HospitalInspections.org

Based upon observation and interview, the facility failed to maintain the fire doors to provide at two-hour integrity fire resistance rating and shall not be equipped with a latch or lock that requires the use of a tool nor key, on one of three floors, NFPA 101, 2000 edition, 19.2.2.2.4

1. Observation made on March 4, 2010, at 9:45 am, revealed that the following fire doors have thermal fire pin devices installed within the meeting edges which will impede egress when engaged.

a. first floor smoke barrier doors labeled MOB 106.
b. first floor smoke barrier doors labeled MOB 101.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, the fire doors have thermal fire pin device installed within the meeting edges.

Based upon observation and interview, the facility failed to maintain the fire doors to provide at two-hour integrity fire resistance rating and shall not be equipped with a latch or lock that requires the use of a tool nor key, on one of three floors, NFPA 101, 2000 edition, 19.2.2.2.4.

1. Observation made on March 3 and 4, 2010, between, 9:40 am and 10:45 am, revealed the following fire doors have thermal fire pin devices installed within the meeting edges which will impede egress when engaged:

a. 9:40 am, third floor main building, from ancillary building fire door labeled MH 308.

b. 10:45 am, second floor, annex fire door to the bridge has a thermal fire pin device installed within the meeting edge.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the installation of thermal fire pin devices in the fire doors.

Based on observation, it was determined the facility failed to maintain the common wall, including all components, for a fire resistance rating of at least two hours in two instances within this component.

Findings include:


1. Observation on March 4, 2010, at 11:18 am, revealed that the second floor door to room 2256-A within the commonwall lacks a label for its fire resistance rating.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door lacks a fire rating label.

2. Observation on March 4, 2010, at 2:00 pm, revealed that the cross corridor commonwall doors first floor next to kitchen storage hag a leading edge gap of greater that one eighth of an inch.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door has a leading edge gap of greater than one eighth of an inch.

Based on observation, it was determined the facility failed to maintain the common wall, including all components, for a fire resistance rating of at least two hours in one of three floors.

Findings include:

Observation on March 4, 2010, between 10:05 am and 10:15 am, revealed there were penetrations in the common wall at the following locations:

a. 10:05 am, first floor, common wall of Main Building at Room 1350, the penetrations above the door need to be resealed due to wear and age.
b. 10:15 am, first floor, common wall of Main Building by room 1346, in front of "Family Waiting", the penetrations need to be resealed due to wear and age.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the penetrations needed to be resealed.

Based on observation, it was determined the facility failed to maintain the common wall, including all components, for a fire resistance rating of at least two hours on one of one floor.

Findings include:

1. Observation on March 4, 2010, at 9:00 am, revealed there were penetrations in the common wall above the MRI doors on the outpatient side.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were penetrations.


2. Observation on March 4, 2010, at 9:15 am, revealed there was an unknown gray caulk used to seal penetrations above the reading room in Zone III.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was gray caulk used.

Based on observation, it was determined the facility failed to maintain the common wall, including all components, for a fire resistance rating of at least two hours on one of three floors.

Findings include:

1. Observation on March 4, 2010, between 1:22 pm and 1:28 pm, revealed there were penetrations in the common wall at the following locations:

a. 1:22 pm, common wall to the Church, above the double doors, reseal around drywall where caulk is pulling away.
b. 1:25 pm, common wall by the file room door, reseal penetrations where caulk has pulled away from the drywall.
c. 1:28 pm, common wall to the medical center link had two unsealed penetrations for wiring on the right side.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were penetrations that needed to be resealed.


2. Observation on March 4, 2010, at 1:25 pm, revealed penetrations in the common wall had been sealed with an unknown gray caulk by the file room door.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were penetrations sealed with gray caulk.


3. Observation on March 4, 2010, at 1:23 pm, revealed the right hand door at the common wall to the church would not latch into the frame.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door was not latching.

Based on observation and interview, the facility failed to maintain proper building construction type in one instance within this component.

Findings include:

Observation made on March 1, 2010, at 1:42 pm, inside the generator penthouse room there were several areas above the generator where the structural steel beam was missing fire proofing material.

Interview with the Director of Plant Operations on March 2, 2010, at 2:15 pm, at the time of the exit conference, confirmed that above the generator in the penthouse there was missing fire proofing material on the structural steel beam.

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the building on one of six floors.

Findings include:

Observation on March 1, 2010, at 11:35 am, revealed fire proof spray used for the fire resistance rating was missing from the ceiling support beam above the switchgear by the outside exit door in the main electrical switch gear room on the first floor.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there was fire proof spray missing from the support beam.

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the building on two of three floors.

Findings include:

Observation on March 4, 2010, between 10:52 am, and 1:24 pm, revealed the following locations that were missing fireproofing material on the structural steel beams.

a. 10:52 am, cancer center lower level mechanical room above the intake for the cooling tower there was a structural steel beam missing fire proofing material.
b. 1:22 pm, at the first floor above the ceiling at the common wall doors to the medical center there was a structural steel beam that was missing fire proofing material.
c. 1:24 pm,the steel beam above the doors of the common wall to the church was missing a patch of fire proofing.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the beam was missing fire proofing.

Based on observation and interview, it was determined the facility failed to provide a smoke tight separation between use rooms and corridors one of three floors.

Findings include:

Observation on March 4, 2010, at 9:53 am, revealed the ceiling of the telephone equipment room 2328 was incomplete and there was a penetration above the ceiling into the room from the corridor side.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the room was not smoke tight.

Based upon observation and interview, it was determined the doors protecting corridor openings in other than hazardous areas are not substantial, nor smoke resistant on one of four floors within this component.

Findings include:

Observation made on March 3, 2010, at 10:25 am, revealed that the second floor Main building anesthesia room corridor door was held open by an unauthorized mean book wedge under the bottom of door.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010 at 2:30 pm confirmed the corridor door was blocked open.

Based upon observation and interview, it was determined the doors protecting corridor openings in other than hazardous areas are not substantial, nor smoke resistant as per regulations in four instances within this component.

Findings include:

1. Observation made on March 1, 2010, between 2:25 pm, and 2:32 pm, revealed that the following doors that did not positively latch or blocked open by unapproved devices.

a. 2:25 pm, second floor Social services office across from room 238 the corridor door was held open by a unapproved device (rubber wedge).
b. 2:32 pm, second floor trash room ( by stair 5) the inactive leaf was not secured and caused the active leaf to fail to positively latch into its frame.

Interview with the Director of Plant Operations on March 2, 2010, at 2:45 pm, at the time of the exit conference, confirmed that the above doors were held open by unapproved devices or failed to latch.
2. Observation made on March 2, 2010, between 10:20 am, and 10:40 am, revealed that the following doors that did not positively latch or blocked open by unapproved devices.

a. 10:20 am, first floor janitors closet across from ultrasound #1 the door latch was taped open.
b. 10:40 am, first floor ultrasound reading room door was held open by a unapproved device (chair).

Interview with the Director of Plant Operations on March 2, 2010, at 2:45 pm, at the time of the exit conference, confirmed that the above doors were held open by unapproved devices or failed to latch.

Based on observation and interview, it was determined the facility failed to ensure the corridor doors had no impediment to closing on one of six floors, NFPA 101, 2000 edition, 19.3.6.3.

Findings include:

Observation on March 1, 2010, at 10:30 am, revealed the cross corridor doors between the OR Suite and the Recovery Unit were not closing into the frame.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the doors would not close.

