HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the corridor partitions at three locations within the facility.

Findings Include:

1. Observation made on September 7, 2011, between 8:30 am and 3:00 pm, revealed there was a plain glass vision panel that forms the corridor wall leading to the Penn Orthopedics Suite at the first floor Cupp Building.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor wall integrity and identified that the facility has an acceptable Fire Safety Evaluation System (FSES) reviewed on September 7-9, 2011 addressing this issue.

2. Observation made on September 8, 2011, at 2:30 pm, revealed an open transfer grill in the corridor wall and missing ceiling tiles at room M01 mechanical space, Myrin Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor wall integrity was not maintained.

3. Observation made on September 8, 2011, at 3:15 pm, revealed there was a cable penetration inside the Wright Saunders telephone closet W-3-TE1, 3rd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor wall integrity was not maintained.

Based on observation and interview, it was determined that the facility failed to maintain closing and latching of corridor doors along the means of egress in three instances within the facility.

Findings Include:

1. Observation made on September 7, 2011, at 11:05 am, revealed there were small holes in the corridor door to the clean utility room C487. In addition, the corridor door is off-set and requires adjustment to latch into the fram, Cupp Building, 4th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor doors require adjustment.

2. Observation made on September 7, 2011, at 11:05 am, revealed the clean linen room corridor double doors outside room 430 requires adjustment, Cupp Building, 4th floor

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor wall integrity was not maintained.

3. Observation made on September 8, 2011, at 11:30 am, revealed corridor door M05 was off-set and would not close, Myring Building basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor doors require adjustment.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of vertical openings in two instances with the building.

Findings Include:

1. Observation made on September 8, 2011, at 11:30 am, revealed there were openings at pipe penetrations through the floor slab behind both sets of access panels, North and South Myrin Building, penthouses.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there were vertical penetrations.

2. Observation made on September 8, 2011, at 1:55 pm, revealed there was an opening in the kitchen dumbwaiter. The vision panel was missing, Wright Saunders Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there were vertical penetrations.

Based on observation and interview, it was determined that the facility failed to maintain the integrity of hold open devices in one instance within the facility.

Findings Include:

Observation made on September 8, 2011, at 1:45 pm, revealed the cover plate was missing over the self-closing/hold open unit at the smoke barrier double doors main OR entrance, Cupp Building 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the magnetic hold-open device was incomplete.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the smoke barrier partitions in one instance within the facility.

Findings Include:

Observation made on September 8, 2011, at 1:47 pm, it was revealed the there was approximately a two inch penetration above the duct filled with insulation only at the smoke barrier doors outside room C119, Cupp Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was a smoke barrier penetration.

Based on observation and interview, it was determined that the facility failed to maintain protection of hazardous areas in seven instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 10:45 am, revealed the mechanical room door was held open with a pipe, Myrin Building, penthouse.
(This is a Repeat deficiency from 10/21/2009 inspection)

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the hazardous area door was held open by an unauthorized means.


2. Observation made on September 8, 2011, at 10:42 am, revealed C500A physical therapy storage room wall adjadent to the office was incomplete above the suspended ceiling. In lieu of automatic sprinkler protection the room requires a one hour rated enclosure, Cupp Building, 5th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage room lacks a rated enclosure.


3. Observation made on September 7, 2011, between 1:50 pm and 2:30 pm, revealed there was storage of 40 gallon trash container, soilen linen carts, stretchers housed along the corridor within the basements, Cupp Building and Wright Saunders Building.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor means of egress was used for hazardous storage.


4. Observation made on September 8, 2011, between 1:50 pm and 2:30 pm, revealed a one hour fire rating was not maintained around the perimeter, including a rated door with self-closing hardware, of storage room W50. Automatic sprinkler protection could not be verified, Wright Saunders Building, basement.


Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage area lacks a rated enclosure.


5. Observation made on September 8, 2011, at 1:08 pm, revealed the X-ray file storage room corridor double doors require adjustment, Wright Saunders, basement. In addition, a self closing device had been disconnected.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage rooms doors require adjustment.


6. Observation made on September 8, 2011, at 1:35 pm, revealed there were very large cardboard boxes used for trash storage in the corridor out TV Rental, Wright Saunder Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage was housed in the corridor.


