HospitalInspections.org

Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 1.1.4.1, 19.1.1.4.2.

Findings include:

On 7/15/10, at approximately 10:00 a.m., during inspections of the two-hour building separations with the Facility Director, the following observations were made.

1. Observed open conduit through two-hour building separation between building A & B on the second floor with no fire stopping material in the conduit.

2. Observed open penetrations through two-hour building separation between building A & B on the first floor with no fire stopping material in the open penetrations.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3.

Findings include:

On 7/27/10, at approximately 11:45 a.m., during inspections of corridor doors with the Facility Director, the following observation was made.

1. Observed the corridor door of Employee Health Coordinators office to have two holes through the door. (Niles)

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1.

Findings include:

On 7/15/10, at approximately 11:00 a.m., during inspections of vertical openings with the Facility Director, the following observations were made.

1. Observed the door to the linen chute on the second floor of building A to be bent and out of adjustment not allowing the door to close to a positive latch.

2. Observed the door of the second floor stairwell A2043 not self-close to a positive latch.

3. Observed two electrical boxes with conduits through the stairwell wall above the door to stairwell A 1003 open through the wall.

On 7/19/10, at approximately 10:00 a.m., during inspections of vertical openings with the Facility Director, the following observations were made.

1. Observed third floor stairwell B NE to have a hole in the stairwell wall approximately 6" long and 1" wide.

2. Observed a conduit and grey cable through corridor wall of stairwell F second floor of the B building open through the wall.

On 7/27/10, at approximately 9:00 a.m., during inspections of vertical openings with the Facility Director, the following observations were made.

1. Observed door to the second floor trash chute not self-close to a positive latch. (Niles)

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

Findings include:

On 7/15/10, at approximately 1:00 p.m., during inspections of smoke barrier walls with the Facility Director, the following observations were made.

1. Observed 1" conduit with blue wires penetrating the smoke barrier wall in room # 2079 with the ends of the conduit open.

2. Observed electrical conduit penetrating the smoke barrier wall across from room # 3023 with the conduit not fire stopped.

3. Observed electrical conduit penetrating the smoke barrier wall above door to room # 3052 with the conduit not fire stopped.

4. Observed 1" conduit with blue wires penetrating the smoke barrier wall above door to room # 3058 with the ends of the conduit open.

5. Observed electrical conduit penetrating the smoke barrier wall next to the third floor service elevator building A with the conduit not fire stopped.

6. Observed approximately 2" x 2" hole in the smoke barrier wall above door to room # 3074.

7. Observed hole behind electrical box in smoke barrier wall above door to room # 3079 not fire stopped.

8. Observed hole in smoke barrier wall next to room # A 1038 not fire stopped.

9. Observed 2" conduit with wires penetrating the smoke barrier wall above the door to room # 1052 with the ends of the conduit open.

On 7/19/10, at approximately 10:00 a.m., during inspections of smoke barrier walls with the Facility Director, the following observations were made.

1. Observed smoke barrier wall above cross corridor smoke barrier doors next to the fourth floor soiled utility room B building to have three pipes through the smoke barrier wall not fire stopped.

2. Observed the east smoke barrier wall of the joint camp room to have several penetrations through the wall, and the smoke barrier wall not finished to the deck.

3. Observed the fourth floor B building managers office to have a sprinkler pipe and electrical conduit through the smoke barrier wall and the top of wall not fire stopped.

4. Observed the fourth floor B building staff rest room next to the nurses station to have several penetrations through the smoke barrier wall and the top of wall not fire stopped.

5. Observed the smoke barrier wall above the cross-corridor doors next to room # 487 not finished to the deck as required.

6. Observed the smoke barrier wall in room # 487 not finished to the deck as required.

7. Observed penetration through smoke barrier wall above smoke barrier doors next to room # 3397.

8. Observed several penetrations of the smoke barrier wall in room # 3397.

9. Observed several penetrations of the smoke barrier wall in room # 3387.

10. Observed the smoke barrier wall next to room # 3379 not finished to the deck as required.

11. Observed the smoke barrier wall above the door next to critical care second floor B building to have two open conduits through the wall with the ends of the conduit open.

12. Observed the second floor B building patient care managers office to have several penetrations through the smoke barrier wall and the top of wall not fire stopped.

13. Observed the smoke barrier wall above the door to CC Family waiting room to have an electrical conduit, black cables and a grey wire through the smoke barrier wall not fire stopped.

