the doors.

On 05/11/16 at 4:03 PM in an interview, Staff Q confirmed the finding.

Based on Life Safety Plan review, observations and staff interview the facility failed to ensure the two hour construction was maintained around vertical openings. This has the potential to affect all patients and visitors in the facility. The facility census was 568.

Findings include:

Observations were made on 05/10/16 at 11:54 AM above the drop ceiling on the fourth floor in conference room SE 4117, and revealed drywall was not sealed around the steel beam in the east wall for Stair-W, leaving an open gap at the beam in that wall section.

This observation was confirmed by Staff M in an interview.





31007

Based on observation and interview, the facility failed to maintain the stated rating of barriers protecting vertical openings. This has the potential to affect all patients and visitors to the facility. The census of the facility was 568 patients.

Findings include:

On 05/11/16 at 3:25 PM observation of the vertical opening in the bedroom area of the trauma attending room located near the elevators revealed in a one hour barrier a two foot by two foot section of single layer drywall.

On 05/11/16 at 3:25 PM in an interview, Staff Q confirmed the finding.



31007

Based on observation and interview, the facility failed to ensure its rated barriers were free of penetrations and their rating maintained. This has the potential to affect all patients and visitors to the facility. The census of the facility was 568 patients.

Findings include:

1.On 05/11/16 at 11:07 AM observation of the double doors in a two hour barrier near an old alcove 2227A revealed they did not have an astragal at the meeting edges to cover a gap of greater than one-eighth of an inch.

2. On 05/11/16 at 11:07 AM observation of the two hour fire barrier over the double doors revealed next to where there is stenciling on the wall that read "2 hour" there were two smooth and two corrugated conduits open to air.

On 05/11/16 at 11:07 AM in an interview, Staff Q confirmed both findings.

3. On 05/11/16 at 11:25 AM observation above the drop down ceiling of supply storage room m2374 revealed a three feet by one foot single layer of drywall with exposed wall studs in the west one hour barrier.

On 05/11/16 at 11:25 AM in an interview, Staff R confirmed the observation.

4. On 05/11/16 at 3:50 PM observation above the drop down ceiling of the one hour barrier over the double doors perpendicular to room NW2297 revealed an open a four inch sleeve holding multiple blue wires.

On 05/11/16 at 3:50 PM in an interview Staff S confirmed the observation stating he found some fire stop material on top of the tile and believed it came out when new wiring was run.

5. On 05/11/16 at 4:10 PM observation above the drop down ceiling at the west wall of dressing area NW1313 revealed three open corrugated conduits which traveled to a junction box and then on through the one hour barrier.

On 05/11/16 at 4:10 PM in an interview Staff Q and R confirmed the observation.




31007

Based on observation and interview, the facility failed to have each door in a two hour rated barrier rated. This has the potential to affect all patients and visitors to the facility. The census of the facility was 568 patients.

Findings include:

On 05/11/16 at 11:52 AM observation above of the single door to the café, west of the main entrance, and located within a two hour barrier revealed it was not rated.

On 05/11/16 at 11:52 AM in an interview, Staff R confirmed the observation.



31007

Based on Life Safety Plan review, observations and staff interview the facility failed to ensure the walls were constructed of at least one hour protection rating around hazardous areas. This has the potential to affect all patients and visitors in the facility. The census was 568.

Findings Include:

1. Observations were made on 05/10/16 above the drop ceiling on the seventh floor in Clean Utility Room 7136, and revealed two 3/4 inch flex conduits with data cables open on the ends above the door to the corridor.

These findings were confirmed by Staff M at 10:30 AM in an interview.

2. Observations were made on 05/10/16 above the drop ceiling on the 4th floor in the equipment room 4137, and revealed a two inch by ten inch gap between the gypsum board and the steel column.

This observation was confirmed by Staff T at 11:40 AM in an interview.





31007

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients and visitors to the facility. The census of the facility was 568 patients.

Findings include:

1.On 05/11/16 at 5:30 PM the facility ' s damper documentation was reviewed with Staff T. The review revealed five dampers that failed, were repaired, and failed again. Three were in the southwest development building and two were in the northwest development building.

On 05/11/16 at 5:30 PM in an interview, Staff T could not show whether they were now functional.

2. The review revealed in the northwest development building five dampers had the description of their repair read, "remove damper or lock in open position." The description did not say which was done.

On 05/11/16 at 5:30 PM in an interview, Staff T could not say which was done.

3. The review revealed five other dampers in the southwest development building where, although they passed, there wasn't a picture, to show their functionality.

4. On 05/11/16 at 3:07 PM observation above the drop down ceiling over the door leading to room NW3280D revealed two dampers, one of which had text on it stating, "fire damper leaks top. "

On 05/11/16 at 3:07 PM in an interview, Staff R confirmed the observation.

5. On 05/11/16 at 3:45 PM observation above the drop down ceiling of room NW2292B revealed a one foot by six inch damper in the west wall, and a one foot by one foot damper in the south wall.

On 05/11/16 at 3:45 PM in an interview, Staff Q and R confirmed the finding.

On 05/11/16 at 5:30 PM in an interview, Staff T was unable to find evidence of testing for the dampers observed in rooms NW3280D and NW2292B had been tested.