7. Observation made on September 8, 2011, at 7:55 am, revealed breakdown storage room C09 corridor double doors self-closure was disconnect, Cupp Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage room door hardware was disengaged.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the stairtower enclosure in two instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 10:39 am, revealed a flexible conduit penetration through the elevator shaft above the ceiling across from the visitor's waiting area M224, Myrin Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was a stairtower penetration.


2. Observation made on September 8, 2011, at 1:31, revealed the stair leading to the eye chart room has sustained water damage and the emergency light was inoperable, Wright Saunders Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was water damage within the stair.

Based on observation and interview, it was determined that the facility failed to maintain thefire resistance rating of the smokeproof stairtowers in two instance within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 10:05 am, revealed the smokeproof vestibule at stairtower 2 corridor door across from OR 10 was rated for 60-minutes in lieu of 90-minutes in an opening greater than three levels, Cupp Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the stair vestibule rating was not maintained.

2. Observation made on September 8, 2011, at 11:52 am, revealed existing leads onto the 1st floor exit passageway. This area was not identified with a minimum one hour fire resistance rating in openings greater than three stories. Note: This area is non-sprinklered.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the rating of the exit passageway must be clearly defined.

Based on observation and interview, it was determined that the facility failed to maintain the minimum headroom clearance for the means of egress in four instances within the facility.

Findings Include:

1. Observation made on September 7-9, 2011, between 8:30 am - 3:00 pm, it was revealed the ceiling height was less than the 6' 8" inch minimum requirement. Examples are the ductwork obstruction measuring 6' 1" inches outside the maintenance office and the sprinkler valve measuriing 6' 4" inches outside room W51, Wright/Saunders, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the obstruction to egress and identified that the facility has an acceptable Fire Safety Evaluation System (FSES) reviewed on September 7-9, 2011 addressing this issue.


2. Observation made on September 7, 2011, at 1:40 pm revealed there was a fan and a tran can arranged in the exit access corridor near the Outpatient Radiology fire doors, Cupp Building, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the obstruction along the means of egress.

3. Observation made on September 7, 2011, at 10:50 am, revealed there were beds housed in the corridor outside elevator lobby 43/44, Cupp Building, 5th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the obstructions along the means of egress.


4. Observation made on September 8, 2011, at 2:25 pm, revealed the exit to stair 6 leads through office W622. In addition, the door can be locked to the office, inhibiting egress, Wright Saunders Building, 6th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the obstructions to egress.

Based on observation and interview, it was determined that the facility failed to maintain installation of exit signs in two instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 11:52 am, it was revealed that the facility lacks an exit sign at the exit passageway above the exit discharge door leading from the 2nd floor Myrin Building stairtower near the Emergency Medicine Administration offices, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the exit sign was not installed.

2. Observation made on September 8, 2011, at 11:53 am, revealed the existing exit sign in the exit passageway from the 2nd floor Myrin Building stairtower near the Emergency Medicine Administration offices had an excessive amount of dust and dirt on the lens, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was debris on the exit sign.

Based on observation and interview, it was determined that the facility failed to maintain manual pull stations readily observable in one instance within the facility.

Findings Include:

Observation made on September 8, 2011, at 10:05 am, revealed the manual pull station was located inside the smokeproof vestibule of stairtower 2 across from OR 10, Cupp Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the fire alarm compnent was not visible.

Based on observation and interview, it was determined that the facility failed to maintain the integrity of the sprinkler components in three instances withnin the building.

Findings Include:

1. Observation made on September 8, 2011, at 2:30 pm, revealed there were data lines (yellow and green) tield to the main sprinkler line outside room M01 mechanical room, Myrin Building basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the sprinkler piping was used to support non-system components.

2. Observation made on September 7, 2011, at 1:50 pm, revealed there were boxes of storage within 18" inches of the sprinkler head inside the Davita Dialysis Unit, administration storage room, Cupp Building, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there were obstructions to the sprinkler head.


3. Observation made on September 7, 2011, at 1:52 pm, revealed the sprinkler head is missing an escutcheon inside the Davita Dialysis Unit file room behind the receptionist desk, Cupp Building, 1st floor. (This is a Repeat deficiency from the 10/21/2009 inspection)

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was an opening around the sprinkler head.

Based on observation and interview, it was determined that the facility failed to maintain fire extinguisher cabinets accessible in five instances within the facility.

Findings Include:

1. Observation made on September 7, 2011, at 11:05 am, revealed the handle to the fire extinguisher cabinet next to room C586 was loose, Cupp Building, 5th floor

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the cabinet requires adjustment.

