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Based on observation it was discovered that the facility failed to properly maintain the corridor opening protection.

findings were

During the survey while accompanied by the Hospital Fire Marshal the following were observed
1) rags were stuffed into latch to keep it from properly latching at Rm. 5814
2) doors to Rms. 3927 & 1255 were found the doors would not latch

Based on observations it was discovered that the facility failed to properly maintain rated doorways


findings were

During the survey while accompanied by the Hospital Fire Marshal
1) the doors by Rm. 2383 has been field modified and may not be listed. it also stays in the open position an excessive amount of time.
2)Rm. 3154 hold open not working properly and found wedged open
3) double fire rated doors on 0 level to PCC do not close properly

Based on observation it was discovered that the facility failed to properly maintain the smoke barriers

findings were

During the survey while accompanied by the Hospital Fire Marshal
1) the smoke barrier by 7548 was found with many small holes thru the barrier
2) penetration in smoke barrier above ceiling at 4 E Family Lounge

Based on observations it was discovered that the facility failed to properly maintain the required separation from hazardous areas


findings were

On June 29, 2012 while accompanied by the Hospital Fire Marshal the following issues were observed

1) Oxygen storage room- fire rated roll-down door does not have required link or heat detector on both sides- only on the room side
2) By 1990 B the fire rated cross corridors doors did not close and latch properly
3) Rm. G 335 Main Electrical Distribution Room.-Fire Rated door does not close and latch properly
4) Rm. G 333 Main Fire Alarm Control Panel Room-Fire Rated door does not close and latch properly

Based on observation it was discovered that the facility failed to properly maintain the means of egress


findings were

On June 29, 2012 while accompanied by the Hospital Maintenance Director.
3 Three of the marked exit doors were observed with unapproved deadbolts installed.

Based on observation it was discovered that the facility failed to properly maintain the exit signs.

findings were

During the survey while accompanied by the Hospital Fire Marshal the EXIT signs were found
1) with misleading directional arrows near Rms. 6125, 7136 and 5201.
2) Emergency EXIT sign directs occupant into construction area 3W ICU project
where the means of egress was not continuously maintained

Based on observation it was discovered that the new /existing fire alarm was not installed or maintained in accordance with NFPA 72

NOTE the facility is in the middle of a project to completely replace the existing fire alarm and detection system . The building was protected by one or both systems at all times thru the phased construction project



findings were
1) location of newly installed smoke detectors on walls are not with in the limites of 4 to 12 inches down from deck as per NFPA 72 section 2-3.4.3, were found in at least but not limited to:
6216, 5516, 5227,4516,4311 G 871 and on 2M near exit to stair #5

2) smoke detectors that had power cut to but not removed or tagged out of service were still installed in at least but not limited to
5197, 5198, 5174, 5111, 8180, 8186

3) open smoke detector base (base without smoke detector head installed ) of new fire alarm system found outside elevator #6 equipment rm reportedly not showing trouble on fire alarm control panel

Based on observation it was discovered that the facility failed to properly install or maintain the fire alarm system in accordance with NFPA 72

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal,

1) wall mounted smoke detector in Rm. 3314 was not in between the required distance of 4 and 12 inches down from deck
2) wall mounted smoke detector in Rm. 225 was not in between the required distance of 4 and 12 inches from deck

Based on observation it was discovered that the facility failed to properly maintain the sprinkler system


findings were

On June 29, 2012 , while accompanied by the Hospital Fire Marshal , the following were observed:

1) Penthouse- No hydraulic data plate was found posted for pre action system
2) Rm. 2081 -sprinkler pattern distrubution is obstructed by light fixture

Based on observation it was discovered that the facility failed to properly maintain the fire extinguishers in accordance with NFPA 10

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal, three fire extinguishers were found obstructed in the Social Services office, in the lobby, in the file room and in the storage closet.

Based on observation and conversations it was determined that the facility failed to properly maintain the cooking facilities ventilation systems


findings were

On June 25, 2012 while accompanied by the Hospital Fire Marshal the ventilation unit DX-P-1 in the penthouse was found dripping excessive amounts of grease from the seams. During conversations with the Facilities Management personal it was learned that this unit services the dishwasher area in the kitchen and had not been on a regular cleaning schedule as are all the other kitchen hoods.

