HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain common walls on one of six floors within this component.

Findings include:

Observation of common walls on May 15, 2012, at 1:50 PM revealed an unsealed penetration around a four inch hydraulic line located in the ground level, D wing, ED Staff Lounge bathroom.

Interview with facility manager on May 15, 2012, at 1:51 PM confirmed the penetration.

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in ten locations on four of six floors.

Findings include:

1. Observation of various aspects of building construction within this component between 1:06 p.m. on May 14, 2012, and 11:10 a.m. on May 15, 2012, revealed the below deficiencies:

a. A supply air diffuser lacks a fire damper where penetrating the suspended ceiling portion of the rated ceiling assembly located closest to the first floor CRBB-1AJ electrical panel. 1:06 p.m. on May 14, 2012.
b. A speaker lacks bonnet protection within the first floor exit access corridor system located closest to CRBB-1AJ electrical panel. 1:10 p.m. on May 14, 2012.
c. A supply air diffuser lacks a fire damper where penetrating the suspended ceiling portion of the rated ceiling assembly located closest to the first floor Radiology Department entrance. 1:15 p.m. on May 14, 2012.
d. Exposed structural steel was noted within the exterior bearing wall within the first floor Cashier's Office at 1:40 p.m. on May 14, 2012.
e. Combustible insulating materials were noted beyond the wall-mounted access panel within the second floor P.C.U. wash station area. 2:00 p.m. on May 14, 2012.
f. A speaker located within the second floor old Mother and baby Waiting Room lacks bonnet protection. 2:16 p.m. on May 14, 2012.
g. Bonnet protection located within the second floor old Mother and Baby Waiting Room requires touch-up. 2:18 p.m. on May 14, 2012.
h. Bonnet protection is lacking on the speaker located closest to the second floor areas A and C entrance. 09:50 a.m. on May 15, 2012.
i. Horizontal structural steel requires touch-up within the sixth floor Medical Director of Behavioral Health's Office. 10:12 a.m. on May 15, 2012.
j. Fourth floor structural steel located within PT Storage requires fireproofing. 11:08 a.m. on May 15, 2012.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the building construction deficiencies.

Based upon observation and interview, it was determined the facility failed to maintain two corridor openings in two locations on one of six floors.

Findings include:

1. Observation of the sixth floor B.H.U. between 10:37 a.m. and 10:46 a.m. on May 15, 2012, revealed the below deficiencies:

a. The Seclusion Room vision panel is non-fire-rated. 10:37 a.m.
b. The Staff Lounge entrance door lacks fire-tight integrity when coupled with the corresponding door frame assembly. 10:46 a.m.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the corridor door deficiencies.

Based upon observation and interview, it was determined the facility failed to construct and maintain vertical openings in multiple locations on six of six floors.

Findings include:

1. Observation of various vertical openings within this component between 11:30 a.m. on May 14, 2012, and 08:45 a.m. on May 16, 2012, revealed the facility to lack two-hour fire resistive integrity on both shaft enclosures and expansion joints in various locations throughout this component.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on May 16, 2012, confirmed the vertical opening deficiency and identified the facility as possessing an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on May 16, 2012 addressing this deficiency.

2. Observation of the area closest to the first floor Staff Lounge at 12:22 p.m. on May 14, 2012, revealed a vertical pipe penetration of the floor slab located beyond the suspended ceiling assembly.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the vertical penetration.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in three locations on six floors within the component.

Findings include:

1. Observation of smoke barrier walls on May 15, 2012, at 10:50 AM revealed an unsealed penetration around an IT wire located on the third floor of D Wing, room #D389.

Interview with facility manager on May 15, 2012, at 10:51 AM confirmed the smoke barrier penetration.

2. Observation of various smoke barrier separation walls between 12:12 p.m. on May 14, 2012, and 11:00 a.m. on May 15, 2012, revealed the below deficiencies:

a. A penetration of the portion of the smoke barrier separation wall was noted closest to the first floor Pre-Admission Testing Nurse's Offices (above smoke barrier doors) at 12:12 p.m. on May 14, 2012.
b. A penetration of the smoke barrier separation wall was noted closest to the fourth floor Pediatrics Entrance at 11:00 a.m. on May 15, 2012 (above doors.)

Interview with facilities manager one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the smoke barrier wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain door openings on one of six floors within the component.

