HospitalInspections.org

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in six locations on three of nine total floors.

Findings include:

1. Observation of various aspects of building construction requirements between 1:25 p.m. on September 12, 2011, and 09:01 a.m. on September 13, 2011, revealed the below deficiencies:

a. Combustible construction plastic materials were noted beyond the suspended ceiling assembly within the first floor Admissions Suite at 1:25 p.m. on September 12, 2011.

b. Horizontal structural steel located within the first floor Medical Records Suite requires touch-up spray fireproofing (closest to the dumb waiter.) 1:34 p.m. on September 12, 2011.

c. Insulating materials exhibiting combustible paper backing were noted beyond the suspended ceiling assembly within the Doctor's Library at 1:55 p.m. on September 12, 2011. Note: at exterior bearing wall location.

d. Two structural steel columns within the first floor Doctor's Library exhibit unprotected, noncombustible, building construction characteristics. 1:52 p.m. and 1:58 p.m. on September 12, 2011.

e. A column located within the basement-level Dietary Department exhibits unprotected, noncombustible, building construction characteristics. 08:33 a.m. on September 13, 2011.

f. Horizontal structural steel within the third floor Pediatrics Suite requires spray fireproofing (closest to Nurse's Station.) 09:01 a.m. on September 13, 2011.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on September 13, 2011, confirmed the above building construction deficiencies.

Based upon observation and interview, it was determined the facility failed to maintain one vertical opening in one location on one of nine floors.

Findings include:

Observation of the third floor portion of the shaft enclosure located at the A and B Wing crossover at 2:20 p.m. on September 12, 2011, revealed a duct penetration within the enclosure to require a seal of the annular spaces.

Interview with facilities manager at 2:21 p.m. on September 12, 2011, confirmed the shaft enclosure penetration.

Based upon observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall in one location on one of one floors.

Findings include:

Observation of the portion of the smoke barrier separation wall located closest to the electrical room entrance door at 11:23 a.m. on September 12, 2011, revealed a penetration beyond the smoke barrier separation doors.

Interview with facilities manager at 11:24 a.m. on September 12, 2011, confirmed the smoke barrier separation wall penetration.

Based upon observation and interview, it was determined the facility failed to maintain one hazardous area enclosure in one location on one of nine floors.

Findings include:

Observation of the first floor Medical Records Suite entrance door at 1:38 p.m. on September 12, 2011, revealed the door to lack a self-closing device.

Interview with facilities manager at 1:39 a.m. on September 12, 2011, confirmed the door to lack a self-closing device.

Based upon observation and interview, it was determined the facility failed to maintain one exit stair tower in one location on one of nine floors.

Findings include:

Observation of the basement-level portion of the Colfax stair tower at 2:06 p.m. on September 12, 2011, revealed three wheelchairs, each with an "e-style" oxygen cylinder, to be stored within this enclosure.

Interview with facilities manager at 2:07 p.m. on September 12, 2011, confirmed the storage within the stair tower.

Based upon observation and interview, it was determined the facility failed to install illuminated exit signage in six locations on six of nine floors.

Findings include:

Observation of the D Wing exit access corridor systems between 2:03 p.m. and 2:23 p.m. on September 12, 2011, revealed illuminated exit signage lacking on floors three through eight in the vicinity of the Mulberry Street windows.

Interview with facilities manager at 2:25 p.m. on September 12, 2011, confirmed the lack of exit signage in the above locations.

Based upon observation and interview, it was determined the facility failed to maintain the automatic sprinkler systems in two locations on two of nine total floors.

Findings include:

1. Observation of various aspects of the automatic sprinkler systems between 12:45 p.m. on September 12, 2011, and 09:10 a.m. on September 13, 2011, revealed the below deficiencies:

a. Miscellaneous wiring is affixed to branch sprinkler piping within the first floor Main Lobby area (closest to reception.) at 12:45 p.m. on September 11, 2011.

b. Miscellaneous wiring affixed to branch sprinkler piping was noted within the third floor Pediatrics Department (closest to the Nurse's Station) at 09:10 a.m. on September 13, 2011.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on September 13, 2011, confirmed the wiring affixed to the sprinkler piping.

Based upon observation and interview, it was determined the facility failed to construct and maintain one soiled linen chute termination room in one location on one of nine floors.

Findings include:

Observation of the basement-level soiled linen chute termination room at 08:54 a.m. on September 13, 2011, revealed the enclosure to lack required two-hour fire resistive integrity on one of four enclosure walls. Note: recessed lighting fixture removed from monolithic ceiling assembly revealed one of four walls open beyond ceiling assembly and subsequent floor slab assembly.

Interview with facilities manager at 08:55 a.m. on September 13, 2011, confirmed the enclosure wall to lack required two-hour fire resistive integrity.

