HospitalInspections.org

Based on observation the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2.

Findings include:

On 10/19/10, at approximately 1:47 P.M., during an inspection of rooms, the following observation was made:
1. In electrical room 1003 all ceiling tiles had been removed and were not in the metal grid, which were in place.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect occupants of the facility contributing to the spread of smoke into the corridor exposing occupants to the products of combustion and rendering the corridor system unusable for evacuation of the facility.

Findings include:

1. On 10/19/10, at approximately 11:20 A.M., during an inspection of corridor walls with the maintenance personnel, the following observations were made:

a. The large mechanical room in the basement near the kitchen was observed to have an approximately 3' x 3' louver in the corridor wall. This louver was provided with a fire damper with a fusible link, however this device does not provide a smoke resistance rating for the corridor wall. There is no smoke detection installed to automatically cause the damper to close on detection of smoke.

b. The door to the large mechanical room in the basement near the kitchen did not positively latch when the door closes.

This deficiency was confirmed with M2 during the inspection and the maintenance supervisor at the time of exit.

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. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire and smoke into the corridor exposing occupants to fire and the products of combustion rendering the corridor unusable for evacuation of the facility.

Findings include:

1. On 10/19/10, during an inspection of corridor doors with the maintenance staff, the following observations were made:

a. At approximately 10:15 A.M., the East basement surgical elevator room doors to the corridor near the Fit Stop were observed not to close to a positive latch. The doors were obstructed by plastic hole plugs in the top of the door jamb that were not fully sealed.

b. At approximately 10:45 A.M., the door to the electrical room was observed to bind on the floor after opening, preventing the door from self closing.

c. At approximately 1:00 P.M., the E.R. suite doors to the corridor were observed to have a door leaf that is out of adjustment to self close and latch.

d. At approximately 1:30 P.M., room 1648 in Behavior Health was observed to have a dutch door with a top leaf that does not automatically latch into the bottom leaf when closed. The upper leaf was provided with a manual throw bolt to latch the top leaf into the bottom leaf.

e. At approximately 1:45 P.M., patient room 1622 in Behavior Health was observed not to latch when closed, and the door has a gap over the top of the door when closed.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.







27710


Findings include:

On 10/20/10, at approximately 9:20 A.M., thru 11:00 A.M., the following observations were made:

2. The double doors for the south end of the admitting room had over a 1/8th of an inch gap when closed.

3. The cross corridor doors for Endoscopy check in area had over a 1/8th of an inch gap when closed.

4. The door to the Auto Chemistry room did not close to a positive latch because it was catching on a trash can.

5. The lab exit into the lobby did not close to a positive latch when tested.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.



29475


Findings include:

6. On 10/19/10, at approximately 9:20 A.M., during an inspection of corridor doors in the area of South 4 Rehab, it was observed that the metal 1 1/2 hour rated door would not fully close.

7. On 10/19/10, at approximately 10:10 A.M., it was observed that the rated storage room door that separated the storage area from the Social Workers office did not have a self closer. It was also observed that the self closer on the Social Workers office door that led to the corridor had been removed.

8. On 10/19/10, at approximately 10:43 A.M., it was observed that the fire rated door for the 2 hour wall in the corridor of 4 Center by the Social Workers office would not fully close.

9. On 10/19/10, at approximately 10:54 A.M., it was observed that the fire barrier doors on the north end of Center 4 would not fully close.

10. On 10/19/10, at approximately 1:10 P.M., it was observed that the fire barrier doors in the area of North Vascular would not fully close.

11. On 10/19/10, at approximately 1:15 P.M., it was observed that the fire barrier doors in the area of room 1007 would not fully close.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

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 10/19/10, at approximately 9:15 A.M., the following observation was made:
1. A one inch hole was observed in the cement block shaft wall located near exhaust fan #5 on 7 North.

On 10/19/10, at approximately 9:30 A.M., the following observation was made:
2. The door to Stair 6 on 5 North did not consistently self latch.

On 10/19/10, at approximately 9:50 A.M., the following observation was made:
3. The door to Stair 7 on 5 North did not self latch.

On 10/19/10, at approximately 11 A.M., the following observation was made:
4. Approximately 20 wires and flex conduits were observed in an open floor conduit located in Electrical Closet 4360.

On 10/19/10, at approximately 12:35 P.M., the following observation was made:
5. There was an open 3 inch floor conduit located in Electrical Closet 3360.

On 10/19/10, at approximately 1:30 P.M., the following observation was made:
6. There was an open 3 inch floor conduit located in Communication Room 2343.

On 10/19/10, at approximately 12:40 P.M., the following observation was made:
7. There was an open 3 inch floor conduit located in Storage Room near N321.

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide for door hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire and exposing occupants to fire and the products of combustion.

Findings include:

1. On 10/19/10, during an inspection of doors with the maintenance staff, the following observations were made:

a. At approximately 9:30 A.M., the storeroom area was observed to have a set of double doors on the corridor that were equipped with a manual closer over ride switch that allowed staff to over ride the automatic closing requirements, preventing the doors from automatically closing. Staff in the area were unable to provide additional information to determine whether activation of smoke detection causes the fire alarm system to over ride this function to cause the doors to close.

b. At approximately 10:30 A.M., the East basement mechanical room was observed to be used for storage. The double doors to the corridor were observed to have an inactive leaf that was not provided with a self closing device.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.

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 10/19/10, at approximately 11:10 A.M., the following observation was made:
1. The double corridor doors located between 4N and 4C did not completely close. The second door leaf remained open approximately 2 inches.

