HospitalInspections.org

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. Room # A468, there were penetrations in rated walls that were not properly sealed to maintain the required fire rating of the walls.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 8th Floor, North Tower,- Hemo, Corridor door with self closing device held open with Electro-Magnetic device , did not close upon activation of Fire Alarm as required.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. The fire door to the eight floor diverter shaft 125 is not self-closing and latching.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. There is a hole in the smoke barrier wall above doors 904A.

Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. 4 th Floor - Cross Corridor smoke doors ( # 077B) and (# A457) did not close for smoke tight seal when tested.

Based on observation, on April 26, 2011 at approximately 7:30 am onward,

1. There are holes in the door to housekeeping room M055 - the door equipped with a hasp that prevents exiting from inside the room.

2. Electrical rooms R-701 & 702 - 2-hr rated walls - There was no fire damper in Exhaust duct thru walls.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The special locking arrangements for selected doors are noncompliant based upon the following:

a. lack of complete installation in accordance with required building codes - locks at doors 40075C and CCU (7th floor) are not provided with a master release on/off switch at a supervised nurse's station.

2. 6th Floor , Stairwell #61, Exit door equipped with Mag- locks did not release with activation of Fire Alarm, the door did release with over ride switch at door. This must be corrected immediately.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. There is approximately a half inch gap between the meeting edge of fire doors RT01 - the astragal provided is not sufficient to maintain required fire rating.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The exit access doors require greater than a thirty pound force to set the doors in motion - doors from Chinese garden.

Based on observation, on April 26, 2011 at approximately 7:30am onward,

1. The horizontal sliding door to room R419 is used as an exit access door - the doors to similar rooms are not located within a suite of rooms.

Based on observation Monday , 4/25/2011 at approximately 1:00 PM onward :

1. 9th Floor : There was no lighting on Emergency Circuit ( LS Branch) for family waiting room # 90064

2. There was not exit discharge lighting in the exit discharge path from the first floor Reynolds to West & Watlington. (1st floor Reynolds)

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. There is no lighting identified on the Life Safety Branch of the essential electrical system in the following areas:

a. central corridor near the dialysis coordinator office - eight floor

b. corridor near bio-med office - eight floor

c. corridor near eight floor nurse's station

Based on observation, on April 26, 2011 at approximately 7:30am onward

1. There is no exit sign near cross corridor doors to fourth floor ICU - door 40075C.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. Staff in operating room suite was not familiar with unlabeled air handler shutdown switch - located at abandoned room in third floor north tower.

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. There is no smoke detector located within eight floor nurse's station area - near door hold-open device located in required smoke barrier.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. There is no sprinklers provided for closets located adjacent to corridors between rooms B-1119 and B-1120 - there are other similar closets on the same floor without sprinklers.


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2. Adult ED/ Fast Track - Room across from FT3 - Storage on shelves blocking sprinkler head coverage.

Based on observation on Monday 4/25/2011 at approx 1:00 PM onward:
1. K61 - potter tamper switches with cords are not approved by NFPA standards for monitoring four sprinkler control valves in main mechanical room.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. Sprinkler system components are incomplete in the following areas:

a. storage room 4B026 - utilizes green bulb sprinklers rated for 90 degrees Celsius.

b. staff lounge hallway sprinkler is cover with lint - near room 4B047.

c. room 4D066 - ceiling furring obstructs pendent sprinkler.

2. Sub-basement pump room - Tamper switch when tested did not send alarm.

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. mechanical systems in the following areas are incomplete:

a. mechanical room PH019 - duct penetrations of vertical chase are not equipped with service access openings and breakaway connections for fire dampers - could not verify installation a time of survey.

b. air handlers #3, and #4 are not equipped with emergency shutdown switch(es) - eight floor.

Based on observation, on April 27, 2011 at approximately 5:30am onward:

1. The soiled linen chute door will not self-close and latch - fifth floor soiled utility near A-577.

A. Based on observation, on April 25, 2011 at approximately 1:00pm onward:

1. There is unattended storage of impediments in the corridor near eight floor elevators - items were not in immediate and continuous use. Note: This condition existed thru-out the entire campus in several areas.

2. Flat screen monitors, mounted on corridor walls, extend greater than three and one half inches into required corridor headroom clearance - located in area containing room R-408.


3. 7th Floor - Wall mounted charting tables in the corridor that were not self retracting/closing

4. Linen Closets at room R709 - with Corridor doors not self closing or open 180 degrees.

Based on observation, on April 27, 2011 at approximately 8:00am onward,

1.There are full and empty oxygen cylinders are intermingled in the same storage racks - north tower, third floor operating room suite, 5th Floor Respitory Therapy.

Based on observation on Monday 4/25/2011 at approximately 1:00 PM onward:

1. Oxygen/ Med Gas gauges not registering correctly - could not test alarms.

Based on observation, on April 26, 2011 at approximately 8:00am onward,

1. There is no lighting identified on the Critical Branch of the essential electrical system in the following area:

a. eight floor nurse's station

2. Fire alarm power supply, circuit #27, is wired to critical branch panelboard CL-4-C - panelboard is located in room 4D068.

Based on observation, on April 25, 2011 at approximately 1:00pm onward,

1. electrical systems are incomplete in the following areas:

a. exposed bulb fluorescent light fixture is used above storage shelf - penthouse floor storage room near cafeteria.

b. medication refrigerator in medication preparation room is connected to normal power receptacle - eight floor.

c. light in medication preparation room is not connected to the critical branch of the essential electrical system - eight floor.