2. Observation made on September 7, 2011, at 9:57 am, revealed the following fire extinguishers monthly inspection had not been conducted since June 19, 2011:

a. inside the elevator machine room 44/45, Cupp Building, penthouse
b. in the corridor outside elevator machine room 44/45, Cupp Building, penthouse

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the fire extinguishers were not maintained.


3. Observation made on September 8, 2011, at 1:20 pm, revealed the following fire extinguisher cabinets lack handles for accessibility:

a. across from the ton rack room, Wright Saunders, basement
b. next to room W-31, Wright Saunders, basement

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the fire extinguishers were inaccessible.

Based on observation and interview, it was determined that the facility failed to maintain protection of cooking areas within the facility


Findings Include:

Observation made on September 8, 2011, at 1:55 pm, revealed there was a paper bag with frozen french fries next to the unattended deep fat fryer in which the oil smelled like it was burning. The temperature was reduced and it was verified with kitchen personnel that the deep fat fryer was equipped with a temperature control valve, Wright Saunders Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was a potential hazard with cooking equipment.

Based on observation and interview, it was determined that the facility failed to maintain the two hour fire resistance rating of the linen chute discharge enclosures in two instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 1:25 pm, revealed the following items were noted of the linen chute discharge room across from the ton rack room in the Wright Saunders Building, basement:

a. There was an opening around the linen chute penetrating the ceiling slab
b. There was a B labeled corridor door. Verification is requested on whether this is a 60-minute of 90-minute B labeled door. A 90-minute rating is required for a two hour enclosure
c. The inner door hardware was incomplete. There was a partial opening in the door

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the linen chute enclosure was not maintained.


2. Observation made on September 8, 2011, at 1:45 pm, revealed the following items were noted of linen chute discharge room W48 in the Wright Saunders Building, basement:

a. There is a manual thumb latch which lacks marking to indicate UL (fire rated)
b. There were openings around the perimeter of the room

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the linen chute enclosure was maintained.

Based on observation and interview, it was determined that the facility failed to maintain storage of medical gas cylinders in four instances within the facility.

Findings Include:

1. Observation made on September 7, 2011, at 2:27 pm, revealed the following items inside the medical gas manifold room located inside the Cupp Building, basement:

a. There were electrical outlets (at least three) less than 60-inches from the floor (currently 12 inches)
b. The medical gas cylinders (nitrous oxide, oxygen, nitrogen, etc), were not individually secured
c. The room requires a dedicated exhaust system. There was a small 6x6" inch vent that has an excessive build-up of dust/dirt.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed medical gas storage areas were not maintained.


2. Observation made on September 8, 2011, at 2:45 pm, revealed there was an unsecured oxygen E cylinder housed inside W567 Oral Surgery, Wright Saunders Building, 5th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed medical gas storage areas were not maintained.

Based on observation and interview, it was determined that the facility failed to maintain the integrity of medical gas piping in two instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 10:13 am, revealed there were data lines (white and orange) laying on medical gas piping inside M203 inside SICU, Myrin Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the medical gas lines were used to support non-system components..


2. Observation made on September 8, 2011, at 12:30 pm, revealed the medical gas master alarm panels for the Myrin, Cupp, and Wright Saunders Buildings were located behind a cabinet door, inhibiting observation of the visual signal of the panel inside the Command Center, Wright Saunders Building, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the medical gas alarm panel was not readily observable.

Based on observation and interview, it was determined that the facility failed to maintain protection of electrical components in one instance within the building.

Findings Include:

Observation made on September 8, 2011, at 10:45 am, revealed there was an open junction box above the ceiling inside the office across from elevators 44/45, Cupp Building, 5th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the electrical component lacks protection.

Based on observation and interview, it was determined that the facility failed to maintain installation of Alcohol Based Hand Rubs (ABHRs) devices in five instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, between 9:58 am and 2:55 pm, revealed AHBRs were installed above or adjacent to electrical outlets/switches at the following locations:

a. 9:58 am, OR 6 at the scrub sink, Cupp Building, 2nd floor
b. 11:40 am, adjacent to light switch at room C353, Cupp Building, 3rd floor
c. 2:55 pm, next to light switch at rooms W485, Wright Saunders Building, 5th floor

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the ABHRs were not secured properly.