On 10/19/10, at approximately 1:45 P.M., the following observation was made:
2. The double corridor doors located near room 224 did not completely close. The second door leaf remained open approximately 2 inches.


This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.





29475


Findings include:

During an inspection of smoke barrier walls, the following observations were made:

3. On 10/19/10, at approximately 10:10 A.M., in the area of center 4, center corridor, it was observed that there was a gray electrical conduit and blue wires that penetrated the smoke barrier wall that were not properly sealed.

4. On 10/19/10, at approximately 11:15 A.M., in the area above the fire doors at the north end of central 3 corridor by room 3212, it was observed that there was a gray 4" electrical conduit penetrating the smoke barrier wall that had too many wires in it without any type of sealant.

5. On 10/19/10, at approximately 1:05 P.M., in the area above the fire barrier doors Ambulatory Care by room 1029, it was observed that there was a flexible green metal cable, 2 small gray cables, and 1 1/2" gray conduit that penetrated the smoke barrier wall that were not properly sealed.

6. On 10/19/10, at approximately 1:08 P.M., in the area above the fire barrier doors of Vascular North, it was observed that dry wall material was used as sealant around a bundle of blue wires, not a rated calking material.

7. On 10/19/10, at approximately 1:20 P.M., in the area above the fire barrier doors near room 1007, it was observed that there were three 3/4" gray conduits, multiple blue wires, black cables, and black wires that penetrated the smoke barrier wall that were not properly sealed.

8. On 10/19/10, at approximately 1:47 P.M., in the area above the fire barrier doors near room 1003, it was observed that there was one 1" gray conduit and one 1/2" gray conduit that penetrated the smoke barrier wall that were not properly sealed.

9. On 10/20/10, at approximately 10:24 A.M., in the area above the fire barrier doors near room 1246, it was observed that the fire calking material had become dislodged from around the wiring and conduits penetrating the wall and were not properly sealed.

10. On 10/20/10, at approximately 10:42 A.M., in the area above the fire barrier doors near room 1153, it was observed that the fire calking material had become dislodged from around the wiring and conduits penetrating the wall and were not properly sealed.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

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. This deficient practice could potentially affect occupants of the facility by permitting smoke and fire to travel between smoke compartment exposing occupants to the products of combustion.

Findings include:

1. On 10/19/10, at approximately 1:15 P.M., during an inspection of smoke barrier doors with the maintenance supervisor, the following observation was made:

a. The cross corridor doors before Behavior Health were observed to have a coordinating device that was malfunctioning, preventing the door from properly closing.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire between a protected area and unprotected area exposing occupants to fire and the products of combustion.

Findings include:

On 10/19/10, at approximately 12:55 P.M., the following observation was made:
1. The Treatment Room on 3N is now being used as a storage room. The door does not have a self closure.

On 10/19/10, at approximately 1:05 P.M., the following observation was made:
2. The "Old Chapel" in 3431 3N is now being used as a storage room and the door does not have a self closure.

On 10/19/10, at approximately 11:10 A.M., the following observation was made:
3. Tape was placed over the door strike so that the door to Clean Hold Nourishment on 2N would not latch.

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.



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Findings include:

4. On 10/19/10, during an inspection of hazard rooms with the maintenance staff, the following observations were made:

a. At approximately 10:50 A.M., the medical records office was observed to have excessive boxes of materials being stored in the office area. This area is not designed as a storage room.

b. At approximately 10:55 A.M., the volunteer storage room door to the office area was observed to have a self closing device that allowed the door to be held in the open position with no smoke detection provided to automatically cause the door to close on detection of smoke.

c. At approximately 11:05 A.M., the basement x-ray storage room was observed to have 2 ceiling penetrations where the fire stopping material has been removed.

d. At approximately 11:15 A.M., the janitors closet room door in the kitchen was out of adjustment to self close and latch.

e. At approximately 12:30 P.M., the medical air manifold room was observed to have paint being stored within the room.

f. At approximately 1:05 P.M., the E.R. suite IT room by exam room 5 was observed to have 2 access panels in the ceiling that were not latched shut, and a 3 inch sleeve penetrating the ceiling where the fire stopping material has been removed.

g. At approximately 1:25 P.M., storage room door to 1634 in Behavior Health was observed not to be provided with a self closing device.

h. At approximately 1:50 P.M., Behavior Health room 1635 was observed to have a hole in the wall, and fire stopping removed from a ceiling penetration.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.



27710


Findings include:

On 10/20/10, at approximately 9:30 A.M., thru 10:10 A.M., the following observations were made:

5. There is an approximately one inch penetration to the smoke barrier around phone wires in communications room 1381.

6. There is an approximately one inch penetration to the smoke barrier around flexible conduit in electrical room 1320.

7. There is an approximately one inch penetration to the smoke barrier around computer cables in electrical room located in the back corridor of surgery.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11.

Findings include:

On 10/19/10, at approximately 11:20 A.M., during an inspection of the stairwell enclosure, the following observation was made:
1. In the Central 3 stairwell there were two black cables that penetrated the exterior wall of the stairwell on the third floor. These cables were run through the flooring material along the side of the fire department stand pipe, and then penetrated the stairwell wall again on the 1st floor.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3.

Findings include:

On 10/20/10, during an inspection of exits the following observations were made:

1. At approximately 9:41 A.M., it was observed there were carts and stretchers obstructing the required width of the corridor in the area of the mobile MRI Trailer.

