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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 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 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 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, 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, 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 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 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 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 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, 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.