Based on observation and interview, it was determined the facility failed to ensure the corridor doors were substantial, 1 ? inch solid-bonded core wood, capable of resisting the passage of smoke with no impediment to closing in (universe), NFPA 101, 2000 edition, 19.3.6.3.

Findings include:

1. Observation on March 4, 2010, at 9:50 am, revealed the inactive leaf of the door to room 2315 was not latched in the frame, preventing the principal leaf from latching.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door would not latch.


2. Observation on March 4, 2010, at 10:00 am, revealed the corridor door of room 2308 was blocked by a linen cart, preventing it from being closed in one motion.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door was blocked.

Based upon observation and interview, it was determined that the vertical openings between floors are not enclosed with construction having a fire resistive rating of one hour in two instances within this component.

Findings include:

Observation made on March 1, 2010, between 1:35 pm, and 2:38 pm, revealed the following locations that lacked fire resistive rating of one hour between floors for vertical openings.

a. 1:35 pm, in the penthouse behind the compressor there was a rated access door that was missing its closer spring.
b. 2:38 pm, second floor electrical room next to stair 5 there were two unsealed vertical penetrations for electrical conduit through to the first floor.

Interview with the Director of Plant Operations on March 2, 2010, at 2:45 pm, at the time of the exit conference, confirmed that the above vertical openings lacked the correct fire resistive rating.

Based upon observation and interview, the facility failed to maintain smoke barriers with at least a one half hour fire resistance rating in one instance within the component, NFPA 101, 2000 edition, 19.3.7.3.

Observation made on March 3, 2010, at 11:40 am, revealed that located on the Main building second floor service lobby smoke barrier wall had and unsealed horizontal penetration around orange armored cabel.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was penetration.

Based upon observation and interview, the facility failed to maintain smoke barriers with at least a one half hour fire resistance rating on two of six floors.

Findings include:

1.Observation on March 1, 2010, at 9:55 am, revealed a small rectangular cut out in the smoke barrier wall, above the suspended ceiling, in the Recovery Unit of the third floor, above the linen warmer near the nurses station.
a. Observation made on March 1, 2010, at 10:20 am, revealed that located on the third floor, inside room 3312, there was a dry wall patch in the smoke barrier wall were the patch edges were sealed with combustible foam insulation.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there were penetrations in the smoke barrier walls.

2. Observation on March 1. 2010, at 10:30 am, revealed that there is a eight-ten inch round duct located inside the Diabetes/Speech therapy classroom which penetrates the smoke barrier wall and lacks a smoke damper.
a. Observation on March 1. 2010, at 10:30 am, revealed that the third floor Diabetes/Speech classroom has an six inch by ten inch air duct which penetrates smoke barrier wall which lacks a smoke damper.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed that the HVAC system was not maintained properly.

Based upon observation and interview, it was determined that the facility failed to maintain the smoke barrier door assemblies in proper operating condition on three of four floors within the facility.

Findings include:

1. Observation made on March 3, 2010 between 10:30 am and 11:10 am, revealed the following smoke barrier doors have thermal fire pin device installed in the meeting edge which will impede egress when engaged:

a.10:30 am, fourth floor, main building smoke barrier doors at EEG office and electrical closet 4402.
b. 10:45 am, fourth floor, main building smoke barrier doors at pulmonary diagnostic 4492 and nurses manager office.
c. 10:50 am, fourth floor, main building smoke barrier doors at patient rooms 4424 and 4425.
d.10:55 am, fourth floor, main building smoke barrier doors at patient rooms 4455 and 4456.

e. 11:00 am, fourth floor, main building smoke barrier doors at patient room 4451

f. 11:10 am, third floor, main building smoke barrier doors at electric closet 3302.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4,2010, at 2:30 pm, confirmed the smoke barrier doors have thermal fire pin device installed within the meeting edges.


2. Observation made on March 4, 2010, between 9:55 am and 10:00 am, revealed the following smoke barrier doors have thermal fire pin device installed in the meeting edge which will impede egress when engaged:

a. 9:55 am, second floor, main building smoke barrier doors at room 2A staff lounge.

b. 10:00 am, second floor, main building smoke barrier doors at clean utility 2299 and patient room 2251.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the smoke barrier doors have thermal fire pin device installed within the meeting edges.

Based upon observation and interview, the facility failed to maintain the smoke barrier doors to provide at least twenty minutes fire resistance rating and shall not be equipped with a latch or lock that requires the use of a tool nor key, on two of six floors, NFPA 101, 2000 edition, 19.2.2.2.4.

Findings include:

1.Observation made on March 1, 2010, revealed that the follow smoke barrier doors had dual fire pins installed in the meeting edge which will impede egress when engaged.

a. 9:00 am, smoke barrier doors on the fifth floor, near room 5213.
b. 1:15 pm, second floor smoke barrier doors labled 21153 SD-3.
c. 1:20 pm second floor smoke barrier doors labled 21153 SD-2.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there device installed within the smoke barrier doors.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations in one instance within this component..

Findings include:

Observation made on March 4, 2010, at 10:45 am, revealed that the lower level LNAC medical records room door failed to latch.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that the LNAC medical records storage room failed to latch.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the stair towers, and/or maintain a continuous path of escape in one of three stair towers.

Findings include:

Observation on March 1, 2010, at 9:30 am, revealed the fire rated access panel in the ceiling of Stair Tower 2 would not automatically close.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the panel did not automatically close.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the stair towers, and/or maintain a continuous path of escape.

Findings include:

Observation on March 4, 2010, between 9:40 am and 10:30 am, revealed there were penetrations in the smoke towers at the following locations:

a. 9:40 am, third floor, stair tower in the back of the OR Suite had a penetration of fire alarm bx cable.
b. 9:43 am, second floor, stair tower in the back of the OR Suite, in the interior of the tower, to the left of the New Patient Wing door, there are penetrations by two white insulated pipes.
c. 10:30 am, first floor, stair tower by Bay 20, the stairtower wall is not sealed to the deck with fire rated material over the fire rated insulation.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were penetrations into the stair towers.

Based upon observation and interview, it was determined that the facility failed to maintain exit stairways with a two hour fire resistance rating within this component

Findings include:

Observation made on March 1, 2010, at 1:15 pm, revealed that first floor horizontal exit passageway for fire stair tower two had a fifty gallon trash can was being stored inside this stairtower.


Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the obstructed passageway.

Based on observation and interview, it was determined the facility failed to ensure that the exit stairways are free from obstructions and are not used as storage areas in one instance within this component.


1. Observation made on March 3, 2010, at 9:25 pm, revealed that within MOB building south fire exit stair tower had environmental services signs being stored inside the first floor foyer.


Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the stairtower was used for storage.


2. Observation made on March 3, 2010 at 1:35 pm, revealed that the ER addition building control doors at patient treatment rooms 20 and 21, had thermal fire pin device installed in the meeting edge which will impede egress when engaged.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on, March 4, 2010 at 2:30 pm, confirmed there were impediments to egress.

Based on observation and interview, it was determined the facility failed to provide readily accessible exit access on one instance within the facility.

Findings include:

Observation made on March 4, 2010, at 9:40, revealed that located on the second floor MOB building the exit access on the second floor, in suite 210, at the back, was blocked with medical equipment.


Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010 at 2:30 pm confirmed exit was blocked.

Based upon observation and interview, it was determined that the facility failed to maintain exit access is not arranged to be accessible at all times in nine instances within this component.