2. At approximately 9:56 A.M., it was observed that in the area between ultrasound rooms B & C, the aisle width in the corridor for the transportation of patients on gurneys did not meet the required 6 foot width.

3. At approximately 10:35 A.M., it was observed in the area of the x-ray filing room, there were multiple carts obstructing the aisle way leading to the exit door.

4. At approximately 10:35 A.M., in the area of the corridor by surgical room 5, it was observed that there was a large blue trash bin on wheels and a black cart that were obstructing the minimum required width of the corridor.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.5.

Findings include:

On 10/19/10, at approximately 12:55 P.M., during an inspection of exits, the following observation was made:
1. The main exit emergency doors in the Ambulatory Care area would not open. This was due to new tile being installed in the breezeway which would not allow the doors to swing to a full open position.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide exit and directional signs in accordance with the LSC section 19.2.10.1.

Findings include:

On 10/19/10, at approximately 12:40 P.M., the following observation was made:
1. The exit sign located in the corridor near N314 was not displaying a right arrow which points towards the path of egress (stairs).

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.

Based on a review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6.

Findings include:

On 10/19/10, at approximately 11:00 A.M., the following observation was made:
1. During a review of the fire alarm testing reports there was no documentation available to show that the required sensitivity testing has been performed within the last two years for the behavioral health building.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4.

Findings include:

On 10/20/10, at approximately 10:10 A.M., the following observation was made:

1. There is a smoke detector that is within 3 feet of a supply air diffuser in the East PACU area.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.




29475


Findings include:

During an inspection of the fire alarm system, the following observations were made:

2. On 10/19/10, at approximately 11:04 A.M., in the area of the Physiology Office, it was observed that blue tape had been placed over the audible speaker portion of the horn and strobe device #A-28V53.

3. On 10/20/10, at approximately 9:45 A.M., in the area of the corridor leading to the MRI machine, it was observed that there was not a manual pull station installed by the marked exit door.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1. This deficient practice could potentially affect occupants of the facility by contributing to a failure of the sprinkler system to operate without facility knowledge of a deficient condition which may contribute to the failure of the sprinkler system to suppress a fire increasing exposure of occupants to a hazardous condition.

Findings include:

1. On 10/19/10, at approximately 11:00 A.M., during an inspection of the sprinkler system with the maintenance staff, the following observation was made:

a. The control valves on both sides of the check valve on the main water supply to the sprinkler system were not electrically supervised through the fire alarm system. The valves were chained and locked only.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.

Based on observation 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. This deficient practice could potentially affect occupants of the facility by contributing to a failure or delay of the sprinkler system to operate as a result of inadequate maintenance and testing.

Findings include:

1. On 10/19/10, during an inspection with the maintenance staff, the following observations were made:

a. At approximately 10:10 A.M., the computer training room was observed to have 2 ceiling tiles missing.

b. At approximately 11:20 A.M., the Men's locker room by the kitchen was observed to have a ceiling tile missing.

c. At approximately 1:10 P.M., the E.R. storage room A had combustibles within 18 inches of the sprinkler heads.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.



27710


Findings include:

On 10/20/10, at approximately 9:50 A.M., thru 10:15 A.M., the following observations were made:

2. There is a sprinkler escutcheon plate missing in the endoscopy break room.

3. There is a sprinkler escutcheon plate missing in the surgery storage room 139.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.



29475


Findings include:

On 10/19/10, during an inspection of the sprinkler system, the following observations were made:

4. At approximately 9:26 A.M., above the ceiling tiles along the entire length of the south 4 corridor, it was observed that multiple blue wires had been attached to the support brackets of the sprinkler system piping by the means of wire loops.

5. At approximately 9:51 A.M., in the area of south 4 clean supply room, it was observed that the escutcheon plate was missing from the sprinkler head.

6. At approximately 9:58 A.M., in the area of the south 4 laundry room, storage of combustible materials, toilet paper and paper towels had not been maintained 18" below the deflector of the sprinkler head.

7. At approximately 10:49 A.M., in the area of center 4 storage area, the storage of combustible materials (a fold up hid-a-bed mattress) had not been maintained 18" away from the deflector of the sprinkler head.

8. At approximately 10:49 A.M., in the area of center furnace room, it was observed that the storage of combustible materials had not been maintained 18" below the deflector of the sprinkler head.

9. At approximately 11:00 A.M., in the area of central 3 Great Lakes storage room, it was observed that the storage of combustible materials had not been maintained 18" below the deflector of the sprinkler head.

10. At approximately 11:10 A.M., throughout the area of the pharmacy, it was observed that the storage of combustible materials had not been maintained 18" below the deflector of the sprinkler head.

11. At approximately 1:11 P.M., above the ceiling tiles in the corridor outside of vascular south, it was observed that red fire alarm system wiring had been secured to the sprinkler system piping.

On 10/20/10, during an inspection of the sprinkler system, the following observations were made:

12. At approximately 9:41 A.M., in the area of the MRI waiting room, it was observed that there was a sprinkler head within 1" of the wall, and the escutcheon plate was missing.

13. At approximately 10:04 A.M., in the area of radiology engineering office, it was observed that the storage of combustible materials had not been maintained 18" below the deflector of the sprinkler head.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6.

Findings include:

On 10/20/10, at approximately 11:10 A.M., the following observation was made:
1. The top of the fire extinguisher located in Lab 1213 was located too high from the finished floor. The maximum allowed height is 5 feet. This extinguisher was approximately 5'6".