Findings include:

Observation of door openings in smoke barriers on May 15, 2012, at 2:30 PM revealed the Medical Library door located on the ground level, B Wing, lacked a self closing device.

Interview with facility manager on May 15, 2012, at 2:31 PM confirmed the door lacked a self closing device.

Based upon observation and interview, it was determined the facility failed to maintain one hazardous area enclosure in two locations on one of six floors.

Findings include:

1. Observation of the fourth floor Med-Surg Storeroom between 11:15 a.m. and 11:17 a.m. on May 15, 2012, revealed the following:

a. The room lacked a forty-five minute rated door. 11:15 a.m.
b. The room lacked a rated ceiling level access panel. 11:17 a.m.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the hazardous area enclosure deficiencies.

Based upon observation and interview, it was determined the facility failed to provide two exits, remote from one another, on one of six floors within this component.

Findings include:

Observation of the sub-basement mechanical space at 10:22 a.m. on May 14, 2012, revealed less than two acceptable exits from this area.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on May 16, 2012, confirmed the exiting deficiency and identified the facility as possessing an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on May 16, 2012, addressing this issue.

Based upon observation and interview, it was determined the facility failed to properly construct one exit stair tower in two locations on two of six floors.

Findings include:

Observation of stair tower number ten between 12:23 p.m. and 12:24 p.m. on May 14, 2012, revealed headroom within to be compromised at basement and first floor levels due to an overhead protrusion.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on May 16, 2012, confirmed the headroom deficiency and identified the facility as possessing an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on May 16, 2012, addressing this deficiency.

Based upon observation and interview, it was determined the facility failed to install and maintain illuminated exit signage in two locations on one of six floors.

Findings include:

1. Observation of various exit access corridor systems within this component between 09:33 a.m. and 09:37 a.m. on May 15, 2012, revealed the following areas to require illuminated exit signage:

a. The area beyond the first floor smoke barrier separation doors closest to the Main Lobby area. 09:33 a.m. on May 15, 2012.
b. Within the first floor portion of stair tower eight. 09:37 a.m. on May 15, 2012.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the above areas to lack illuminated exit signage.

Based upon documentation review and interview, it was determined the facility failed to conduct one of twelve required fire drills.

Findings include:

Observation of facility fire drill documentation between 07:55 a.m. and 08:09 a.m. on May 15, 2012, revealed the absence of a first shift fire drill within the fourth quarter of the calendar year 2011.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the facility to lack one of twelve required fire drills.

Based upon observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location on one of six floors.

Findings include:

Observation of the first floor equipment room at 12:33 p.m. on May 14, 2012, revealed several ceiling tiles removed from this area which would then require upright sprinkler heads. Note: Surface-mounted sprinkler heads presently in use in this area.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the sprinkler system deficiency.

Based upon observation and interview, it was determined the facility failed to install and maintain the piped-in medical gas systems in nine locations on three of six floors.

Findings include:

1. Observation of various aspects of the piped-in medical gas systems between 12:44 p.m. on May 14, 2012, and 11:20 a.m. on May 15, 2012, revealed the below deficiencies:

a. Medical gas piping located closest to first floor MRI Waiting requires labeling (corridor location.) 12:44 p.m. on May 14, 2012.
b. Medical gas piping (vertical) located closest to the elevator enclosure lacks labeling and is held in place by dissimilar metallic surfaces. 1:49 p.m. on May 14, 2012.
c. Medical gas piping located within B-231 lacks labeling. 1:57 p.m. on May 14, 2012.
d. Medical gas piping located within B-245 lacks labeling. 2:02 p.m. on May 14, 2012.
e. Wires are affixed to medical air piping closest to the Area A and Area C entrance. 09:50 a.m. on May 14, 2012.
f. Oxygen and Vacuum piping within the sixth floor Mother and Baby Room A201 lacks labeling. 09:52 a.m. on may 15, 2012.
g. Vacuum piping resides atop electrical conduit within the fourth floor exit access corridor system closest to the staff elevators. 10:55 a.m. on May 15, 2012.
h. Multiple wires are affixed to vacuum piping closest to the fourth floor stairwell eight entrance. 11:12 a.m. on May 15, 2012.
i. Non-labeled oxygen piping was noted within the fourth floor pantry closest to B434 at 11:20 a.m. on May 15, 2012.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the medical gas system deficiencies stated above.

Based on observation and interview, it was determined the facility failed to maintain common walls on one of six floors within this component.