2. Observation made on September 7-8, 2011, between 10:50 am and 3:00 pm, revealed there were ABHRs housed above soiled linen carts, eg. between rooms C560 and 561, Cupp Building, 5th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the ABHRs were installed above hazardous contiainers.


3. Observation made on September 7, 2011, at 11:25 am, revealed there was an ABHR next to a light switch at the Emergency Department Nurses Station, Myrin Building 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the ABHRs were not secured properly.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the corridor partitions at three locations within the facility.

Findings Include:

1. Observation made on September 7, 2011, between 8:30 am and 3:00 pm, revealed there was a plain glass vision panel that forms the corridor wall leading to the Penn Orthopedics Suite at the first floor Cupp Building.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor wall integrity and identified that the facility has an acceptable Fire Safety Evaluation System (FSES) reviewed on September 7-9, 2011 addressing this issue.

2. Observation made on September 8, 2011, at 2:30 pm, revealed an open transfer grill in the corridor wall and missing ceiling tiles at room M01 mechanical space, Myrin Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor wall integrity was not maintained.

3. Observation made on September 8, 2011, at 3:15 pm, revealed there was a cable penetration inside the Wright Saunders telephone closet W-3-TE1, 3rd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor wall integrity was not maintained.

Based on observation and interview, it was determined that the facility failed to maintain closing and latching of corridor doors along the means of egress in three instances within the facility.

Findings Include:

1. Observation made on September 7, 2011, at 11:05 am, revealed there were small holes in the corridor door to the clean utility room C487. In addition, the corridor door is off-set and requires adjustment to latch into the fram, Cupp Building, 4th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor doors require adjustment.

2. Observation made on September 7, 2011, at 11:05 am, revealed the clean linen room corridor double doors outside room 430 requires adjustment, Cupp Building, 4th floor

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor wall integrity was not maintained.

3. Observation made on September 8, 2011, at 11:30 am, revealed corridor door M05 was off-set and would not close, Myring Building basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor doors require adjustment.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of vertical openings in two instances with the building.

Findings Include:

1. Observation made on September 8, 2011, at 11:30 am, revealed there were openings at pipe penetrations through the floor slab behind both sets of access panels, North and South Myrin Building, penthouses.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there were vertical penetrations.

2. Observation made on September 8, 2011, at 1:55 pm, revealed there was an opening in the kitchen dumbwaiter. The vision panel was missing, Wright Saunders Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there were vertical penetrations.

Based on observation and interview, it was determined that the facility failed to maintain the integrity of hold open devices in one instance within the facility.

Findings Include:

Observation made on September 8, 2011, at 1:45 pm, revealed the cover plate was missing over the self-closing/hold open unit at the smoke barrier double doors main OR entrance, Cupp Building 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the magnetic hold-open device was incomplete.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the smoke barrier partitions in one instance within the facility.

Findings Include:

Observation made on September 8, 2011, at 1:47 pm, it was revealed the there was approximately a two inch penetration above the duct filled with insulation only at the smoke barrier doors outside room C119, Cupp Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was a smoke barrier penetration.

Based on observation and interview, it was determined that the facility failed to maintain protection of hazardous areas in seven instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 10:45 am, revealed the mechanical room door was held open with a pipe, Myrin Building, penthouse.
(This is a Repeat deficiency from 10/21/2009 inspection)

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the hazardous area door was held open by an unauthorized means.


2. Observation made on September 8, 2011, at 10:42 am, revealed C500A physical therapy storage room wall adjadent to the office was incomplete above the suspended ceiling. In lieu of automatic sprinkler protection the room requires a one hour rated enclosure, Cupp Building, 5th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage room lacks a rated enclosure.


3. Observation made on September 7, 2011, between 1:50 pm and 2:30 pm, revealed there was storage of 40 gallon trash container, soilen linen carts, stretchers housed along the corridor within the basements, Cupp Building and Wright Saunders Building.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the corridor means of egress was used for hazardous storage.


4. Observation made on September 8, 2011, between 1:50 pm and 2:30 pm, revealed a one hour fire rating was not maintained around the perimeter, including a rated door with self-closing hardware, of storage room W50. Automatic sprinkler protection could not be verified, Wright Saunders Building, basement.


Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage area lacks a rated enclosure.


5. Observation made on September 8, 2011, at 1:08 pm, revealed the X-ray file storage room corridor double doors require adjustment, Wright Saunders, basement. In addition, a self closing device had been disconnected.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage rooms doors require adjustment.