This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.




29475


Findings include:

On 10/19/10, at approximately 9:15 A.M., during an inspection of fire extinguishers in the area of South 5 Penthouse, the following observation was made:
2. There is only one fire extinguisher serving the entire area, exceeding the maximum allowable travel distance to an extinguisher.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on a review of records the facility failed to provide building services in accordance with the LSC sections 19.5.2.1, 9.2, 19.6.2.2.

Findings include:

On 10/19/10, at approximately 12:30 P.M., the following observation was made:
1. During a review of records the facility's fire damper inspection report dated 05/04/09 indicated that approximately 492 fire dampers were not tested due to lack of acceptability.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6.

Findings include:

On 10/20/10, at approximately 11:10 A.M., the following observation was made:
1. The cooking appliances located at each end of hood # l in the main kitchen were not placed completely under the hood. Each of the two appliances were approximately 3 inches outside of the hood.

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10.

Findings include:

On 10/19/10, at approximately 12:40 P.M., the following observation was made:
1. The doors on the corridor nurse charting stations near rooms N305 and N317 did not completely close.

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.

Based on observation and review of records, the facility failed to ensure the facility was free of combustible decorations in accordance with section 19.7.5.4. This could affect occupants of the facility by contributing to spread of fire and development of toxic smoke due to the decorations not being flame retardant, exposing occupants to fire and the products of combustion.

Findings include:

On 10/20/10, at approximately 10:10 A.M., during an inspection of corridors, the following observation was made:

1. There were 5 paper/cardboard decorative Halloween skeletons; approximately 4 feet in length, hanging on the wall in the area of the radiology nurses station.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect occupants of the facility by contributing to the development and spread of fire, exposing occupants to fire and the products of combustion.

Findings include:

On 10/19/10, at approximately 12:30 P.M., the following observation was made:
1. Seventeen oxygen cylinders were observed in N3 3361. The cylinders were not labeled as being "full" or "empty."

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.



12815


Findings include:

2. On 10/19/10, at approximately 12:45 P.M., during an inspection of oxygen storage with the maintenance supervisor, the following observation was made:

a. The oxygen storage room prior to the E.R. Suite was not provided with a vent.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.





29475


Findings include:

During an inspection of oxygen storage, the following observations were made:

3. On 10/19/10, at approximately 10:52 A.M., in the area of Center 4, there were 8 oxygen tanks being stored within 5 feet of other combustible materials.

4. On 10/20/10, at approximately 10:14 A.M., in the area of the radiology film development room, there were 7 oxygen tanks being stored with 5 feet of other combustible materials.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide an essential electrical system in accordance with NFPA 99. This deficient practice could potentially affect occupants of the facility by contributing to the failure of emergency systems increasing occupants exposure to hazardous conditions and delaying emergency services and evacuation of the facility in an emergency.

Findings include:

1. On 10/19/10, at approximately 11:05 A.M., during an inspection of the electrical system with the maintenance staff, the following observation was made:

a. The emergency generator room in the basement was observed to have penetrations on the exterior wall of the generator room that were not fire stopped.

This deficiency was confirmed with M2 during the inspection and the maintenance supervisor at the time of exit.

Clean agent fire suppression systems shall be maintained in full operating condition at all times. Actuation, impairment, and restoration of this protection shall be reported promptly to the authority having jurisdiction. Any troubles or impairments shall be corrected in a timely manner consistent with the hazard protected. NFPA 2001.

Based on observation the facility failed to provide a fully operating FM 200 system. This deficient practice could potentially affect occupants of the facility by contributing to a failure or delay of the suppression system to operate as a result of inadequate maintenance and testing.

Findings include:

1. On 10/19/10, at approximately 11:00 A.M., during an inspection with the maintenance staff, the following observations were made:

a. The FM 200 system in the computer center was observed to have numerous trouble lights illuminated on the system panel.

b. The computer room was observed to have ceiling tiles missing.

This deficiency was confirmed with M2 during the inspection and the maintenance supervisor at the time of exit.

Based on a review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99.

Findings include:

On 10/19/20, at approximately 10:00 A.M., the following observations were made:

1. The monthly 30 minute load test for the emergency room building generator dated 8/13/10 indicated that the cool down period for the emergency generator was three minutes.

2. The monthly 30 minute load test for the south patient tower generator dated 8/11/10 indicated that the cool down period for the emergency generator was two minutes.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2.

Findings include:

On 10/20/10, at approximately 10:50 A.M., the following observation was made:
1. There is an extension cord plugged into a power strip that is being used as permanent wiring in the east end of the auto chemistry room.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.





29475


Findings include:

During an inspection of electrical systems, the following observations were made:

2. On 10/19/10, at approximately 9:14 A.M., in the South 5 penthouse area, along the south wall, it was observed that there was an open 4"x4" electrical junction box with exposed wiring by the old pneumatic control box.

3. On 10/19/10, at approximately 10:45 A.M., in the Central 4 Furnace room storage area, south wall, it was observed that there were two open 4"x4" electrical junction boxes with exposed wiring.

During an inspection of smoke barrier walls, the following observation was made:

4. On 10/19/10, at approximately 1:20 P.M., above the ceiling tiles by room 1007, it was observed that there were two black unknown types of wires that had been cut and left in place with exposed wiring on the ends.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2.