Findings include:

Observation made during document review on March 1, 2010, revealed that the following control doors have thermal fire pin devices installed within the following doors which will impede egress when engaged:

a. March 1, 2010, at 9:00 am, second floor back hallway at elevator lobby for critical care unit the control doors have thermal fire pin device installed within doors.

b March 1, 2010, at 9:00 am, third floor, control doors leading to link have thermal fire pin device installed within doors.

c. March 1, 2010, at 9:00 am, second floor, control doors leading to link have a thermal fire pin device installed within doors.

d. March 1, 2010, at 9:00 am, ground floor cross corridor doors at Physical medicine, the control doors had a thermal fire pin device installed within doors.

e. March 1, 2010, at 9:00 am, ground floor double control door from the cafeteria to the exit stairtower have a thermal fire pin device installed within doors.

f. March 1, 2010, at 9:00 am, cross corridor doors at the Pharmacy, the control doors have a thermal fire pin device installed within doors.

g. March 1, 2010, at 9:00 am, exit doors from the kitchen storage and central supply, and out of the alcove they lead to, all are equipped with thermal fire pin devices installed within doors.

h March 1, 2010, at 9:00 am, cross corridor doors ground floor at the library, have a thermal fire pin device installed within doors.

i. March 1, 2010, at 9:00 am, cross corridor doors next to the medical affairs academic affairs office, have a thermal fire pin device installed within doors.

Reference: 2000 edition NFPA 101 chapter 7.2.1.5.

Interview with the Director of Plant Operations on March 2, 2010, at 2:45 pm, at the time of the exit conference, confirmed that the above listed door have thermal fire pin device installed and are in the process of being repaired.

Based upon observation and interview, it was determined the facility failed to maintain the exit access to be accessible at all times in accordance in one instance within this component.

Findings include:

Observation made on March 4, 2010, at 10:15 am, revealed that the exit door from the cafe cashier area was blocked by a metal stand with a metal bucket full of potato chips.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that this exit was blocked.

Based upon observation and interview the facility failed to maintain clear and unobstructed exit corridors in accordance in one instance within this component.

Findings include:

Observation made on March 4, 2010, at 1:30 pm, revealed the second floor exit corridor at the Cath Lab near room 2473 was blocked with four plastic rolling cart, one metal cart,two tall rolling carts.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that this corridor was blocked by carts stored in the corridor.

Based on observation and interview, it was determined that the facility failed to keep the corridors serving as exit access clear and unobstructed on one of three floors.

Findings include:

Observation on March 4, 2010, at 10:40 am, revealed there was a computer-on-wheels charging in the corridor by Bay 27.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the computer-on-wheels was charging in the corridor.

Based on observation and interview, it was determined that the facility failed to keep the corridors serving as exit access clear and unobstructed on one of three floors.

Findings include:

Observation on March 4, 2010, at 1:28 pm, revealed the Main Street corridor by the back doors had trash and a gurney stored in it.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were items kept in the corridor.

Based upon observation and interview, it was determined that the exit and directional signs are not in accordance with regulations in one instance within this component.

Findings include:

Observation made on March 3, 2010, at 1:49 pm, revealed that on the second floor at the commonwall doors from the main to the pavilion lacked an exit sign.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that above the commonwall doors from the main to the pavilion lacked an exit sign.

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per NFPA 13 in one instance within this component.

Findings include:

Observation made on March 4, 2010, at 10:56 am, revealed that inside the lower level mechanical room back under the ductwork for the cooling tower intake lacks sprinkler coverage in two locations at far wall and the middle.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the lack of sprinkler coverage at the above locations in the cancer center mechanical room under the intake for the cooling tower.

Based on observation and interview, it was determined that the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in one instance within this component.


1.Observation made on March 3 and 4, 2010, revealed that the following areas fire department connection capping were not in place.
a. first floor Main building fire department connection capping were not in place across from telecommunication room
b. Main building loading dock area fire department connection capping were not in place.

reference NFPA 25 1998 edition section 9-7.1 (c).

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed thethe automatic sprinkler system was not maintained properly.

Based on observation and interview, it was determined the automatic sprinkler system was not continuously maintained in reliable operating condition in one instance within the facility, NFPA 101, 19.7.6, NFPA 13, and NFPA 25, 1999 editions.


1.Observation made on March 3, 2010, between 1:45 pm and 1:54 pm, revealed that the following closets lack automatic sprinkler protection. (these closets approximate square footage is two feet by sixteen feet).

a. 1:45 pm, air conditioning control closet
b. 1:54 pm, IT closet across from treatment area three.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010 at 2:30 pm, confirmed automatic sprinkler system was not maintained properly.

Based on observation, and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on one of six floors within this component.

Findings include:

1. Observation made on March 1, 2010, at 1:15 pm, revealed that first floor horizontal exit passageway for fire stair tower two lacks complete automatic sprinkler protection leading to discharge door and the public way the total square footage four by eight feet.

(NFPA 13 1999 edition - Section 4-13.2.2).

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed that this conditions exist.

2. Observation made on March 1, 2010, at 1:35 pm, revealed that the first floor emergency department information sign in the first floor corridor obstructs the nearby sprinkler head.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the automatic sprinkler head was obstructed.

Based on observation, documentation review, and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition and free of non sprinkler components attached or supported by sprinkler components or kept free of obstructions in four instances within this component.

Findings include:

Observation made on March 4, 2010, between 10:47 am, and 11:16 am, revealed the following locations were the sprinkler systems were not maintained by the facility.

a. 10:47 am, LNAC supply storage room had storage within eighteen inches of the sprinkler head's deflector (six inches).
b. 10:50 am, Cancer center mechanical room back in front of the boiler there was air lines for the boiler ziptied to the sprinkler piping and also a electrical armored conduit ( for a two by four lighting fixture)ziptied to the sprinkler piping.
c. 10:58 am, Cancer center mechanical room back above the AH-1 and AH-3 there was three quarter inch conduit attached to the sprinkler piping.
d. 11:16 am, inside the lower level elevator machine room the sprinkler head was missing its escutcheon.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the above obstructions and non sprinkler components tied to sprinkler components.

Based on interview, it was determined the facility failed to maintain and inspect the kitchen supersession systems in one instance within this component.

Findings include:

Observation made on March 4, 2010, at 10:15 am, revealed that the kitchen suppression systems in the Pavilion building (both systems) lacked the monthly quick checks to be documented on the back of the semi-annual inspection tags.
Reference: NFPA 101 2000 edition Chapter 19.3.2.6 and Chapter 9.2.3.
NFPA 96 1998 Edition Chapter 7-2.2.1.
* NFPA 17 1998 Edition Chapter 9-2
* NFPA 17A 1998 Edition Chapter 5-2

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that the Pavilion building kitchen suppression systems lack the monthly quick checks.

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were stored properly in one instance within the component, NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition.

Observation made on Mach 3, 2010, at 10:30 am, revealed the third floor ancillary wing OR sterile storage room gas storage room had an M size argon gas cylinder that was not properly secured or adequately fastened at the time of inspection.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the cylinder were unsecured.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations.

Findings include:

Observation made on March 3, 2010, at 11:46 am, revealed that the Cath Lab heart center oxygen storage room above the corridor door from the inside there were unsealed penetrations through to the corridor side .

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the existence of this unsealed penetration in the Cath Lab oxygen storage room

Based on observation and interview, it was determined that the facility failed to protect medical gas system in one instances within this component.

Findings Include:

Observation on March 1, 2010, at 11:00 am, revealed there was no locking mechanism to prevent unauthorized access to the emergency oxygen tie-in.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the emergency oxygen tie-in had no locking mechanism.

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were stored properly on one of one floor.

Findings include:

Observation on March 4, 2010, at 9:06 am, revealed an unsecured "E" sytle oxygen cylinder in the MRI Antechamber.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was an unsecured oxygen cylinder.