14. Observed the cross-corridor smoke barrier wall next to the Cafe entrance to have holes through the wall and a 4" conduit 100% filled with wires not fire stopped.

15. Observed the cross-corridor smoke barrier wall next to the Cafe entrance to have the top of the wall finished with a non UL listed top of wall assembly.

16. Observed a bundle of wires through the smoke barrier wall next to the door of the Lobby/Family waiting room first floor B building not fire stopped.

17. Observed the smoke barrier wall above the cross-corridor smoke barrier doors next to the rear entrance of the Cafe to have a bundle of wires and two new security flex cables not fire stopped.

18. Observed the smoke barrier wall across from the employee health office to have a conduit through the wall not fire stopped.

19. Observed conduit penetrating the smoke barrier wall above the door to the Chaplain office with the ends of the conduit open.

On 7/27/10, at approximately 2:00 p.m., during inspections of smoke barrier walls with the Facility Director, the following observations were made.

1. Observed black cable and pipe through the smoke barrier wall outside the Unit supervisors office third floor not fire stopped. (Niles)

2. Observed a yellow wire through the smoke barrier wall in the second floor women restroom not fire stopped. (Niles)

3. Observed bundle of grey & black wires through the smoke barrier wall above the double doors to OB not fire stopped. (Niles)

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6.

Findings include:

On 7/19/10, at approximately 3:00 p.m., during inspections of smoke barrier doors with the Facility Director, the following observations were made.

1. Observed door to room # 3387 to be in a smoke barrier wall and the door does not have a self-closing device as required.

2. Observed door to wheel chair storage room across from room # 3386 to be in a smoke barrier wall and the door was being held open with wheel chairs not allowing the door to close as required.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1.

Findings include:

On 7/15/10, at approximately 3:00 p.m., during inspections of hazard rooms with the Facility Director, the following observations were made.

1. Observed 1" empty conduit through the north wall of the first floor clean supply room open on the ends of the conduit.

2. Observed seven conduits and the top of the wall not finished in the south wall of the transportation equipment storage room.

3. Observed two conduits through the corridor wall of the basement soiled holding room open on the ends of the conduit.

On 7/19/10, at approximately 1:00 p.m., during inspections of hazard rooms with the Facility Director, the following observations were made.

1. Observed a sprinkler pipe and a grey wire through the wall of the labor & delivery soiled utility/storage room not fire stopped.

2. Observed pipes and wires through the wall of the storage room across from room # 3003 not fire stopped.

3. Observed a patient room second floor B building being used as a storage room. The room does not meet storage room requirements.

4. Observed pipes through the wall of the Mechanical room second floor B building not fire stopped.

5. Observed a janitors closet door in the second floor recovery area that does not have a self-closing device on the door as required.

On 7/22/10, at approximately 4:00 p.m., during inspections of hazard rooms with the Facility Director, the following observations were made.

1. Observed the janitors closet door in the kitchen area not self-close to a positive latch.

2. Observed the janitors closet door across from the EMS office blocked by a cleaning cart not allowing the door to close to a positive latch.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1.

Findings include:

On 7/22/10, at approximately 9:00 a.m., during inspections of exits with the Facility Director, the following observations were made.

1. Observed three kids tables, several chairs and a bookshelf in the exit corridor blocking the path of egress out of the marked exit door from the Emergency Room waiting area.

2. Observed the main entrance to the OB area to have a power operated cross-corridor door. The door has panic hardware; but when you push on the door hardware, the door does not open without excess force.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5.

Findings include:

On 7/27/10, at approximately 4:00 p.m., during inspections of sprinkler system with the Facility Director, the following observation was made.

1. Observed the CEM PAK storage room to have only one sprinkler head in the room. The single sprinkler head does not provide proper coverage of the entire room.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5.

Findings include:

On 7/19/10, at approximately 11:20 a.m., during inspections of the sprinkler system with the Facility Director, the following observations were made.

1. Observed the sprinkler line in the fifth floor B building student lounge to have a wireless Internet box attached to the sprinkler line.

2. Observed the sprinkler head in room # 3398 to be missing an escutcheon.

3. Observed the sprinkler head in the data closet second floor B building to be up in the ceiling. The ceiling is a hard lid and the sprinkler head is only half exposed.

4. Observed the central supply room to be missing several ceiling tiles. The ones that are in place have several holes in the tiles. This is a sprinklered room.

On 7/22/10, at approximately 9:15 a.m., during inspections of the sprinkler system with the Facility Director, the following observation was made.

