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Based on observation and interview, the facility failed to maintain the two-hour fire resistance rating of common walls to a non-conforming building in one location, on one of four floors.

Findings include:

Observation on March 3, 2010, at 10:20 AM revealed an unsealed penetration inside a conduit containing blue, yellow and white wires, above fire door A.3.5, located on the 3rd Floor.

Interview with the Director of Facilities on March 3, 2010, at 10:20 AM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed the unsealed penetration and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined the facility failed to protect structural steel maintaining the fire resistive construction of the building in two locations, on two of six floors.

Findings include:

1. Observation on March 2, 2010, at 11:40 AM, revealed there was exposed structural steel in Building C Penthouse, by electrical panel P.12.

Interview with the Director of Facilities on March 2, 2010, at 11:40 AM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed that there was an exposed area of the steel beam.

2. Observation on March 3, 2010, at 11:43 AM, revealed there was a 16-inch x 16-inch area of an exposed structural steel I-beam, where the fire resistive coating was removed in the interstitial space on the 3rd Floor.

Interview with the Supervisor of Facilities on March 3, 2010, at 11:43 AM and again at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed that there was an exposed area of the steel beam.

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of an elevator shaft in one location, on one of six floors.

Findings include:

Observation on March 3, 2010, at 1:11 PM revealed that there was an unsealed penetration inside an MC cable penetrating the elevator shaft, in the 2nd Floor CSS area.

Interview with the Supervisor of Facilities on March 3, 2010, at 1:11 PM, and again at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed there was an unsealed penetration in the elevator shaft and the subsequent correction of the deficiency during the survey.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in five locations, on three of five floors.

Findings include:

1. Observation on March 2, 2010, at 11:51 AM revealed the Basement corridor wall above the smoke barrier doors near the Mechanical Room had a one-inch penetration.

Interview with the Supervisor of Facilities on March 2, 2010, at 11:51 AM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed there was a smoke barrier wall penetration and the subsequent correction during the survey.

2. Observation on March 2, 2010, at 1:20 PM revealed that the 4th Floor Materials Management Office smoke barrier wall was not sealed on the right side of a steel I-beam, behind the door.

Interview with the Director of Facilities on March 2, 2010, at 1:20 PM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed the unsealed penetration.

3. Observation on March 3, 2010, between 9:20 AM and 1:47 PM revealed the following unsealed smoke barrier penetrations:

a) 9:20 AM, inside a conduit with white wire, inside an approximate one-inch hole and an approximate one-inch x two-inch hole, located above the 4th Floor OR Control Room window;
b) 1:30 PM, an approximate two-inch piece of drywall was missing, above the 2nd Floor Electrical Room smoke door (M.2.106);
c) 1:47 PM, a section of drywall was pulled away from the wall leaving an unsealed penetration, in the corridor by the 2nd Floor Director of Critical Care Office.

Interview with the Director of Facilities on March 3, 2010, at 1:47 PM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed the unsealed penetrations and the subsequent correction of items a, b, and c at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barriers in accordance with the regulations in one location, on one of five floors.

Findings include:

Observation on March 3, 2010, at 11:15 AM revealed the 3rd Floor corridor double doors, by the Hospitalist Office, were equipped with a mechanism (thermal plunger) installed at the meeting edge, which when activated, would prevent movement from one smoke zone to another.

Interview with the Director of Facilities on March 3, 2010, at11:15 AM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed that the smoke barrier doors were equipped with a locking mechanism.

Based on observation and interview, it was determined the facility failed to provide the proper fire resistance rating of smoke barrier openings in two locations, on one of five floors.

Findings include:

1. Observation on March 2, 2010, at 1:12 PM revealed that smoke barrier door S.C.4.4-279 to the 4th Floor Consultation Room was equipped with a plain/tempered glass vision panel.

Interview with the Director of Facilities on March 2, 2010, at 1:12 PM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed that the door was equipped with a plain glass vision panel.