6. Observation made on September 8, 2011, at 1:35 pm, revealed there were very large cardboard boxes used for trash storage in the corridor out TV Rental, Wright Saunder Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage was housed in the corridor.


7. Observation made on September 8, 2011, at 7:55 am, revealed breakdown storage room C09 corridor double doors self-closure was disconnect, Cupp Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the storage room door hardware was disengaged.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the stairtower enclosure in two instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 10:39 am, revealed a flexible conduit penetration through the elevator shaft above the ceiling across from the visitor's waiting area M224, Myrin Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was a stairtower penetration.


2. Observation made on September 8, 2011, at 1:31, revealed the stair leading to the eye chart room has sustained water damage and the emergency light was inoperable, Wright Saunders Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was water damage within the stair.

Based on observation and interview, it was determined that the facility failed to maintain thefire resistance rating of the smokeproof stairtowers in two instance within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 10:05 am, revealed the smokeproof vestibule at stairtower 2 corridor door across from OR 10 was rated for 60-minutes in lieu of 90-minutes in an opening greater than three levels, Cupp Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the stair vestibule rating was not maintained.

2. Observation made on September 8, 2011, at 11:52 am, revealed existing leads onto the 1st floor exit passageway. This area was not identified with a minimum one hour fire resistance rating in openings greater than three stories. Note: This area is non-sprinklered.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the rating of the exit passageway must be clearly defined.

Based on observation and interview, it was determined that the facility failed to maintain the minimum headroom clearance for the means of egress in four instances within the facility.

Findings Include:

1. Observation made on September 7-9, 2011, between 8:30 am - 3:00 pm, it was revealed the ceiling height was less than the 6' 8" inch minimum requirement. Examples are the ductwork obstruction measuring 6' 1" inches outside the maintenance office and the sprinkler valve measuriing 6' 4" inches outside room W51, Wright/Saunders, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the obstruction to egress and identified that the facility has an acceptable Fire Safety Evaluation System (FSES) reviewed on September 7-9, 2011 addressing this issue.


2. Observation made on September 7, 2011, at 1:40 pm revealed there was a fan and a tran can arranged in the exit access corridor near the Outpatient Radiology fire doors, Cupp Building, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the obstruction along the means of egress.

3. Observation made on September 7, 2011, at 10:50 am, revealed there were beds housed in the corridor outside elevator lobby 43/44, Cupp Building, 5th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the obstructions along the means of egress.


4. Observation made on September 8, 2011, at 2:25 pm, revealed the exit to stair 6 leads through office W622. In addition, the door can be locked to the office, inhibiting egress, Wright Saunders Building, 6th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the obstructions to egress.

Based on observation and interview, it was determined that the facility failed to maintain installation of exit signs in two instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 11:52 am, it was revealed that the facility lacks an exit sign at the exit passageway above the exit discharge door leading from the 2nd floor Myrin Building stairtower near the Emergency Medicine Administration offices, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the exit sign was not installed.

2. Observation made on September 8, 2011, at 11:53 am, revealed the existing exit sign in the exit passageway from the 2nd floor Myrin Building stairtower near the Emergency Medicine Administration offices had an excessive amount of dust and dirt on the lens, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was debris on the exit sign.

Based on observation and interview, it was determined that the facility failed to maintain manual pull stations readily observable in one instance within the facility.

Findings Include:

Observation made on September 8, 2011, at 10:05 am, revealed the manual pull station was located inside the smokeproof vestibule of stairtower 2 across from OR 10, Cupp Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the fire alarm compnent was not visible.

Based on observation and interview, it was determined that the facility failed to maintain the integrity of the sprinkler components in three instances withnin the building.

Findings Include:

1. Observation made on September 8, 2011, at 2:30 pm, revealed there were data lines (yellow and green) tield to the main sprinkler line outside room M01 mechanical room, Myrin Building basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the sprinkler piping was used to support non-system components.

2. Observation made on September 7, 2011, at 1:50 pm, revealed there were boxes of storage within 18" inches of the sprinkler head inside the Davita Dialysis Unit, administration storage room, Cupp Building, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there were obstructions to the sprinkler head.


3. Observation made on September 7, 2011, at 1:52 pm, revealed the sprinkler head is missing an escutcheon inside the Davita Dialysis Unit file room behind the receptionist desk, Cupp Building, 1st floor. (This is a Repeat deficiency from the 10/21/2009 inspection)

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was an opening around the sprinkler head.

