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Tag No.: K0020
Based on observation and interview, the facility failed to assure corridor vertical shafts were maintained.
The findings include:
Observation and interview with the Maintenance Director, on January 9, 2012 at 2:20 p.m. confirmed the Electrical room on LL1 had a dumbwaiter shaft that was open on one side through to the ground floor above.
Tag No.: K0025
Based on observation and interview, the facility failed to assure smoke barrier fire ratings are maintained.
The findings include:
Observation and interview with the Maintenance Director, on January 9, 2012 between 9:30 am and 2:00 p.m. confirmed unsealed penetrations in the LL2 A-wing corridor above the ceiling outside the electrical room, The " Disaster Supply Room " corridor wall, and The connector hallway behind ICU electrical room corridor wall
Tag No.: K0045
Based on observation and interview, the facility failed to assure the exit discharges from the building were not illuminated such that the failure of any single lighting fixture (bulb) would not leave the area in darkness (NFPA 101, 7.8.1.4).
The findings include:
Observation and interview with the Maintenance Director, on January 9, 2012 at 3:20 p.m. confirmed the outside lights at the exits from the women ' s pavilion 3rd floor by room 024 was not provided with multiple fixtures.
Tag No.: K0072
Based on observation and interview, the facility failed to assure the corridors in the means of egress were maintained clear of all obstructions (NFPA 101- 7.1.10.2.1.)
The findings include:
Observation and interview with the Maintenance Director and Radiology Manager, on January 10, 2012 confirmed the Emergency Department back corridor and Radiology department corridor had furniture, carts, linen bins, and portable blood pressure equipment stored (not in use).
Tag No.: K0075
Based on observation and staff interview, the facility failed to assure combustible decorations were fire retardant (NFPA 110, 19.7.5.4).
The findings include:
Observation and interview with the Maintenance Director, on January 10, 2012 at 2:00 p.m. confirmed the facility failed to treat the quilt hanging in the corridor across room C391.
Tag No.: K0147
Based on observation and interview, the facility failed to assure electrical junction boxes had their covers installed. (NFPA 70, 314.28 (C).
The findings include:
Observation and interview with the Maintenance Director, on January 9, 2012 at 2:00 p.m. confirmed junction boxes without covers in ceiling by Tower 4 Nurses Station vestibule above light, Dialysis equipment room, 2W across from storage room with exposed wires, LL2 between stairwell and elevator, Women ' s Pavillion 1st floor outside elevator equipment room, and ICU in the corridor by 15-20.
Tag No.: K0020
Based on observation and interview, the facility failed to assure corridor vertical shafts were maintained.
The findings include:
Observation and interview with the Maintenance Director, on January 9, 2012 at 2:20 p.m. confirmed the Electrical room on LL1 had a dumbwaiter shaft that was open on one side through to the ground floor above.
Tag No.: K0025
Based on observation and interview, the facility failed to assure smoke barrier fire ratings are maintained.
The findings include:
Observation and interview with the Maintenance Director, on January 9, 2012 between 9:30 am and 2:00 p.m. confirmed unsealed penetrations in the LL2 A-wing corridor above the ceiling outside the electrical room, The " Disaster Supply Room " corridor wall, and The connector hallway behind ICU electrical room corridor wall
Tag No.: K0045
Based on observation and interview, the facility failed to assure the exit discharges from the building were not illuminated such that the failure of any single lighting fixture (bulb) would not leave the area in darkness (NFPA 101, 7.8.1.4).
The findings include:
Observation and interview with the Maintenance Director, on January 9, 2012 at 3:20 p.m. confirmed the outside lights at the exits from the women ' s pavilion 3rd floor by room 024 was not provided with multiple fixtures.
Tag No.: K0072
Based on observation and interview, the facility failed to assure the corridors in the means of egress were maintained clear of all obstructions (NFPA 101- 7.1.10.2.1.)
The findings include:
Observation and interview with the Maintenance Director and Radiology Manager, on January 10, 2012 confirmed the Emergency Department back corridor and Radiology department corridor had furniture, carts, linen bins, and portable blood pressure equipment stored (not in use).
Tag No.: K0075
Based on observation and staff interview, the facility failed to assure combustible decorations were fire retardant (NFPA 110, 19.7.5.4).
The findings include:
Observation and interview with the Maintenance Director, on January 10, 2012 at 2:00 p.m. confirmed the facility failed to treat the quilt hanging in the corridor across room C391.
Tag No.: K0147
Based on observation and interview, the facility failed to assure electrical junction boxes had their covers installed. (NFPA 70, 314.28 (C).
The findings include:
Observation and interview with the Maintenance Director, on January 9, 2012 at 2:00 p.m. confirmed junction boxes without covers in ceiling by Tower 4 Nurses Station vestibule above light, Dialysis equipment room, 2W across from storage room with exposed wires, LL2 between stairwell and elevator, Women ' s Pavillion 1st floor outside elevator equipment room, and ICU in the corridor by 15-20.