Based upon observation and interview, it was determined the facility failed to construct and maintain one medical gas storage room in one location on one of one floors.

Findings include:

Observation of the Emergency Department oxygen storage room at 11:58 a.m. on September 12, 2011, revealed the electrical switch within to be installed less than sixty inches from finished floor level.

Interview with facilities manager at 11:59 a.m. on September 12, 2011, confirmed the electrical switch placement.

Based upon observation and interview, it was determined the facility failed to maintain one oxygen storage location in three instances on one of nine total floors.

Findings include:

1. Observation of the third floor oxygen storage room located within the D Wing between 2:16 p.m. and 2:18 p.m. on September 12, 2011, revealed the below deficiencies:

a. The electrical switch is located less than sixty inches from finished floor level. 2:16 p.m.

b. The enclosure entrance door lacks smoke-tight integrity when coupled with the adjacent door frame assembly. 2:17 p.m.

c. The entrance door lacks proper signage depicting it as an oxygen storage location.

Interview with facilities manager at 2:19 p.m. on September 12, 2011, confirmed the oxygen storage room issues stated above.

Based upon observation and interview, it was determined the facility failed to install and maintain the piped-in medical gas systems in two locations on two of nine floors.

Findings include:

1. Observation of various aspects of the piped-in medical gas system between 1:33 p.m. on September 12, 2011, and 09:09 a.m. on September 13, 2011, revealed the below deficiencies:

a. Oxygen, vacuum, and medical air piping lack shut-off valves at the base of their respective risers within the first floor Medical Records Suite. 1:33 p.m. on September 12, 2011.

b. Vacuum and medical gas piping lack shut-off valves at the base of their respective risers within the basement-level soiled line chute termination room. 09:09 a.m. on September 13, 2011.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on September 13, 2011, confirmed the lack of shut-off valves.

Based upon observation and interview, it was determined the facility failed to properly install the piped-in medical gas system in multiple locations on one of one floors.

Findings include:

Observation of medical gas piping beyond the suspended ceiling assemblies in various locations between 11:15 a.m. and 11:55 a.m. on September 12, 2011, revealed the piping to reside atop galvanized metal hangers (dissimilar metal.)

Interview with facilities manager at various times between 11:15 a.m. and 11:55 a.m. on September 12, 2011, confirmed medical gas piping to be in contact with dissimilar metals in multiple locations.

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in six locations on three of nine total floors.

Findings include:

1. Observation of various aspects of building construction requirements between 1:25 p.m. on September 12, 2011, and 09:01 a.m. on September 13, 2011, revealed the below deficiencies:

a. Combustible construction plastic materials were noted beyond the suspended ceiling assembly within the first floor Admissions Suite at 1:25 p.m. on September 12, 2011.

b. Horizontal structural steel located within the first floor Medical Records Suite requires touch-up spray fireproofing (closest to the dumb waiter.) 1:34 p.m. on September 12, 2011.

c. Insulating materials exhibiting combustible paper backing were noted beyond the suspended ceiling assembly within the Doctor's Library at 1:55 p.m. on September 12, 2011. Note: at exterior bearing wall location.

d. Two structural steel columns within the first floor Doctor's Library exhibit unprotected, noncombustible, building construction characteristics. 1:52 p.m. and 1:58 p.m. on September 12, 2011.

e. A column located within the basement-level Dietary Department exhibits unprotected, noncombustible, building construction characteristics. 08:33 a.m. on September 13, 2011.

f. Horizontal structural steel within the third floor Pediatrics Suite requires spray fireproofing (closest to Nurse's Station.) 09:01 a.m. on September 13, 2011.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on September 13, 2011, confirmed the above building construction deficiencies.

Based upon observation and interview, it was determined the facility failed to maintain one vertical opening in one location on one of nine floors.

Findings include:

Observation of the third floor portion of the shaft enclosure located at the A and B Wing crossover at 2:20 p.m. on September 12, 2011, revealed a duct penetration within the enclosure to require a seal of the annular spaces.

Interview with facilities manager at 2:21 p.m. on September 12, 2011, confirmed the shaft enclosure penetration.

Based upon observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall in one location on one of one floors.

Findings include:

Observation of the portion of the smoke barrier separation wall located closest to the electrical room entrance door at 11:23 a.m. on September 12, 2011, revealed a penetration beyond the smoke barrier separation doors.

Interview with facilities manager at 11:24 a.m. on September 12, 2011, confirmed the smoke barrier separation wall penetration.

Based upon observation and interview, it was determined the facility failed to maintain one hazardous area enclosure in one location on one of nine floors.

Findings include:

Observation of the first floor Medical Records Suite entrance door at 1:38 p.m. on September 12, 2011, revealed the door to lack a self-closing device.