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were stored properly, NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition.

Findings include:

Observation on March 4, 2010, at 9:06 am, revealed an unsecured "E" sytle oxygen cylinder in the MRI Antechamber.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was an unsecured oxygen cylinder.

Based upon observation and interview, the piped in medical gas system does not comply with regulations.

Findings include:

1. Observation made on March 3, 2010, at 8:30 am and 2:45 pm, revealed that the facility representatives and inspector was unable to verify that the pipe in medical gas system, risers for two oxygen risers and the two medical vacuum risers located on the first floor main building and within human resources office have shut off valves adjacent to the riser connection. The facility must verify that pipe in medical gas system, risers are provided with shut off valves.

Please reference NFPA 99 1999 edition chapter 4-3.1.2.3 [c].

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on July 15, 2009, at 2:00 pm, confirmed pipe in medical gas system risers.

Based upon observation and interview, it was determined the facility failed to maintain electrical wiring and/or components in a workmanlike manner, ensure all electrical equipment's protective plates and covers are secured. The facility failed to ensure proper use of powerstrips and maintain the component free of the use of extension cords in eight instances within this component.

Findings include:

1. Observation made on March 3, 2010, at 10:35 am, revealed that on the third floor both nurses stations A and B had transport monitors powered by a powerstrip(A-side three and B-side two).

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that there was medical equipment powered by a powerstrip on the third floor at both nursing stations.

2. Observation made on March 3, 2010, at 10:50 am, revealed that on the third floor above the ceiling in room 3524 on-call room there was temporary lighting left above the ceiling.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the temporary lighting above the ceiling in room 3524.

3. Observation made on March 3, 2010, at 11:44 am, revealed that on the second floor in the Cath Lab heart center oxygen storage room 2435 above the rated ceiling access panel there were six open junction boxes five of which have uncapped wires hanging out of the junction boxes.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the open junction boxes above the ceiling in room 2435.

4. Observation made on March 4, 2010, at 9:00 am,revealed that on the first floor Pavilion mechanical room in the rear back behind the chillers there were two extension cords in use.


Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the use of the above extension cord.

5. Observation made on March 4, 2010, at 9:15 am, revealed that inside the first floor Transformer vault the rated door had a gap of more that an eighth of an inch gap between the leading edges.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the gap of greater that 1/8th inch between the leading edges of the rated doors for the transformer vault.

6. Observation made on March 4, 2010, at 9:15 am, revealed that inside the first floor Transformer vault there were the following items stored within the transformer vault: two refrigerators, scaffolding, a door and door closer assemblies.
Refer to NFPA 70 1999 edition article 450-48.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the existence of the storage within the transformer vault.

Based upon observation and interview, it was determined the facility failed to maintain electrical wiring and/or components in a workmanlike manner, ensure all electrical equipment's protective plates and covers are secured. The facility failed to ensure proper use of powerstrips and maintain the component free of the use of extension cords in three instances within this component.

Findings include:

1. Observation made on March 4, 2010, between 10:40 am, and 11:10 am, revealed the following locations that had extension cords in use.

a. 10:40 am, on the lower level main clinic desk there was a heater powered by a powerstrip.
b. 11:10 am, lower level CT control room there was a extension cord in use.
first floor electrical closet near the link had a TV cable amplifier powered by a extension cord that travels across the ceiling through the wall into the IT room and then plugs into a outlet.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the use of extension cords at the above locations.

2. Observation made on March 4, 2010, at 10:50 am, revealed that in the lower level mechanical room there was a protective cover plate unsecured for panel labeled MCC-1 and there was a large gauge wire run into the panel between the unsecured protective cover and the panel box .
Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed this improper electrical installation.

Based upon observation and interview, it was determined the facility failed to maintain electrical wiring and/or components in a workmanlike manner, ensure all electrical equipment's protective plates and covers are secured. The facility failed to maintain the proper width of working space in front of electrical equipment; and the facility failed to ensure proper use of powerstrips and free of the use of extension cords in ten instances within this component.

Findings include:

1. Observation made on March 1, 2010, at 1:54 pm, inside the third floor Nourishment room across from room 322 there was a extension cord in use powering a coffee maker.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the use of this extension cord and was removed by maintenance personnel at the time of the survey.

2. Observation made on March 2, 2010, between 10:55 am, and 11:45 am, revealed the following locations that improper use of powerstrips was found.

a. 10:55 am, ground floor inside then boiler room there was a powerstrip that was powering a refrigerator, two microwaves, a toaster and a coffee maker.
b. 11:42 am, ground floor staff development rear right side office there was a refrigerator powered by a powerstrip.
c. 11:45 am, ground floor Info systems office inside the breakroom the coffee maker was powered by a powerstrip.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed improper use of the above listed powerstrips.

3. Observation made on March 1, 2010, between 2:38 pm, and 2:44 pm, revealed the following electrical panels that were missing protective circuit breaker blanks.

a. 2:38 pm, second floor electrical room by stair 5 inside panel marked 2DDE slot #11.
b. 2:45 pm, second floor inside room 212 there was a unsecured outlet with a cracked protective face plate.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the above panels had missing protective cover plates and blanks.

4. Observation made on March 2, 2010, between 10:15 am, and 10:44 am, revealed the following electrical panels that were missing protective circuit breaker blanks.

a. 10:15 am, first floor electrical room by rear service entrance of the emergency room in panels marked ILD2 and IDDE3 both were missing protective circuit breaker blanks.
b. 10:44 am, inside the first floor electrical room on the link in panel marked 1AC there was a protective circuit breaker blank in slot #41.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the above panels had missing protective cover plates and blanks.

5. Observation made on March 2, 2010, between 10:44 am, and 11:35 am, revealed the following location that the facility failed to maintain the proper width of working space in front of electrical equipment.

a. 10:44 am, inside the first floor electrical room on the link the panel marked 1DE was blocked from access by a large picture and frame stored in front of the panel.
b. 11:35 am, inside the ground floor electrical room the panel marked GDA-E was blocked from access by a ladder being stored infront of this panel.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the above electrical panels with storage blocking access to the panels.

6. Observation made on March 2, 2010, at 9:50 am, at the rear service entrance to the emergency room above the door there was a dead-ended BX wire capped off outside a junction box.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the above wiring capped outside a junction box.

Based upon observation and interview, it was determined the facility failed to maintain the electrical elements in working order in (universe).

Findings include:

1. Observation on March 1, 2010, at 10:25 am, revealed exposed wiring from a bx cable, above the supsended ceiling at the smoke barrier near room 5044, on the fifth floor in the Moss Rehab suite.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there was exposed wiring.

2. Observation on March 1, 2010, at 11:15 am, revealed an open junction box in the third floor Physicial Library, room 3012, above the suspended ceiling, at the duct work, by the clock.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there was an open junction box.

a. Observation made on March 1, 2010, at 1:40 pm, revealed that a power strip surge suppressor is being used for medical equipment in the first floor physical therapy unit.

.Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there was an power strip in use.

Based upon observation and interview, it was determined the facility failed to maintain the electrical elements in working order on one of three floors, Department of Health message board, message dated October 30, 2009, and NFPA 70.

Findings include:

Observation on March 4, 2010, at 10:10 am, revealed there were appliances plugged into an extension cord in room 1350.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was an unapproved power tap device in use.