Findings include:

Observation of common walls on May 15, 2012, at 1:50 PM revealed an unsealed penetration around a four inch hydraulic line located in the ground level, D wing, ED Staff Lounge bathroom.

Interview with facility manager on May 15, 2012, at 1:51 PM confirmed the penetration.

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in ten locations on four of six floors.

Findings include:

1. Observation of various aspects of building construction within this component between 1:06 p.m. on May 14, 2012, and 11:10 a.m. on May 15, 2012, revealed the below deficiencies:

a. A supply air diffuser lacks a fire damper where penetrating the suspended ceiling portion of the rated ceiling assembly located closest to the first floor CRBB-1AJ electrical panel. 1:06 p.m. on May 14, 2012.
b. A speaker lacks bonnet protection within the first floor exit access corridor system located closest to CRBB-1AJ electrical panel. 1:10 p.m. on May 14, 2012.
c. A supply air diffuser lacks a fire damper where penetrating the suspended ceiling portion of the rated ceiling assembly located closest to the first floor Radiology Department entrance. 1:15 p.m. on May 14, 2012.
d. Exposed structural steel was noted within the exterior bearing wall within the first floor Cashier's Office at 1:40 p.m. on May 14, 2012.
e. Combustible insulating materials were noted beyond the wall-mounted access panel within the second floor P.C.U. wash station area. 2:00 p.m. on May 14, 2012.
f. A speaker located within the second floor old Mother and baby Waiting Room lacks bonnet protection. 2:16 p.m. on May 14, 2012.
g. Bonnet protection located within the second floor old Mother and Baby Waiting Room requires touch-up. 2:18 p.m. on May 14, 2012.
h. Bonnet protection is lacking on the speaker located closest to the second floor areas A and C entrance. 09:50 a.m. on May 15, 2012.
i. Horizontal structural steel requires touch-up within the sixth floor Medical Director of Behavioral Health's Office. 10:12 a.m. on May 15, 2012.
j. Fourth floor structural steel located within PT Storage requires fireproofing. 11:08 a.m. on May 15, 2012.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the building construction deficiencies.

Based upon observation and interview, it was determined the facility failed to maintain two corridor openings in two locations on one of six floors.

Findings include:

1. Observation of the sixth floor B.H.U. between 10:37 a.m. and 10:46 a.m. on May 15, 2012, revealed the below deficiencies:

a. The Seclusion Room vision panel is non-fire-rated. 10:37 a.m.
b. The Staff Lounge entrance door lacks fire-tight integrity when coupled with the corresponding door frame assembly. 10:46 a.m.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the corridor door deficiencies.

Based upon observation and interview, it was determined the facility failed to construct and maintain vertical openings in multiple locations on six of six floors.

Findings include:

1. Observation of various vertical openings within this component between 11:30 a.m. on May 14, 2012, and 08:45 a.m. on May 16, 2012, revealed the facility to lack two-hour fire resistive integrity on both shaft enclosures and expansion joints in various locations throughout this component.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on May 16, 2012, confirmed the vertical opening deficiency and identified the facility as possessing an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on May 16, 2012 addressing this deficiency.

2. Observation of the area closest to the first floor Staff Lounge at 12:22 p.m. on May 14, 2012, revealed a vertical pipe penetration of the floor slab located beyond the suspended ceiling assembly.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the vertical penetration.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in three locations on six floors within the component.

Findings include:

1. Observation of smoke barrier walls on May 15, 2012, at 10:50 AM revealed an unsealed penetration around an IT wire located on the third floor of D Wing, room #D389.

Interview with facility manager on May 15, 2012, at 10:51 AM confirmed the smoke barrier penetration.

2. Observation of various smoke barrier separation walls between 12:12 p.m. on May 14, 2012, and 11:00 a.m. on May 15, 2012, revealed the below deficiencies:

a. A penetration of the portion of the smoke barrier separation wall was noted closest to the first floor Pre-Admission Testing Nurse's Offices (above smoke barrier doors) at 12:12 p.m. on May 14, 2012.
b. A penetration of the smoke barrier separation wall was noted closest to the fourth floor Pediatrics Entrance at 11:00 a.m. on May 15, 2012 (above doors.)

Interview with facilities manager one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the smoke barrier wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain door openings on one of six floors within the component.

Findings include:

Observation of door openings in smoke barriers on May 15, 2012, at 2:30 PM revealed the Medical Library door located on the ground level, B Wing, lacked a self closing device.