2. Observation on March 3, 2010, at 9:17 AM revealed that the approximate three foot x three foot OR Control Room window, which is part of a smoke wall located on the 4th Floor, was equipped with plain/tempered glass.

Interview with the Director of Facilities on March 3, 2010, at 9:17 AM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed that the door was equipped with a plain glass vision panel.

Based on observation and interview, it was determined the facility failed to provide the proper fire resistance rating of hazardous areas in five locations, on three of five floors. 19.3.2.1

Findings include:

1. Observation on March 3, 2010, between 9:59 AM and 11:39 AM revealed the following hazardous areas unsealed penetrations:

a) 9:59 AM, 1st Floor ED Equipment Storage Room, inside a conduit near the ceiling fan;
b) 10:45 AM, 1st Floor C1 X-Ray Film Storage Room, inside a conduit and above a four-inch sprinkler pipe;
c) 11:35 AM, M Basement Telephone Room, has six holes;
d) 11:39 AM, M Basement, behind Return Fan #17, has a two-inch hole near ceiling.

Interview with the Supervisor of Facilities on March 3, 2010, at 11:39 AM and again at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing confirmed the unsealed penetrations and the subsequent correction of same during the survey.

2. Observation on March 3, 2010, at 10:05 AM revealed an unsealed penetration inside a conduit, through the 4th Floor OR Equipment Storage Room, by the Staff Lounge.

Interview with the Director of Facilities on March 3, 2010, at 10:05 AM and again at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing confirmed the unsealed penetration and the subsequent correction of the deficiency during the survey.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of exit component enclosures in three locations, on three of six floors.

Findings include:

1. Observation on March 2, 2010, at 11:30 AM revealed the following unsealed penetrations to Building E Penthouse stair tower:

a) the wall facing the penthouse was not sealed between the flutes, at the corrugated deck;
b) around steel I-beams;
c) the drywall was not sealed to the block wall inside the stair;
d) inside a conduit with white wire above the door, outside of the stair tower.

Interview with the Director of Facilities on March 2, 2010, at 11:30 AM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed the unsealed penetrations.

2. Observation on March 3, 2010, at 10:55 AM revealed two unsealed penetrations above the 3rd Floor Pediatric stair tower door (C.3.26), by the Staff Lounge.

Interview with the Director of Facilities on March 3, 2010, at 10:55 AM and again at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed the unsealed penetration above the door.

3. Observation on March 3, 2010, at 10:59 AM revealed that there was a large penetration around a sprinkler pipe, above the 1st Floor C1 X-Ray Room spiral staircase door.

Interview with the Supervisor of Facilities on March 3, 2010, at 10:59 AM and again at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed there was an unsealed penetration above the door.

Based on observation and interview, the facility failed to maintain battery-powered emergency lighting in one location, on one of six floors.

Findings include:

Observation on March 3, 2010, at 2:45 PM revealed the battery-operated emergency lights in the E Basement Electrical Room had a dead battery.

Interview with the Supervisor of Facilities on March 3, 2010, at 2:45 PM and again at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed the battery-operated emergency lights were inoperable.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage areas in accordance with regulations in one location, on one of five floors.

Findings include:

Observation on March 3, 2010, at 10:42 AM revealed that the oxygen cylinders located in the 3rd Floor Pediatric Clean Storage Room were not separated full and empty.

Interview with the Director of Facilities on March 3, 2010, at 10:42 AM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed that the cylinders were not separated and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, the facility failed to maintain the proper use of surge protectors in one location, on one of six floors.

Findings include:

Observation on March 2, 2010, at 9:45 AM revealed that a microwave and refrigerator were plugged into a surge protector, in the 4th Floor Department of Anesthesia Chairman's Office.

Interview with the Director of Facilities on March 2, 2010, at 9:45 AM and again on March 3, 2010, at 3:00 PM with the Director of Facilities and Supervisor of Facilities during the Exit Briefing, confirmed the improper use of the surge protector.