Based upon observation and interview, the facility failed to maintain the fire doors to provide at two-hour integrity fire resistance rating and shall not be equipped with a latch or lock that requires the use of a tool nor key, on one of three floors, NFPA 101, 2000 edition, 19.2.2.2.4

1. Observation made on March 4, 2010, at 9:45 am, revealed that the following fire doors have thermal fire pin devices installed within the meeting edges which will impede egress when engaged.

a. first floor smoke barrier doors labeled MOB 106.
b. first floor smoke barrier doors labeled MOB 101.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, the fire doors have thermal fire pin device installed within the meeting edges.

Based upon observation and interview, the facility failed to maintain the fire doors to provide at two-hour integrity fire resistance rating and shall not be equipped with a latch or lock that requires the use of a tool nor key, on one of three floors, NFPA 101, 2000 edition, 19.2.2.2.4.

1. Observation made on March 3 and 4, 2010, between, 9:40 am and 10:45 am, revealed the following fire doors have thermal fire pin devices installed within the meeting edges which will impede egress when engaged:

a. 9:40 am, third floor main building, from ancillary building fire door labeled MH 308.

b. 10:45 am, second floor, annex fire door to the bridge has a thermal fire pin device installed within the meeting edge.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the installation of thermal fire pin devices in the fire doors.

Based on observation, it was determined the facility failed to maintain the common wall, including all components, for a fire resistance rating of at least two hours in two instances within this component.

Findings include:


1. Observation on March 4, 2010, at 11:18 am, revealed that the second floor door to room 2256-A within the commonwall lacks a label for its fire resistance rating.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door lacks a fire rating label.

2. Observation on March 4, 2010, at 2:00 pm, revealed that the cross corridor commonwall doors first floor next to kitchen storage hag a leading edge gap of greater that one eighth of an inch.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door has a leading edge gap of greater than one eighth of an inch.

Based on observation, it was determined the facility failed to maintain the common wall, including all components, for a fire resistance rating of at least two hours in one of three floors.

Findings include:

Observation on March 4, 2010, between 10:05 am and 10:15 am, revealed there were penetrations in the common wall at the following locations:

a. 10:05 am, first floor, common wall of Main Building at Room 1350, the penetrations above the door need to be resealed due to wear and age.
b. 10:15 am, first floor, common wall of Main Building by room 1346, in front of "Family Waiting", the penetrations need to be resealed due to wear and age.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the penetrations needed to be resealed.

Based on observation, it was determined the facility failed to maintain the common wall, including all components, for a fire resistance rating of at least two hours on one of one floor.

Findings include:

1. Observation on March 4, 2010, at 9:00 am, revealed there were penetrations in the common wall above the MRI doors on the outpatient side.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were penetrations.


2. Observation on March 4, 2010, at 9:15 am, revealed there was an unknown gray caulk used to seal penetrations above the reading room in Zone III.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was gray caulk used.

Based on observation, it was determined the facility failed to maintain the common wall, including all components, for a fire resistance rating of at least two hours on one of three floors.

Findings include:

1. Observation on March 4, 2010, between 1:22 pm and 1:28 pm, revealed there were penetrations in the common wall at the following locations:

a. 1:22 pm, common wall to the Church, above the double doors, reseal around drywall where caulk is pulling away.
b. 1:25 pm, common wall by the file room door, reseal penetrations where caulk has pulled away from the drywall.
c. 1:28 pm, common wall to the medical center link had two unsealed penetrations for wiring on the right side.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were penetrations that needed to be resealed.


2. Observation on March 4, 2010, at 1:25 pm, revealed penetrations in the common wall had been sealed with an unknown gray caulk by the file room door.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were penetrations sealed with gray caulk.


3. Observation on March 4, 2010, at 1:23 pm, revealed the right hand door at the common wall to the church would not latch into the frame.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door was not latching.

Based on observation and interview, the facility failed to maintain proper building construction type in one instance within this component.

Findings include:

Observation made on March 1, 2010, at 1:42 pm, inside the generator penthouse room there were several areas above the generator where the structural steel beam was missing fire proofing material.

Interview with the Director of Plant Operations on March 2, 2010, at 2:15 pm, at the time of the exit conference, confirmed that above the generator in the penthouse there was missing fire proofing material on the structural steel beam.

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the building on one of six floors.

Findings include:

Observation on March 1, 2010, at 11:35 am, revealed fire proof spray used for the fire resistance rating was missing from the ceiling support beam above the switchgear by the outside exit door in the main electrical switch gear room on the first floor.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there was fire proof spray missing from the support beam.

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the building on two of three floors.

Findings include:

Observation on March 4, 2010, between 10:52 am, and 1:24 pm, revealed the following locations that were missing fireproofing material on the structural steel beams.

a. 10:52 am, cancer center lower level mechanical room above the intake for the cooling tower there was a structural steel beam missing fire proofing material.
b. 1:22 pm, at the first floor above the ceiling at the common wall doors to the medical center there was a structural steel beam that was missing fire proofing material.
c. 1:24 pm,the steel beam above the doors of the common wall to the church was missing a patch of fire proofing.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the beam was missing fire proofing.

Based on observation and interview, it was determined the facility failed to provide a smoke tight separation between use rooms and corridors one of three floors.

Findings include:

Observation on March 4, 2010, at 9:53 am, revealed the ceiling of the telephone equipment room 2328 was incomplete and there was a penetration above the ceiling into the room from the corridor side.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the room was not smoke tight.

Based upon observation and interview, it was determined the doors protecting corridor openings in other than hazardous areas are not substantial, nor smoke resistant on one of four floors within this component.

Findings include:

Observation made on March 3, 2010, at 10:25 am, revealed that the second floor Main building anesthesia room corridor door was held open by an unauthorized mean book wedge under the bottom of door.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010 at 2:30 pm confirmed the corridor door was blocked open.

Based upon observation and interview, it was determined the doors protecting corridor openings in other than hazardous areas are not substantial, nor smoke resistant as per regulations in four instances within this component.

Findings include:

1. Observation made on March 1, 2010, between 2:25 pm, and 2:32 pm, revealed that the following doors that did not positively latch or blocked open by unapproved devices.

a. 2:25 pm, second floor Social services office across from room 238 the corridor door was held open by a unapproved device (rubber wedge).
b. 2:32 pm, second floor trash room ( by stair 5) the inactive leaf was not secured and caused the active leaf to fail to positively latch into its frame.

Interview with the Director of Plant Operations on March 2, 2010, at 2:45 pm, at the time of the exit conference, confirmed that the above doors were held open by unapproved devices or failed to latch.
2. Observation made on March 2, 2010, between 10:20 am, and 10:40 am, revealed that the following doors that did not positively latch or blocked open by unapproved devices.

a. 10:20 am, first floor janitors closet across from ultrasound #1 the door latch was taped open.
b. 10:40 am, first floor ultrasound reading room door was held open by a unapproved device (chair).

Interview with the Director of Plant Operations on March 2, 2010, at 2:45 pm, at the time of the exit conference, confirmed that the above doors were held open by unapproved devices or failed to latch.

Based on observation and interview, it was determined the facility failed to ensure the corridor doors had no impediment to closing on one of six floors, NFPA 101, 2000 edition, 19.3.6.3.

Findings include:

Observation on March 1, 2010, at 10:30 am, revealed the cross corridor doors between the OR Suite and the Recovery Unit were not closing into the frame.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the doors would not close.

Based on observation and interview, it was determined the facility failed to ensure the corridor doors were substantial, 1 ? inch solid-bonded core wood, capable of resisting the passage of smoke with no impediment to closing in (universe), NFPA 101, 2000 edition, 19.3.6.3.