Interview with facilities manager at 1:39 a.m. on September 12, 2011, confirmed the door to lack a self-closing device.

Based upon observation and interview, it was determined the facility failed to maintain one exit stair tower in one location on one of nine floors.

Findings include:

Observation of the basement-level portion of the Colfax stair tower at 2:06 p.m. on September 12, 2011, revealed three wheelchairs, each with an "e-style" oxygen cylinder, to be stored within this enclosure.

Interview with facilities manager at 2:07 p.m. on September 12, 2011, confirmed the storage within the stair tower.

Based upon observation and interview, it was determined the facility failed to install illuminated exit signage in six locations on six of nine floors.

Findings include:

Observation of the D Wing exit access corridor systems between 2:03 p.m. and 2:23 p.m. on September 12, 2011, revealed illuminated exit signage lacking on floors three through eight in the vicinity of the Mulberry Street windows.

Interview with facilities manager at 2:25 p.m. on September 12, 2011, confirmed the lack of exit signage in the above locations.

Based upon observation and interview, it was determined the facility failed to maintain the automatic sprinkler systems in two locations on two of nine total floors.

Findings include:

1. Observation of various aspects of the automatic sprinkler systems between 12:45 p.m. on September 12, 2011, and 09:10 a.m. on September 13, 2011, revealed the below deficiencies:

a. Miscellaneous wiring is affixed to branch sprinkler piping within the first floor Main Lobby area (closest to reception.) at 12:45 p.m. on September 11, 2011.

b. Miscellaneous wiring affixed to branch sprinkler piping was noted within the third floor Pediatrics Department (closest to the Nurse's Station) at 09:10 a.m. on September 13, 2011.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on September 13, 2011, confirmed the wiring affixed to the sprinkler piping.

Based upon observation and interview, it was determined the facility failed to construct and maintain one soiled linen chute termination room in one location on one of nine floors.

Findings include:

Observation of the basement-level soiled linen chute termination room at 08:54 a.m. on September 13, 2011, revealed the enclosure to lack required two-hour fire resistive integrity on one of four enclosure walls. Note: recessed lighting fixture removed from monolithic ceiling assembly revealed one of four walls open beyond ceiling assembly and subsequent floor slab assembly.

Interview with facilities manager at 08:55 a.m. on September 13, 2011, confirmed the enclosure wall to lack required two-hour fire resistive integrity.

Based upon observation and interview, it was determined the facility failed to construct and maintain one medical gas storage room in one location on one of one floors.

Findings include:

Observation of the Emergency Department oxygen storage room at 11:58 a.m. on September 12, 2011, revealed the electrical switch within to be installed less than sixty inches from finished floor level.

Interview with facilities manager at 11:59 a.m. on September 12, 2011, confirmed the electrical switch placement.

Based upon observation and interview, it was determined the facility failed to maintain one oxygen storage location in three instances on one of nine total floors.

Findings include:

1. Observation of the third floor oxygen storage room located within the D Wing between 2:16 p.m. and 2:18 p.m. on September 12, 2011, revealed the below deficiencies:

a. The electrical switch is located less than sixty inches from finished floor level. 2:16 p.m.

b. The enclosure entrance door lacks smoke-tight integrity when coupled with the adjacent door frame assembly. 2:17 p.m.

c. The entrance door lacks proper signage depicting it as an oxygen storage location.

Interview with facilities manager at 2:19 p.m. on September 12, 2011, confirmed the oxygen storage room issues stated above.

Based upon observation and interview, it was determined the facility failed to install and maintain the piped-in medical gas systems in two locations on two of nine floors.

Findings include:

1. Observation of various aspects of the piped-in medical gas system between 1:33 p.m. on September 12, 2011, and 09:09 a.m. on September 13, 2011, revealed the below deficiencies:

a. Oxygen, vacuum, and medical air piping lack shut-off valves at the base of their respective risers within the first floor Medical Records Suite. 1:33 p.m. on September 12, 2011.

b. Vacuum and medical gas piping lack shut-off valves at the base of their respective risers within the basement-level soiled line chute termination room. 09:09 a.m. on September 13, 2011.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on September 13, 2011, confirmed the lack of shut-off valves.

Based upon observation and interview, it was determined the facility failed to properly install the piped-in medical gas system in multiple locations on one of one floors.

Findings include:

Observation of medical gas piping beyond the suspended ceiling assemblies in various locations between 11:15 a.m. and 11:55 a.m. on September 12, 2011, revealed the piping to reside atop galvanized metal hangers (dissimilar metal.)

Interview with facilities manager at various times between 11:15 a.m. and 11:55 a.m. on September 12, 2011, confirmed medical gas piping to be in contact with dissimilar metals in multiple locations.