Based on observation and interview, it was determined that the facility failed to maintain fire extinguisher cabinets accessible in five instances within the facility.

Findings Include:

1. Observation made on September 7, 2011, at 11:05 am, revealed the handle to the fire extinguisher cabinet next to room C586 was loose, Cupp Building, 5th floor

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the cabinet requires adjustment.

2. Observation made on September 7, 2011, at 9:57 am, revealed the following fire extinguishers monthly inspection had not been conducted since June 19, 2011:

a. inside the elevator machine room 44/45, Cupp Building, penthouse
b. in the corridor outside elevator machine room 44/45, Cupp Building, penthouse

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the fire extinguishers were not maintained.


3. Observation made on September 8, 2011, at 1:20 pm, revealed the following fire extinguisher cabinets lack handles for accessibility:

a. across from the ton rack room, Wright Saunders, basement
b. next to room W-31, Wright Saunders, basement

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the fire extinguishers were inaccessible.

Based on observation and interview, it was determined that the facility failed to maintain protection of cooking areas within the facility


Findings Include:

Observation made on September 8, 2011, at 1:55 pm, revealed there was a paper bag with frozen french fries next to the unattended deep fat fryer in which the oil smelled like it was burning. The temperature was reduced and it was verified with kitchen personnel that the deep fat fryer was equipped with a temperature control valve, Wright Saunders Building, basement.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed there was a potential hazard with cooking equipment.

Based on observation and interview, it was determined that the facility failed to maintain the two hour fire resistance rating of the linen chute discharge enclosures in two instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 1:25 pm, revealed the following items were noted of the linen chute discharge room across from the ton rack room in the Wright Saunders Building, basement:

a. There was an opening around the linen chute penetrating the ceiling slab
b. There was a B labeled corridor door. Verification is requested on whether this is a 60-minute of 90-minute B labeled door. A 90-minute rating is required for a two hour enclosure
c. The inner door hardware was incomplete. There was a partial opening in the door

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the linen chute enclosure was not maintained.


2. Observation made on September 8, 2011, at 1:45 pm, revealed the following items were noted of linen chute discharge room W48 in the Wright Saunders Building, basement:

a. There is a manual thumb latch which lacks marking to indicate UL (fire rated)
b. There were openings around the perimeter of the room

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the linen chute enclosure was maintained.

Based on observation and interview, it was determined that the facility failed to maintain storage of medical gas cylinders in four instances within the facility.

Findings Include:

1. Observation made on September 7, 2011, at 2:27 pm, revealed the following items inside the medical gas manifold room located inside the Cupp Building, basement:

a. There were electrical outlets (at least three) less than 60-inches from the floor (currently 12 inches)
b. The medical gas cylinders (nitrous oxide, oxygen, nitrogen, etc), were not individually secured
c. The room requires a dedicated exhaust system. There was a small 6x6" inch vent that has an excessive build-up of dust/dirt.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed medical gas storage areas were not maintained.


2. Observation made on September 8, 2011, at 2:45 pm, revealed there was an unsecured oxygen E cylinder housed inside W567 Oral Surgery, Wright Saunders Building, 5th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed medical gas storage areas were not maintained.

Based on observation and interview, it was determined that the facility failed to maintain the integrity of medical gas piping in two instances within the facility.

Findings Include:

1. Observation made on September 8, 2011, at 10:13 am, revealed there were data lines (white and orange) laying on medical gas piping inside M203 inside SICU, Myrin Building, 2nd floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the medical gas lines were used to support non-system components..


2. Observation made on September 8, 2011, at 12:30 pm, revealed the medical gas master alarm panels for the Myrin, Cupp, and Wright Saunders Buildings were located behind a cabinet door, inhibiting observation of the visual signal of the panel inside the Command Center, Wright Saunders Building, 1st floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the medical gas alarm panel was not readily observable.

Based on observation and interview, it was determined that the facility failed to maintain protection of electrical components in one instance within the building.

Findings Include:

Observation made on September 8, 2011, at 10:45 am, revealed there was an open junction box above the ceiling inside the office across from elevators 44/45, Cupp Building, 5th floor.

Interview with Facility Personnel on September 9, 2011, between 9:30 am and 11:00 am, confirmed the electrical component lacks protection.