Findings include:

1. Observation on March 4, 2010, at 9:50 am, revealed the inactive leaf of the door to room 2315 was not latched in the frame, preventing the principal leaf from latching.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door would not latch.


2. Observation on March 4, 2010, at 10:00 am, revealed the corridor door of room 2308 was blocked by a linen cart, preventing it from being closed in one motion.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the door was blocked.

Based upon observation and interview, it was determined that the vertical openings between floors are not enclosed with construction having a fire resistive rating of one hour in two instances within this component.

Findings include:

Observation made on March 1, 2010, between 1:35 pm, and 2:38 pm, revealed the following locations that lacked fire resistive rating of one hour between floors for vertical openings.

a. 1:35 pm, in the penthouse behind the compressor there was a rated access door that was missing its closer spring.
b. 2:38 pm, second floor electrical room next to stair 5 there were two unsealed vertical penetrations for electrical conduit through to the first floor.

Interview with the Director of Plant Operations on March 2, 2010, at 2:45 pm, at the time of the exit conference, confirmed that the above vertical openings lacked the correct fire resistive rating.

Based upon observation and interview, the facility failed to maintain smoke barriers with at least a one half hour fire resistance rating in one instance within the component, NFPA 101, 2000 edition, 19.3.7.3.

Observation made on March 3, 2010, at 11:40 am, revealed that located on the Main building second floor service lobby smoke barrier wall had and unsealed horizontal penetration around orange armored cabel.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was penetration.

Based upon observation and interview, the facility failed to maintain smoke barriers with at least a one half hour fire resistance rating on two of six floors.

Findings include:

1.Observation on March 1, 2010, at 9:55 am, revealed a small rectangular cut out in the smoke barrier wall, above the suspended ceiling, in the Recovery Unit of the third floor, above the linen warmer near the nurses station.
a. Observation made on March 1, 2010, at 10:20 am, revealed that located on the third floor, inside room 3312, there was a dry wall patch in the smoke barrier wall were the patch edges were sealed with combustible foam insulation.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there were penetrations in the smoke barrier walls.

2. Observation on March 1. 2010, at 10:30 am, revealed that there is a eight-ten inch round duct located inside the Diabetes/Speech therapy classroom which penetrates the smoke barrier wall and lacks a smoke damper.
a. Observation on March 1. 2010, at 10:30 am, revealed that the third floor Diabetes/Speech classroom has an six inch by ten inch air duct which penetrates smoke barrier wall which lacks a smoke damper.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed that the HVAC system was not maintained properly.

Based upon observation and interview, it was determined that the facility failed to maintain the smoke barrier door assemblies in proper operating condition on three of four floors within the facility.

Findings include:

1. Observation made on March 3, 2010 between 10:30 am and 11:10 am, revealed the following smoke barrier doors have thermal fire pin device installed in the meeting edge which will impede egress when engaged:

a.10:30 am, fourth floor, main building smoke barrier doors at EEG office and electrical closet 4402.
b. 10:45 am, fourth floor, main building smoke barrier doors at pulmonary diagnostic 4492 and nurses manager office.
c. 10:50 am, fourth floor, main building smoke barrier doors at patient rooms 4424 and 4425.
d.10:55 am, fourth floor, main building smoke barrier doors at patient rooms 4455 and 4456.

e. 11:00 am, fourth floor, main building smoke barrier doors at patient room 4451

f. 11:10 am, third floor, main building smoke barrier doors at electric closet 3302.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4,2010, at 2:30 pm, confirmed the smoke barrier doors have thermal fire pin device installed within the meeting edges.


2. Observation made on March 4, 2010, between 9:55 am and 10:00 am, revealed the following smoke barrier doors have thermal fire pin device installed in the meeting edge which will impede egress when engaged:

a. 9:55 am, second floor, main building smoke barrier doors at room 2A staff lounge.

b. 10:00 am, second floor, main building smoke barrier doors at clean utility 2299 and patient room 2251.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the smoke barrier doors have thermal fire pin device installed within the meeting edges.

Based upon observation and interview, the facility failed to maintain the smoke barrier doors to provide at least twenty minutes fire resistance rating and shall not be equipped with a latch or lock that requires the use of a tool nor key, on two of six floors, NFPA 101, 2000 edition, 19.2.2.2.4.

Findings include:

1.Observation made on March 1, 2010, revealed that the follow smoke barrier doors had dual fire pins installed in the meeting edge which will impede egress when engaged.

a. 9:00 am, smoke barrier doors on the fifth floor, near room 5213.
b. 1:15 pm, second floor smoke barrier doors labled 21153 SD-3.
c. 1:20 pm second floor smoke barrier doors labled 21153 SD-2.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there device installed within the smoke barrier doors.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations in one instance within this component..

Findings include:

Observation made on March 4, 2010, at 10:45 am, revealed that the lower level LNAC medical records room door failed to latch.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that the LNAC medical records storage room failed to latch.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the stair towers, and/or maintain a continuous path of escape in one of three stair towers.

Findings include:

Observation on March 1, 2010, at 9:30 am, revealed the fire rated access panel in the ceiling of Stair Tower 2 would not automatically close.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the panel did not automatically close.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the stair towers, and/or maintain a continuous path of escape.

Findings include:

Observation on March 4, 2010, between 9:40 am and 10:30 am, revealed there were penetrations in the smoke towers at the following locations:

a. 9:40 am, third floor, stair tower in the back of the OR Suite had a penetration of fire alarm bx cable.
b. 9:43 am, second floor, stair tower in the back of the OR Suite, in the interior of the tower, to the left of the New Patient Wing door, there are penetrations by two white insulated pipes.
c. 10:30 am, first floor, stair tower by Bay 20, the stairtower wall is not sealed to the deck with fire rated material over the fire rated insulation.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were penetrations into the stair towers.

Based upon observation and interview, it was determined that the facility failed to maintain exit stairways with a two hour fire resistance rating within this component

Findings include:

Observation made on March 1, 2010, at 1:15 pm, revealed that first floor horizontal exit passageway for fire stair tower two had a fifty gallon trash can was being stored inside this stairtower.


Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the obstructed passageway.

Based on observation and interview, it was determined the facility failed to ensure that the exit stairways are free from obstructions and are not used as storage areas in one instance within this component.


1. Observation made on March 3, 2010, at 9:25 pm, revealed that within MOB building south fire exit stair tower had environmental services signs being stored inside the first floor foyer.


Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the stairtower was used for storage.


2. Observation made on March 3, 2010 at 1:35 pm, revealed that the ER addition building control doors at patient treatment rooms 20 and 21, had thermal fire pin device installed in the meeting edge which will impede egress when engaged.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on, March 4, 2010 at 2:30 pm, confirmed there were impediments to egress.

Based on observation and interview, it was determined the facility failed to provide readily accessible exit access on one instance within the facility.

Findings include:

Observation made on March 4, 2010, at 9:40, revealed that located on the second floor MOB building the exit access on the second floor, in suite 210, at the back, was blocked with medical equipment.


Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010 at 2:30 pm confirmed exit was blocked.

Based upon observation and interview, it was determined that the facility failed to maintain exit access is not arranged to be accessible at all times in nine instances within this component.