1. Observed several sprinkler heads in the lab to be missing escutcheons.

Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 1.1.4.1, 19.1.1.4.2.

Findings include:

On 7/15/10, at approximately 10:00 a.m., during inspections of the two-hour building separations with the Facility Director, the following observations were made.

1. Observed open conduit through two-hour building separation between building A & B on the second floor with no fire stopping material in the conduit.

2. Observed open penetrations through two-hour building separation between building A & B on the first floor with no fire stopping material in the open penetrations.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3.

Findings include:

On 7/27/10, at approximately 11:45 a.m., during inspections of corridor doors with the Facility Director, the following observation was made.

1. Observed the corridor door of Employee Health Coordinators office to have two holes through the door. (Niles)

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1.

Findings include:

On 7/15/10, at approximately 11:00 a.m., during inspections of vertical openings with the Facility Director, the following observations were made.

1. Observed the door to the linen chute on the second floor of building A to be bent and out of adjustment not allowing the door to close to a positive latch.

2. Observed the door of the second floor stairwell A2043 not self-close to a positive latch.

3. Observed two electrical boxes with conduits through the stairwell wall above the door to stairwell A 1003 open through the wall.

On 7/19/10, at approximately 10:00 a.m., during inspections of vertical openings with the Facility Director, the following observations were made.

1. Observed third floor stairwell B NE to have a hole in the stairwell wall approximately 6" long and 1" wide.

2. Observed a conduit and grey cable through corridor wall of stairwell F second floor of the B building open through the wall.

On 7/27/10, at approximately 9:00 a.m., during inspections of vertical openings with the Facility Director, the following observations were made.

1. Observed door to the second floor trash chute not self-close to a positive latch. (Niles)

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

Findings include:

On 7/15/10, at approximately 1:00 p.m., during inspections of smoke barrier walls with the Facility Director, the following observations were made.

1. Observed 1" conduit with blue wires penetrating the smoke barrier wall in room # 2079 with the ends of the conduit open.

2. Observed electrical conduit penetrating the smoke barrier wall across from room # 3023 with the conduit not fire stopped.

3. Observed electrical conduit penetrating the smoke barrier wall above door to room # 3052 with the conduit not fire stopped.

4. Observed 1" conduit with blue wires penetrating the smoke barrier wall above door to room # 3058 with the ends of the conduit open.

5. Observed electrical conduit penetrating the smoke barrier wall next to the third floor service elevator building A with the conduit not fire stopped.

6. Observed approximately 2" x 2" hole in the smoke barrier wall above door to room # 3074.

7. Observed hole behind electrical box in smoke barrier wall above door to room # 3079 not fire stopped.

8. Observed hole in smoke barrier wall next to room # A 1038 not fire stopped.

9. Observed 2" conduit with wires penetrating the smoke barrier wall above the door to room # 1052 with the ends of the conduit open.

On 7/19/10, at approximately 10:00 a.m., during inspections of smoke barrier walls with the Facility Director, the following observations were made.

1. Observed smoke barrier wall above cross corridor smoke barrier doors next to the fourth floor soiled utility room B building to have three pipes through the smoke barrier wall not fire stopped.

2. Observed the east smoke barrier wall of the joint camp room to have several penetrations through the wall, and the smoke barrier wall not finished to the deck.

3. Observed the fourth floor B building managers office to have a sprinkler pipe and electrical conduit through the smoke barrier wall and the top of wall not fire stopped.

4. Observed the fourth floor B building staff rest room next to the nurses station to have several penetrations through the smoke barrier wall and the top of wall not fire stopped.

5. Observed the smoke barrier wall above the cross-corridor doors next to room # 487 not finished to the deck as required.

6. Observed the smoke barrier wall in room # 487 not finished to the deck as required.

7. Observed penetration through smoke barrier wall above smoke barrier doors next to room # 3397.

8. Observed several penetrations of the smoke barrier wall in room # 3397.

9. Observed several penetrations of the smoke barrier wall in room # 3387.

10. Observed the smoke barrier wall next to room # 3379 not finished to the deck as required.

11. Observed the smoke barrier wall above the door next to critical care second floor B building to have two open conduits through the wall with the ends of the conduit open.

12. Observed the second floor B building patient care managers office to have several penetrations through the smoke barrier wall and the top of wall not fire stopped.

13. Observed the smoke barrier wall above the door to CC Family waiting room to have an electrical conduit, black cables and a grey wire through the smoke barrier wall not fire stopped.

14. Observed the cross-corridor smoke barrier wall next to the Cafe entrance to have holes through the wall and a 4" conduit 100% filled with wires not fire stopped.