Findings include:

On 10/19/10, at approximately 1:47 P.M., during an inspection of rooms, the following observation was made:
1. In electrical room 1003 all ceiling tiles had been removed and were not in the metal grid, which were in place.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect occupants of the facility contributing to the spread of smoke into the corridor exposing occupants to the products of combustion and rendering the corridor system unusable for evacuation of the facility.

Findings include:

1. On 10/19/10, at approximately 11:20 A.M., during an inspection of corridor walls with the maintenance personnel, the following observations were made:

a. The large mechanical room in the basement near the kitchen was observed to have an approximately 3' x 3' louver in the corridor wall. This louver was provided with a fire damper with a fusible link, however this device does not provide a smoke resistance rating for the corridor wall. There is no smoke detection installed to automatically cause the damper to close on detection of smoke.

b. The door to the large mechanical room in the basement near the kitchen did not positively latch when the door closes.

This deficiency was confirmed with M2 during the inspection and the maintenance supervisor at the time of exit.

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. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire and smoke into the corridor exposing occupants to fire and the products of combustion rendering the corridor unusable for evacuation of the facility.

Findings include:

1. On 10/19/10, during an inspection of corridor doors with the maintenance staff, the following observations were made:

a. At approximately 10:15 A.M., the East basement surgical elevator room doors to the corridor near the Fit Stop were observed not to close to a positive latch. The doors were obstructed by plastic hole plugs in the top of the door jamb that were not fully sealed.

b. At approximately 10:45 A.M., the door to the electrical room was observed to bind on the floor after opening, preventing the door from self closing.

c. At approximately 1:00 P.M., the E.R. suite doors to the corridor were observed to have a door leaf that is out of adjustment to self close and latch.

d. At approximately 1:30 P.M., room 1648 in Behavior Health was observed to have a dutch door with a top leaf that does not automatically latch into the bottom leaf when closed. The upper leaf was provided with a manual throw bolt to latch the top leaf into the bottom leaf.

e. At approximately 1:45 P.M., patient room 1622 in Behavior Health was observed not to latch when closed, and the door has a gap over the top of the door when closed.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.







27710


Findings include:

On 10/20/10, at approximately 9:20 A.M., thru 11:00 A.M., the following observations were made:

2. The double doors for the south end of the admitting room had over a 1/8th of an inch gap when closed.

3. The cross corridor doors for Endoscopy check in area had over a 1/8th of an inch gap when closed.

4. The door to the Auto Chemistry room did not close to a positive latch because it was catching on a trash can.

5. The lab exit into the lobby did not close to a positive latch when tested.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.



29475


Findings include:

6. On 10/19/10, at approximately 9:20 A.M., during an inspection of corridor doors in the area of South 4 Rehab, it was observed that the metal 1 1/2 hour rated door would not fully close.

7. On 10/19/10, at approximately 10:10 A.M., it was observed that the rated storage room door that separated the storage area from the Social Workers office did not have a self closer. It was also observed that the self closer on the Social Workers office door that led to the corridor had been removed.

8. On 10/19/10, at approximately 10:43 A.M., it was observed that the fire rated door for the 2 hour wall in the corridor of 4 Center by the Social Workers office would not fully close.

9. On 10/19/10, at approximately 10:54 A.M., it was observed that the fire barrier doors on the north end of Center 4 would not fully close.

10. On 10/19/10, at approximately 1:10 P.M., it was observed that the fire barrier doors in the area of North Vascular would not fully close.

11. On 10/19/10, at approximately 1:15 P.M., it was observed that the fire barrier doors in the area of room 1007 would not fully close.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

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 10/19/10, at approximately 9:15 A.M., the following observation was made:
1. A one inch hole was observed in the cement block shaft wall located near exhaust fan #5 on 7 North.

On 10/19/10, at approximately 9:30 A.M., the following observation was made:
2. The door to Stair 6 on 5 North did not consistently self latch.

On 10/19/10, at approximately 9:50 A.M., the following observation was made:
3. The door to Stair 7 on 5 North did not self latch.

On 10/19/10, at approximately 11 A.M., the following observation was made:
4. Approximately 20 wires and flex conduits were observed in an open floor conduit located in Electrical Closet 4360.

On 10/19/10, at approximately 12:35 P.M., the following observation was made:
5. There was an open 3 inch floor conduit located in Electrical Closet 3360.

On 10/19/10, at approximately 1:30 P.M., the following observation was made:
6. There was an open 3 inch floor conduit located in Communication Room 2343.

On 10/19/10, at approximately 12:40 P.M., the following observation was made:
7. There was an open 3 inch floor conduit located in Storage Room near N321.

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide for door hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire and exposing occupants to fire and the products of combustion.

Findings include:

1. On 10/19/10, during an inspection of doors with the maintenance staff, the following observations were made:

a. At approximately 9:30 A.M., the storeroom area was observed to have a set of double doors on the corridor that were equipped with a manual closer over ride switch that allowed staff to over ride the automatic closing requirements, preventing the doors from automatically closing. Staff in the area were unable to provide additional information to determine whether activation of smoke detection causes the fire alarm system to over ride this function to cause the doors to close.

b. At approximately 10:30 A.M., the East basement mechanical room was observed to be used for storage. The double doors to the corridor were observed to have an inactive leaf that was not provided with a self closing device.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.

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 10/19/10, at approximately 11:10 A.M., the following observation was made:
1. The double corridor doors located between 4N and 4C did not completely close. The second door leaf remained open approximately 2 inches.

On 10/19/10, at approximately 1:45 P.M., the following observation was made:
2. The double corridor doors located near room 224 did not completely close. The second door leaf remained open approximately 2 inches.