Findings include:

Observation made during document review on March 1, 2010, revealed that the following control doors have thermal fire pin devices installed within the following doors which will impede egress when engaged:

a. March 1, 2010, at 9:00 am, second floor back hallway at elevator lobby for critical care unit the control doors have thermal fire pin device installed within doors.

b March 1, 2010, at 9:00 am, third floor, control doors leading to link have thermal fire pin device installed within doors.

c. March 1, 2010, at 9:00 am, second floor, control doors leading to link have a thermal fire pin device installed within doors.

d. March 1, 2010, at 9:00 am, ground floor cross corridor doors at Physical medicine, the control doors had a thermal fire pin device installed within doors.

e. March 1, 2010, at 9:00 am, ground floor double control door from the cafeteria to the exit stairtower have a thermal fire pin device installed within doors.

f. March 1, 2010, at 9:00 am, cross corridor doors at the Pharmacy, the control doors have a thermal fire pin device installed within doors.

g. March 1, 2010, at 9:00 am, exit doors from the kitchen storage and central supply, and out of the alcove they lead to, all are equipped with thermal fire pin devices installed within doors.

h March 1, 2010, at 9:00 am, cross corridor doors ground floor at the library, have a thermal fire pin device installed within doors.

i. March 1, 2010, at 9:00 am, cross corridor doors next to the medical affairs academic affairs office, have a thermal fire pin device installed within doors.

Reference: 2000 edition NFPA 101 chapter 7.2.1.5.

Interview with the Director of Plant Operations on March 2, 2010, at 2:45 pm, at the time of the exit conference, confirmed that the above listed door have thermal fire pin device installed and are in the process of being repaired.

Based upon observation and interview, it was determined the facility failed to maintain the exit access to be accessible at all times in accordance in one instance within this component.

Findings include:

Observation made on March 4, 2010, at 10:15 am, revealed that the exit door from the cafe cashier area was blocked by a metal stand with a metal bucket full of potato chips.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that this exit was blocked.

Based upon observation and interview the facility failed to maintain clear and unobstructed exit corridors in accordance in one instance within this component.

Findings include:

Observation made on March 4, 2010, at 1:30 pm, revealed the second floor exit corridor at the Cath Lab near room 2473 was blocked with four plastic rolling cart, one metal cart,two tall rolling carts.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that this corridor was blocked by carts stored in the corridor.

Based on observation and interview, it was determined that the facility failed to keep the corridors serving as exit access clear and unobstructed on one of three floors.

Findings include:

Observation on March 4, 2010, at 10:40 am, revealed there was a computer-on-wheels charging in the corridor by Bay 27.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the computer-on-wheels was charging in the corridor.

Based on observation and interview, it was determined that the facility failed to keep the corridors serving as exit access clear and unobstructed on one of three floors.

Findings include:

Observation on March 4, 2010, at 1:28 pm, revealed the Main Street corridor by the back doors had trash and a gurney stored in it.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there were items kept in the corridor.

Based upon observation and interview, it was determined that the exit and directional signs are not in accordance with regulations in one instance within this component.

Findings include:

Observation made on March 3, 2010, at 1:49 pm, revealed that on the second floor at the commonwall doors from the main to the pavilion lacked an exit sign.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that above the commonwall doors from the main to the pavilion lacked an exit sign.

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per NFPA 13 in one instance within this component.

Findings include:

Observation made on March 4, 2010, at 10:56 am, revealed that inside the lower level mechanical room back under the ductwork for the cooling tower intake lacks sprinkler coverage in two locations at far wall and the middle.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the lack of sprinkler coverage at the above locations in the cancer center mechanical room under the intake for the cooling tower.

Based on observation and interview, it was determined that the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in one instance within this component.


1.Observation made on March 3 and 4, 2010, revealed that the following areas fire department connection capping were not in place.
a. first floor Main building fire department connection capping were not in place across from telecommunication room
b. Main building loading dock area fire department connection capping were not in place.

reference NFPA 25 1998 edition section 9-7.1 (c).

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed thethe automatic sprinkler system was not maintained properly.

Based on observation and interview, it was determined the automatic sprinkler system was not continuously maintained in reliable operating condition in one instance within the facility, NFPA 101, 19.7.6, NFPA 13, and NFPA 25, 1999 editions.


1.Observation made on March 3, 2010, between 1:45 pm and 1:54 pm, revealed that the following closets lack automatic sprinkler protection. (these closets approximate square footage is two feet by sixteen feet).

a. 1:45 pm, air conditioning control closet
b. 1:54 pm, IT closet across from treatment area three.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010 at 2:30 pm, confirmed automatic sprinkler system was not maintained properly.

Based on observation, and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on one of six floors within this component.

Findings include:

1. Observation made on March 1, 2010, at 1:15 pm, revealed that first floor horizontal exit passageway for fire stair tower two lacks complete automatic sprinkler protection leading to discharge door and the public way the total square footage four by eight feet.

(NFPA 13 1999 edition - Section 4-13.2.2).

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed that this conditions exist.

2. Observation made on March 1, 2010, at 1:35 pm, revealed that the first floor emergency department information sign in the first floor corridor obstructs the nearby sprinkler head.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the automatic sprinkler head was obstructed.

Based on observation, documentation review, and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition and free of non sprinkler components attached or supported by sprinkler components or kept free of obstructions in four instances within this component.

Findings include:

Observation made on March 4, 2010, between 10:47 am, and 11:16 am, revealed the following locations were the sprinkler systems were not maintained by the facility.

a. 10:47 am, LNAC supply storage room had storage within eighteen inches of the sprinkler head's deflector (six inches).
b. 10:50 am, Cancer center mechanical room back in front of the boiler there was air lines for the boiler ziptied to the sprinkler piping and also a electrical armored conduit ( for a two by four lighting fixture)ziptied to the sprinkler piping.
c. 10:58 am, Cancer center mechanical room back above the AH-1 and AH-3 there was three quarter inch conduit attached to the sprinkler piping.
d. 11:16 am, inside the lower level elevator machine room the sprinkler head was missing its escutcheon.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the above obstructions and non sprinkler components tied to sprinkler components.

Based on interview, it was determined the facility failed to maintain and inspect the kitchen supersession systems in one instance within this component.

Findings include:

Observation made on March 4, 2010, at 10:15 am, revealed that the kitchen suppression systems in the Pavilion building (both systems) lacked the monthly quick checks to be documented on the back of the semi-annual inspection tags.
Reference: NFPA 101 2000 edition Chapter 19.3.2.6 and Chapter 9.2.3.
NFPA 96 1998 Edition Chapter 7-2.2.1.
* NFPA 17 1998 Edition Chapter 9-2
* NFPA 17A 1998 Edition Chapter 5-2

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that the Pavilion building kitchen suppression systems lack the monthly quick checks.

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were stored properly in one instance within the component, NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition.

Observation made on Mach 3, 2010, at 10:30 am, revealed the third floor ancillary wing OR sterile storage room gas storage room had an M size argon gas cylinder that was not properly secured or adequately fastened at the time of inspection.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the cylinder were unsecured.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations.

Findings include:

Observation made on March 3, 2010, at 11:46 am, revealed that the Cath Lab heart center oxygen storage room above the corridor door from the inside there were unsealed penetrations through to the corridor side .

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the existence of this unsealed penetration in the Cath Lab oxygen storage room

Based on observation and interview, it was determined that the facility failed to protect medical gas system in one instances within this component.

Findings Include:

Observation on March 1, 2010, at 11:00 am, revealed there was no locking mechanism to prevent unauthorized access to the emergency oxygen tie-in.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed the emergency oxygen tie-in had no locking mechanism.

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were stored properly on one of one floor.

Findings include:

Observation on March 4, 2010, at 9:06 am, revealed an unsecured "E" sytle oxygen cylinder in the MRI Antechamber.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was an unsecured oxygen cylinder.

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were stored properly, NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition.