15. Observed the cross-corridor smoke barrier wall next to the Cafe entrance to have the top of the wall finished with a non UL listed top of wall assembly.

16. Observed a bundle of wires through the smoke barrier wall next to the door of the Lobby/Family waiting room first floor B building not fire stopped.

17. Observed the smoke barrier wall above the cross-corridor smoke barrier doors next to the rear entrance of the Cafe to have a bundle of wires and two new security flex cables not fire stopped.

18. Observed the smoke barrier wall across from the employee health office to have a conduit through the wall not fire stopped.

19. Observed conduit penetrating the smoke barrier wall above the door to the Chaplain office with the ends of the conduit open.

On 7/27/10, at approximately 2:00 p.m., during inspections of smoke barrier walls with the Facility Director, the following observations were made.

1. Observed black cable and pipe through the smoke barrier wall outside the Unit supervisors office third floor not fire stopped. (Niles)

2. Observed a yellow wire through the smoke barrier wall in the second floor women restroom not fire stopped. (Niles)

3. Observed bundle of grey & black wires through the smoke barrier wall above the double doors to OB not fire stopped. (Niles)

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6.

Findings include:

On 7/19/10, at approximately 3:00 p.m., during inspections of smoke barrier doors with the Facility Director, the following observations were made.

1. Observed door to room # 3387 to be in a smoke barrier wall and the door does not have a self-closing device as required.

2. Observed door to wheel chair storage room across from room # 3386 to be in a smoke barrier wall and the door was being held open with wheel chairs not allowing the door to close as required.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1.

Findings include:

On 7/15/10, at approximately 3:00 p.m., during inspections of hazard rooms with the Facility Director, the following observations were made.

1. Observed 1" empty conduit through the north wall of the first floor clean supply room open on the ends of the conduit.

2. Observed seven conduits and the top of the wall not finished in the south wall of the transportation equipment storage room.

3. Observed two conduits through the corridor wall of the basement soiled holding room open on the ends of the conduit.

On 7/19/10, at approximately 1:00 p.m., during inspections of hazard rooms with the Facility Director, the following observations were made.

1. Observed a sprinkler pipe and a grey wire through the wall of the labor & delivery soiled utility/storage room not fire stopped.

2. Observed pipes and wires through the wall of the storage room across from room # 3003 not fire stopped.

3. Observed a patient room second floor B building being used as a storage room. The room does not meet storage room requirements.

4. Observed pipes through the wall of the Mechanical room second floor B building not fire stopped.

5. Observed a janitors closet door in the second floor recovery area that does not have a self-closing device on the door as required.

On 7/22/10, at approximately 4:00 p.m., during inspections of hazard rooms with the Facility Director, the following observations were made.

1. Observed the janitors closet door in the kitchen area not self-close to a positive latch.

2. Observed the janitors closet door across from the EMS office blocked by a cleaning cart not allowing the door to close to a positive latch.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1.

Findings include:

On 7/22/10, at approximately 9:00 a.m., during inspections of exits with the Facility Director, the following observations were made.

1. Observed three kids tables, several chairs and a bookshelf in the exit corridor blocking the path of egress out of the marked exit door from the Emergency Room waiting area.

2. Observed the main entrance to the OB area to have a power operated cross-corridor door. The door has panic hardware; but when you push on the door hardware, the door does not open without excess force.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5.

Findings include:

On 7/27/10, at approximately 4:00 p.m., during inspections of sprinkler system with the Facility Director, the following observation was made.

1. Observed the CEM PAK storage room to have only one sprinkler head in the room. The single sprinkler head does not provide proper coverage of the entire room.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5.

Findings include:

On 7/19/10, at approximately 11:20 a.m., during inspections of the sprinkler system with the Facility Director, the following observations were made.

1. Observed the sprinkler line in the fifth floor B building student lounge to have a wireless Internet box attached to the sprinkler line.

2. Observed the sprinkler head in room # 3398 to be missing an escutcheon.

3. Observed the sprinkler head in the data closet second floor B building to be up in the ceiling. The ceiling is a hard lid and the sprinkler head is only half exposed.

4. Observed the central supply room to be missing several ceiling tiles. The ones that are in place have several holes in the tiles. This is a sprinklered room.

On 7/22/10, at approximately 9:15 a.m., during inspections of the sprinkler system with the Facility Director, the following observation was made.

1. Observed several sprinkler heads in the lab to be missing escutcheons.