This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.





29475


Findings include:

During an inspection of smoke barrier walls, the following observations were made:

3. On 10/19/10, at approximately 10:10 A.M., in the area of center 4, center corridor, it was observed that there was a gray electrical conduit and blue wires that penetrated the smoke barrier wall that were not properly sealed.

4. On 10/19/10, at approximately 11:15 A.M., in the area above the fire doors at the north end of central 3 corridor by room 3212, it was observed that there was a gray 4" electrical conduit penetrating the smoke barrier wall that had too many wires in it without any type of sealant.

5. On 10/19/10, at approximately 1:05 P.M., in the area above the fire barrier doors Ambulatory Care by room 1029, it was observed that there was a flexible green metal cable, 2 small gray cables, and 1 1/2" gray conduit that penetrated the smoke barrier wall that were not properly sealed.

6. On 10/19/10, at approximately 1:08 P.M., in the area above the fire barrier doors of Vascular North, it was observed that dry wall material was used as sealant around a bundle of blue wires, not a rated calking material.

7. On 10/19/10, at approximately 1:20 P.M., in the area above the fire barrier doors near room 1007, it was observed that there were three 3/4" gray conduits, multiple blue wires, black cables, and black wires that penetrated the smoke barrier wall that were not properly sealed.

8. On 10/19/10, at approximately 1:47 P.M., in the area above the fire barrier doors near room 1003, it was observed that there was one 1" gray conduit and one 1/2" gray conduit that penetrated the smoke barrier wall that were not properly sealed.

9. On 10/20/10, at approximately 10:24 A.M., in the area above the fire barrier doors near room 1246, it was observed that the fire calking material had become dislodged from around the wiring and conduits penetrating the wall and were not properly sealed.

10. On 10/20/10, at approximately 10:42 A.M., in the area above the fire barrier doors near room 1153, it was observed that the fire calking material had become dislodged from around the wiring and conduits penetrating the wall and were not properly sealed.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

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. This deficient practice could potentially affect occupants of the facility by permitting smoke and fire to travel between smoke compartment exposing occupants to the products of combustion.

Findings include:

1. On 10/19/10, at approximately 1:15 P.M., during an inspection of smoke barrier doors with the maintenance supervisor, the following observation was made:

a. The cross corridor doors before Behavior Health were observed to have a coordinating device that was malfunctioning, preventing the door from properly closing.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire between a protected area and unprotected area exposing occupants to fire and the products of combustion.

Findings include:

On 10/19/10, at approximately 12:55 P.M., the following observation was made:
1. The Treatment Room on 3N is now being used as a storage room. The door does not have a self closure.

On 10/19/10, at approximately 1:05 P.M., the following observation was made:
2. The "Old Chapel" in 3431 3N is now being used as a storage room and the door does not have a self closure.

On 10/19/10, at approximately 11:10 A.M., the following observation was made:
3. Tape was placed over the door strike so that the door to Clean Hold Nourishment on 2N would not latch.

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.



12815


Findings include:

4. On 10/19/10, during an inspection of hazard rooms with the maintenance staff, the following observations were made:

a. At approximately 10:50 A.M., the medical records office was observed to have excessive boxes of materials being stored in the office area. This area is not designed as a storage room.

b. At approximately 10:55 A.M., the volunteer storage room door to the office area was observed to have a self closing device that allowed the door to be held in the open position with no smoke detection provided to automatically cause the door to close on detection of smoke.

c. At approximately 11:05 A.M., the basement x-ray storage room was observed to have 2 ceiling penetrations where the fire stopping material has been removed.

d. At approximately 11:15 A.M., the janitors closet room door in the kitchen was out of adjustment to self close and latch.

e. At approximately 12:30 P.M., the medical air manifold room was observed to have paint being stored within the room.

f. At approximately 1:05 P.M., the E.R. suite IT room by exam room 5 was observed to have 2 access panels in the ceiling that were not latched shut, and a 3 inch sleeve penetrating the ceiling where the fire stopping material has been removed.

g. At approximately 1:25 P.M., storage room door to 1634 in Behavior Health was observed not to be provided with a self closing device.

h. At approximately 1:50 P.M., Behavior Health room 1635 was observed to have a hole in the wall, and fire stopping removed from a ceiling penetration.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.



27710


Findings include:

On 10/20/10, at approximately 9:30 A.M., thru 10:10 A.M., the following observations were made:

5. There is an approximately one inch penetration to the smoke barrier around phone wires in communications room 1381.

6. There is an approximately one inch penetration to the smoke barrier around flexible conduit in electrical room 1320.

7. There is an approximately one inch penetration to the smoke barrier around computer cables in electrical room located in the back corridor of surgery.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11.

Findings include:

On 10/19/10, at approximately 11:20 A.M., during an inspection of the stairwell enclosure, the following observation was made:
1. In the Central 3 stairwell there were two black cables that penetrated the exterior wall of the stairwell on the third floor. These cables were run through the flooring material along the side of the fire department stand pipe, and then penetrated the stairwell wall again on the 1st floor.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3.

Findings include:

On 10/20/10, during an inspection of exits the following observations were made:

1. At approximately 9:41 A.M., it was observed there were carts and stretchers obstructing the required width of the corridor in the area of the mobile MRI Trailer.

2. At approximately 9:56 A.M., it was observed that in the area between ultrasound rooms B & C, the aisle width in the corridor for the transportation of patients on gurneys did not meet the required 6 foot width.