Findings include:

Observation on March 4, 2010, at 9:06 am, revealed an unsecured "E" sytle oxygen cylinder in the MRI Antechamber.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was an unsecured oxygen cylinder.

Based upon observation and interview, the piped in medical gas system does not comply with regulations.

Findings include:

1. Observation made on March 3, 2010, at 8:30 am and 2:45 pm, revealed that the facility representatives and inspector was unable to verify that the pipe in medical gas system, risers for two oxygen risers and the two medical vacuum risers located on the first floor main building and within human resources office have shut off valves adjacent to the riser connection. The facility must verify that pipe in medical gas system, risers are provided with shut off valves.

Please reference NFPA 99 1999 edition chapter 4-3.1.2.3 [c].

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on July 15, 2009, at 2:00 pm, confirmed pipe in medical gas system risers.

Based upon observation and interview, it was determined the facility failed to maintain electrical wiring and/or components in a workmanlike manner, ensure all electrical equipment's protective plates and covers are secured. The facility failed to ensure proper use of powerstrips and maintain the component free of the use of extension cords in eight instances within this component.

Findings include:

1. Observation made on March 3, 2010, at 10:35 am, revealed that on the third floor both nurses stations A and B had transport monitors powered by a powerstrip(A-side three and B-side two).

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed that there was medical equipment powered by a powerstrip on the third floor at both nursing stations.

2. Observation made on March 3, 2010, at 10:50 am, revealed that on the third floor above the ceiling in room 3524 on-call room there was temporary lighting left above the ceiling.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the temporary lighting above the ceiling in room 3524.

3. Observation made on March 3, 2010, at 11:44 am, revealed that on the second floor in the Cath Lab heart center oxygen storage room 2435 above the rated ceiling access panel there were six open junction boxes five of which have uncapped wires hanging out of the junction boxes.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the open junction boxes above the ceiling in room 2435.

4. Observation made on March 4, 2010, at 9:00 am,revealed that on the first floor Pavilion mechanical room in the rear back behind the chillers there were two extension cords in use.


Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the use of the above extension cord.

5. Observation made on March 4, 2010, at 9:15 am, revealed that inside the first floor Transformer vault the rated door had a gap of more that an eighth of an inch gap between the leading edges.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the gap of greater that 1/8th inch between the leading edges of the rated doors for the transformer vault.

6. Observation made on March 4, 2010, at 9:15 am, revealed that inside the first floor Transformer vault there were the following items stored within the transformer vault: two refrigerators, scaffolding, a door and door closer assemblies.
Refer to NFPA 70 1999 edition article 450-48.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the existence of the storage within the transformer vault.

Based upon observation and interview, it was determined the facility failed to maintain electrical wiring and/or components in a workmanlike manner, ensure all electrical equipment's protective plates and covers are secured. The facility failed to ensure proper use of powerstrips and maintain the component free of the use of extension cords in three instances within this component.

Findings include:

1. Observation made on March 4, 2010, between 10:40 am, and 11:10 am, revealed the following locations that had extension cords in use.

a. 10:40 am, on the lower level main clinic desk there was a heater powered by a powerstrip.
b. 11:10 am, lower level CT control room there was a extension cord in use.
first floor electrical closet near the link had a TV cable amplifier powered by a extension cord that travels across the ceiling through the wall into the IT room and then plugs into a outlet.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed the use of extension cords at the above locations.

2. Observation made on March 4, 2010, at 10:50 am, revealed that in the lower level mechanical room there was a protective cover plate unsecured for panel labeled MCC-1 and there was a large gauge wire run into the panel between the unsecured protective cover and the panel box .
Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed this improper electrical installation.

Based upon observation and interview, it was determined the facility failed to maintain electrical wiring and/or components in a workmanlike manner, ensure all electrical equipment's protective plates and covers are secured. The facility failed to maintain the proper width of working space in front of electrical equipment; and the facility failed to ensure proper use of powerstrips and free of the use of extension cords in ten instances within this component.

Findings include:

1. Observation made on March 1, 2010, at 1:54 pm, inside the third floor Nourishment room across from room 322 there was a extension cord in use powering a coffee maker.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the use of this extension cord and was removed by maintenance personnel at the time of the survey.

2. Observation made on March 2, 2010, between 10:55 am, and 11:45 am, revealed the following locations that improper use of powerstrips was found.

a. 10:55 am, ground floor inside then boiler room there was a powerstrip that was powering a refrigerator, two microwaves, a toaster and a coffee maker.
b. 11:42 am, ground floor staff development rear right side office there was a refrigerator powered by a powerstrip.
c. 11:45 am, ground floor Info systems office inside the breakroom the coffee maker was powered by a powerstrip.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed improper use of the above listed powerstrips.

3. Observation made on March 1, 2010, between 2:38 pm, and 2:44 pm, revealed the following electrical panels that were missing protective circuit breaker blanks.

a. 2:38 pm, second floor electrical room by stair 5 inside panel marked 2DDE slot #11.
b. 2:45 pm, second floor inside room 212 there was a unsecured outlet with a cracked protective face plate.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the above panels had missing protective cover plates and blanks.

4. Observation made on March 2, 2010, between 10:15 am, and 10:44 am, revealed the following electrical panels that were missing protective circuit breaker blanks.

a. 10:15 am, first floor electrical room by rear service entrance of the emergency room in panels marked ILD2 and IDDE3 both were missing protective circuit breaker blanks.
b. 10:44 am, inside the first floor electrical room on the link in panel marked 1AC there was a protective circuit breaker blank in slot #41.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the above panels had missing protective cover plates and blanks.

5. Observation made on March 2, 2010, between 10:44 am, and 11:35 am, revealed the following location that the facility failed to maintain the proper width of working space in front of electrical equipment.

a. 10:44 am, inside the first floor electrical room on the link the panel marked 1DE was blocked from access by a large picture and frame stored in front of the panel.
b. 11:35 am, inside the ground floor electrical room the panel marked GDA-E was blocked from access by a ladder being stored infront of this panel.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the above electrical panels with storage blocking access to the panels.

6. Observation made on March 2, 2010, at 9:50 am, at the rear service entrance to the emergency room above the door there was a dead-ended BX wire capped off outside a junction box.

Interview with the Director of Plant Operations on March 2, 2010, at 2:30 pm, at the time of the exit conference, confirmed the above wiring capped outside a junction box.

Based upon observation and interview, it was determined the facility failed to maintain the electrical elements in working order in (universe).

Findings include:

1. Observation on March 1, 2010, at 10:25 am, revealed exposed wiring from a bx cable, above the supsended ceiling at the smoke barrier near room 5044, on the fifth floor in the Moss Rehab suite.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there was exposed wiring.

2. Observation on March 1, 2010, at 11:15 am, revealed an open junction box in the third floor Physicial Library, room 3012, above the suspended ceiling, at the duct work, by the clock.

Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there was an open junction box.

a. Observation made on March 1, 2010, at 1:40 pm, revealed that a power strip surge suppressor is being used for medical equipment in the first floor physical therapy unit.

.Interview with the Director of Plant Operations on February 1, 2010, at 2:15 pm, at the time of the exit conference, confirmed there was an power strip in use.

Based upon observation and interview, it was determined the facility failed to maintain the electrical elements in working order on one of three floors, Department of Health message board, message dated October 30, 2009, and NFPA 70.

Findings include:

Observation on March 4, 2010, at 10:10 am, revealed there were appliances plugged into an extension cord in room 1350.

Interview at the exit conference with the Director of Plant Operations, the Chief Nursing Officer, and the Vice President on March 4, 2010, at 2:30 pm, confirmed there was an unapproved power tap device in use.