Based on observations it was discovered that the facility failed to properly maintain the means of egress


findings were
On June 26, 2012 while accompanied by the Maintenance Director , the exit discharge from the control room to the public way had not been maintained or constructed in a proper way

Based on observations it was discovered that the facility failed to properly maintain the piped in Medical Gases systems



findings were:

June 26, 2012 at 11:10 while accompanied by the Hospital Fire Marshal the piped in Medical Gas emergency shut off valves were observed blocked by storage in the West ICU near Rm. 6910

Based on observation it was discovered that the facility failed to properly maintain the facility in a safe and code compliant manner


findings were

On June 26, 2012 while accompanied by a representative of the UVA Medical Centers Maintenance Directors office, the following issues were observed

1)staff receptionist could not identify procedures to follow in case of fire
2)Fire Plans do not show required details of device locations
3)Fire Alarm smoke detector sensitivity test reports were not available at time of survey
4) Fire Alarm reports do not show horn strobe locations
5) 3rd floor stairwell # 3040 has improperly seal penetrations in rated walls
6) Near Rm. 3200 fire alarm strobe is loose on the wall
7) No records of annual fire alarm training as required
8)Rm. 3652 Electrical Rm has improperly sealed floor penetrations
9) 3650 hole in the north stairwell's rated wall above ceiling
10) Rm. 3163 clean utility room has open penetrations in rated walls( wire and Pipe openings)
11) Rm. 3163 smoke detector too close to air grill <3 feet
12) Rm. 3133 D -rated soiled utility room with open penetrations above ceiling and fire door does not latch
13) Rm. 2653 -electrical Rm. fire extinguisher is blocked by storage
14) Rm. 2317- sprinkler escutcheon plate was observed missing
15) Rm. 2207- smoke detector too close to air grill< 3 feet
16) stairs 2040 south end has penetrations above ceiling
17) Rm. 2047 sprinkler hydraulic data plate was observed missing
18) Rm. 1042 sprinkler escutcheon plate observed missing
19) 1041- elevator shaft has open penetrations in walls of rated shaft
20) Rm. 1506 A - electrical wiring observed running thru doorway( corrected during the survey )
21) Rm. 1506 A -storage was observed blocking electrical panel-( corrected during survey )
22) Rm. 1506 A -ceiling tiles observed missing
23) Rm. 1506 A- sprinkler escutcheon plate observed missing
24) Rm. 1312 -rated soiled utility room was observed with open penetration in rated walls
25) by 1410 EXIT sign does not work properly
26) by 1316 sprinkler escutcheon plate was observed missing
27) Rm. 3163 power strips were observed improperly connected in series at Residency Area
28) Rm. 3163- open penetration in rated walls above ceiling were observed
29) Rm. 2652 open penetrations was observed around pipe above ceiling
30) Rm. 2114 sprinkler escutcheon was observed missing
31) stairwell 2042 has open penetrations into rated stairwell wall
32) stairwell- gate to indicate discharge level was not working properly
33) Rm. 1506 D type breaker box was observed missing blind cap
34) Rm. 1122 B work station area was observed missing sprinkler escutcheon plate

Based on observations it was discovered that the facility failed to properly maintain the back up electrical lighting system.




findings were

On June 25 while accompanied by the UVA Medical Center's Maintenance Director, the emergency lights in Rm. 1106 and Rm. 1048 were observed not to test properly

Based on observation it was discovered that the facility failed to properly maintain the alcohol hand wash dispensers

finds were

On July 03, 2012 while accompanied by the Hospital Fire Marshal the hand wash dispensers were found in corridors less than 6 feet by 3114, 1422 and 1430.

Based on observation and record review it was discovered that the facility failed to properly control the use of alcohol hand wash


findings were

During the survey while accompanied by the Hospital Fire Marshal
1) the Hospital policy to control amount of product in fire areas was not followed in the part of the NICU Unit
2) dispenser was found installed in corridor less than 6 feet wide near Rm. 2230
3) dispenser was found in the Chapel lower than regulations allow
4) after market splash guards were installed under dispensers in the Radiology area in violation of Va. State Fire Code

Based on observation it was discovered that the facility failed to properly maintain the alcohol hand wash dispensers

finds were

On July 03, 2012 while accompanied by the Hospital Fire Marshal the hand wash dispensers were found in corridors less than 6 feet by 3114, 1422 and 1430.

Based on observation and interview it was discovered that the facility failed to properly maintain the Alcohol hand wash in a proper manner.

findings were

On July 3, 3012 while accompanied by the Hospital Fire Marshal the alcohol hand wash dispensers were found installed in corridors less than 6 feet in width near Rms. 1412, 1509 C and 1514.