3. At approximately 10:35 A.M., it was observed in the area of the x-ray filing room, there were multiple carts obstructing the aisle way leading to the exit door.

4. At approximately 10:35 A.M., in the area of the corridor by surgical room 5, it was observed that there was a large blue trash bin on wheels and a black cart that were obstructing the minimum required width of the corridor.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.5.

Findings include:

On 10/19/10, at approximately 12:55 P.M., during an inspection of exits, the following observation was made:
1. The main exit emergency doors in the Ambulatory Care area would not open. This was due to new tile being installed in the breezeway which would not allow the doors to swing to a full open position.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide exit and directional signs in accordance with the LSC section 19.2.10.1.

Findings include:

On 10/19/10, at approximately 12:40 P.M., the following observation was made:
1. The exit sign located in the corridor near N314 was not displaying a right arrow which points towards the path of egress (stairs).

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.

Based on a review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6.

Findings include:

On 10/19/10, at approximately 11:00 A.M., the following observation was made:
1. During a review of the fire alarm testing reports there was no documentation available to show that the required sensitivity testing has been performed within the last two years for the behavioral health building.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4.

Findings include:

On 10/20/10, at approximately 10:10 A.M., the following observation was made:

1. There is a smoke detector that is within 3 feet of a supply air diffuser in the East PACU area.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.




29475


Findings include:

During an inspection of the fire alarm system, the following observations were made:

2. On 10/19/10, at approximately 11:04 A.M., in the area of the Physiology Office, it was observed that blue tape had been placed over the audible speaker portion of the horn and strobe device #A-28V53.

3. On 10/20/10, at approximately 9:45 A.M., in the area of the corridor leading to the MRI machine, it was observed that there was not a manual pull station installed by the marked exit door.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1. This deficient practice could potentially affect occupants of the facility by contributing to a failure of the sprinkler system to operate without facility knowledge of a deficient condition which may contribute to the failure of the sprinkler system to suppress a fire increasing exposure of occupants to a hazardous condition.

Findings include:

1. On 10/19/10, at approximately 11:00 A.M., during an inspection of the sprinkler system with the maintenance staff, the following observation was made:

a. The control valves on both sides of the check valve on the main water supply to the sprinkler system were not electrically supervised through the fire alarm system. The valves were chained and locked only.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.

Based on observation 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. This deficient practice could potentially affect occupants of the facility by contributing to a failure or delay of the sprinkler system to operate as a result of inadequate maintenance and testing.

Findings include:

1. On 10/19/10, during an inspection with the maintenance staff, the following observations were made:

a. At approximately 10:10 A.M., the computer training room was observed to have 2 ceiling tiles missing.

b. At approximately 11:20 A.M., the Men's locker room by the kitchen was observed to have a ceiling tile missing.

c. At approximately 1:10 P.M., the E.R. storage room A had combustibles within 18 inches of the sprinkler heads.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.



27710


Findings include:

On 10/20/10, at approximately 9:50 A.M., thru 10:15 A.M., the following observations were made:

2. There is a sprinkler escutcheon plate missing in the endoscopy break room.

3. There is a sprinkler escutcheon plate missing in the surgery storage room 139.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.



29475


Findings include:

On 10/19/10, during an inspection of the sprinkler system, the following observations were made:

4. At approximately 9:26 A.M., above the ceiling tiles along the entire length of the south 4 corridor, it was observed that multiple blue wires had been attached to the support brackets of the sprinkler system piping by the means of wire loops.

5. At approximately 9:51 A.M., in the area of south 4 clean supply room, it was observed that the escutcheon plate was missing from the sprinkler head.

6. At approximately 9:58 A.M., in the area of the south 4 laundry room, storage of combustible materials, toilet paper and paper towels had not been maintained 18" below the deflector of the sprinkler head.

7. At approximately 10:49 A.M., in the area of center 4 storage area, the storage of combustible materials (a fold up hid-a-bed mattress) had not been maintained 18" away from the deflector of the sprinkler head.

8. At approximately 10:49 A.M., in the area of center furnace room, it was observed that the storage of combustible materials had not been maintained 18" below the deflector of the sprinkler head.

9. At approximately 11:00 A.M., in the area of central 3 Great Lakes storage room, it was observed that the storage of combustible materials had not been maintained 18" below the deflector of the sprinkler head.

10. At approximately 11:10 A.M., throughout the area of the pharmacy, it was observed that the storage of combustible materials had not been maintained 18" below the deflector of the sprinkler head.

11. At approximately 1:11 P.M., above the ceiling tiles in the corridor outside of vascular south, it was observed that red fire alarm system wiring had been secured to the sprinkler system piping.

On 10/20/10, during an inspection of the sprinkler system, the following observations were made:

12. At approximately 9:41 A.M., in the area of the MRI waiting room, it was observed that there was a sprinkler head within 1" of the wall, and the escutcheon plate was missing.

13. At approximately 10:04 A.M., in the area of radiology engineering office, it was observed that the storage of combustible materials had not been maintained 18" below the deflector of the sprinkler head.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6.

Findings include:

On 10/20/10, at approximately 11:10 A.M., the following observation was made:
1. The top of the fire extinguisher located in Lab 1213 was located too high from the finished floor. The maximum allowed height is 5 feet. This extinguisher was approximately 5'6".


This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.