Interview with facility manager on May 15, 2012, at 2:31 PM confirmed the door lacked a self closing device.

Based upon observation and interview, it was determined the facility failed to maintain one hazardous area enclosure in two locations on one of six floors.

Findings include:

1. Observation of the fourth floor Med-Surg Storeroom between 11:15 a.m. and 11:17 a.m. on May 15, 2012, revealed the following:

a. The room lacked a forty-five minute rated door. 11:15 a.m.
b. The room lacked a rated ceiling level access panel. 11:17 a.m.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the hazardous area enclosure deficiencies.

Based upon observation and interview, it was determined the facility failed to provide two exits, remote from one another, on one of six floors within this component.

Findings include:

Observation of the sub-basement mechanical space at 10:22 a.m. on May 14, 2012, revealed less than two acceptable exits from this area.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on May 16, 2012, confirmed the exiting deficiency and identified the facility as possessing an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on May 16, 2012, addressing this issue.

Based upon observation and interview, it was determined the facility failed to properly construct one exit stair tower in two locations on two of six floors.

Findings include:

Observation of stair tower number ten between 12:23 p.m. and 12:24 p.m. on May 14, 2012, revealed headroom within to be compromised at basement and first floor levels due to an overhead protrusion.

Interview with facilities manager during the exit interview process conducted between 09:15 a.m. and 09:30 a.m. on May 16, 2012, confirmed the headroom deficiency and identified the facility as possessing an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on May 16, 2012, addressing this deficiency.

Based upon observation and interview, it was determined the facility failed to install and maintain illuminated exit signage in two locations on one of six floors.

Findings include:

1. Observation of various exit access corridor systems within this component between 09:33 a.m. and 09:37 a.m. on May 15, 2012, revealed the following areas to require illuminated exit signage:

a. The area beyond the first floor smoke barrier separation doors closest to the Main Lobby area. 09:33 a.m. on May 15, 2012.
b. Within the first floor portion of stair tower eight. 09:37 a.m. on May 15, 2012.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the above areas to lack illuminated exit signage.

Based upon documentation review and interview, it was determined the facility failed to conduct one of twelve required fire drills.

Findings include:

Observation of facility fire drill documentation between 07:55 a.m. and 08:09 a.m. on May 15, 2012, revealed the absence of a first shift fire drill within the fourth quarter of the calendar year 2011.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the facility to lack one of twelve required fire drills.

Based upon observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location on one of six floors.

Findings include:

Observation of the first floor equipment room at 12:33 p.m. on May 14, 2012, revealed several ceiling tiles removed from this area which would then require upright sprinkler heads. Note: Surface-mounted sprinkler heads presently in use in this area.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the sprinkler system deficiency.

Based upon observation and interview, it was determined the facility failed to install and maintain the piped-in medical gas systems in nine locations on three of six floors.

Findings include:

1. Observation of various aspects of the piped-in medical gas systems between 12:44 p.m. on May 14, 2012, and 11:20 a.m. on May 15, 2012, revealed the below deficiencies:

a. Medical gas piping located closest to first floor MRI Waiting requires labeling (corridor location.) 12:44 p.m. on May 14, 2012.
b. Medical gas piping (vertical) located closest to the elevator enclosure lacks labeling and is held in place by dissimilar metallic surfaces. 1:49 p.m. on May 14, 2012.
c. Medical gas piping located within B-231 lacks labeling. 1:57 p.m. on May 14, 2012.
d. Medical gas piping located within B-245 lacks labeling. 2:02 p.m. on May 14, 2012.
e. Wires are affixed to medical air piping closest to the Area A and Area C entrance. 09:50 a.m. on May 14, 2012.
f. Oxygen and Vacuum piping within the sixth floor Mother and Baby Room A201 lacks labeling. 09:52 a.m. on may 15, 2012.
g. Vacuum piping resides atop electrical conduit within the fourth floor exit access corridor system closest to the staff elevators. 10:55 a.m. on May 15, 2012.
h. Multiple wires are affixed to vacuum piping closest to the fourth floor stairwell eight entrance. 11:12 a.m. on May 15, 2012.
i. Non-labeled oxygen piping was noted within the fourth floor pantry closest to B434 at 11:20 a.m. on May 15, 2012.

Interview with facilities representative one during the exit interview process conducted between 12:15 p.m. and 12:30 p.m. on May 15, 2012, confirmed the medical gas system deficiencies stated above.