29475


Findings include:

On 10/19/10, at approximately 9:15 A.M., during an inspection of fire extinguishers in the area of South 5 Penthouse, the following observation was made:
2. There is only one fire extinguisher serving the entire area, exceeding the maximum allowable travel distance to an extinguisher.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on a review of records the facility failed to provide building services in accordance with the LSC sections 19.5.2.1, 9.2, 19.6.2.2.

Findings include:

On 10/19/10, at approximately 12:30 P.M., the following observation was made:
1. During a review of records the facility's fire damper inspection report dated 05/04/09 indicated that approximately 492 fire dampers were not tested due to lack of acceptability.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6.

Findings include:

On 10/20/10, at approximately 11:10 A.M., the following observation was made:
1. The cooking appliances located at each end of hood # l in the main kitchen were not placed completely under the hood. Each of the two appliances were approximately 3 inches outside of the hood.

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10.

Findings include:

On 10/19/10, at approximately 12:40 P.M., the following observation was made:
1. The doors on the corridor nurse charting stations near rooms N305 and N317 did not completely close.

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.

Based on observation and review of records, the facility failed to ensure the facility was free of combustible decorations in accordance with section 19.7.5.4. This could affect occupants of the facility by contributing to spread of fire and development of toxic smoke due to the decorations not being flame retardant, exposing occupants to fire and the products of combustion.

Findings include:

On 10/20/10, at approximately 10:10 A.M., during an inspection of corridors, the following observation was made:

1. There were 5 paper/cardboard decorative Halloween skeletons; approximately 4 feet in length, hanging on the wall in the area of the radiology nurses station.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect occupants of the facility by contributing to the development and spread of fire, exposing occupants to fire and the products of combustion.

Findings include:

On 10/19/10, at approximately 12:30 P.M., the following observation was made:
1. Seventeen oxygen cylinders were observed in N3 3361. The cylinders were not labeled as being "full" or "empty."

This deficiency was confirmed with M4 during the inspection and the maintenance supervisor at the time of exit.



12815


Findings include:

2. On 10/19/10, at approximately 12:45 P.M., during an inspection of oxygen storage with the maintenance supervisor, the following observation was made:

a. The oxygen storage room prior to the E.R. Suite was not provided with a vent.

This deficiency was confirmed with the maintenance supervisor at the time of discovery and at the time of exit.





29475


Findings include:

During an inspection of oxygen storage, the following observations were made:

3. On 10/19/10, at approximately 10:52 A.M., in the area of Center 4, there were 8 oxygen tanks being stored within 5 feet of other combustible materials.

4. On 10/20/10, at approximately 10:14 A.M., in the area of the radiology film development room, there were 7 oxygen tanks being stored with 5 feet of other combustible materials.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide an essential electrical system in accordance with NFPA 99. This deficient practice could potentially affect occupants of the facility by contributing to the failure of emergency systems increasing occupants exposure to hazardous conditions and delaying emergency services and evacuation of the facility in an emergency.

Findings include:

1. On 10/19/10, at approximately 11:05 A.M., during an inspection of the electrical system with the maintenance staff, the following observation was made:

a. The emergency generator room in the basement was observed to have penetrations on the exterior wall of the generator room that were not fire stopped.

This deficiency was confirmed with M2 during the inspection and the maintenance supervisor at the time of exit.

Clean agent fire suppression systems shall be maintained in full operating condition at all times. Actuation, impairment, and restoration of this protection shall be reported promptly to the authority having jurisdiction. Any troubles or impairments shall be corrected in a timely manner consistent with the hazard protected. NFPA 2001.

Based on observation the facility failed to provide a fully operating FM 200 system. This deficient practice could potentially affect occupants of the facility by contributing to a failure or delay of the suppression system to operate as a result of inadequate maintenance and testing.

Findings include:

1. On 10/19/10, at approximately 11:00 A.M., during an inspection with the maintenance staff, the following observations were made:

a. The FM 200 system in the computer center was observed to have numerous trouble lights illuminated on the system panel.

b. The computer room was observed to have ceiling tiles missing.

This deficiency was confirmed with M2 during the inspection and the maintenance supervisor at the time of exit.

Based on a review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99.

Findings include:

On 10/19/20, at approximately 10:00 A.M., the following observations were made:

1. The monthly 30 minute load test for the emergency room building generator dated 8/13/10 indicated that the cool down period for the emergency generator was three minutes.

2. The monthly 30 minute load test for the south patient tower generator dated 8/11/10 indicated that the cool down period for the emergency generator was two minutes.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2.

Findings include:

On 10/20/10, at approximately 10:50 A.M., the following observation was made:
1. There is an extension cord plugged into a power strip that is being used as permanent wiring in the east end of the auto chemistry room.

This deficiency was confirmed with M1 during the inspection and the maintenance supervisor at the time of exit.





29475


Findings include:

During an inspection of electrical systems, the following observations were made:

2. On 10/19/10, at approximately 9:14 A.M., in the South 5 penthouse area, along the south wall, it was observed that there was an open 4"x4" electrical junction box with exposed wiring by the old pneumatic control box.

3. On 10/19/10, at approximately 10:45 A.M., in the Central 4 Furnace room storage area, south wall, it was observed that there were two open 4"x4" electrical junction boxes with exposed wiring.

During an inspection of smoke barrier walls, the following observation was made:

4. On 10/19/10, at approximately 1:20 P.M., above the ceiling tiles by room 1007, it was observed that there were two black unknown types of wires that had been cut and left in place with exposed wiring on the ends.

This deficiency was confirmed with M3 during the inspection and the maintenance supervisor at the time of exit.