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Based on observation, the hospital failed to ensure all structural beams had fire proofing in one area of the 22 Bramhall Street location.

Finding:

On 2/19/19, between 1:00 PM and 5:00 PM, a surveyor, with the Safety and Emergency Manager present, observed that there was no fire proofing on the structural beams in the normal Electrical Room S 706. This failure to have fire proofing means that the structural beams would not have the proper fire rating.

Based on observation, the hospital failed to ensure that structural beams had the required fire proofing on steel beams in two areas at the 84 Campus Drive, Scarborough location.

Findings:

On 2/20/19 between 8:00 AM and 10:00 AM, while conducting facility toursof the 2 story outpatient treatment facility which is constructed of poured concrete, with hospital's Life Safety Inspector, surveyors observed the following:

1. Missing fire proofing on steel beams in the Boiler Room.

2. Missing fire proofing on steel beams in Room 108.

The failure of the hospital to maintain sufficient fireproofing of the observed steel beams means that the integrity and strenght of the beams could be compromised leading to premature structural failure of the building in a fire. These findings were confirmed with the hospital's Life Safety Inspector at the time of the obsercvation.

Based on observations, document reviews, and interviews, the hospital has failed to ensure that the Brighton Campus, located at 335 Brighton Avenue in Portland, is the correct construction type in compliance with NFPA 101 Life Safety Code, 2012 Edition Section 19.1.6.1. for a 5 story building.

Findings:

The Brighton Campus location is a five-story building constructed of poured concrete with a basement; it is comprised of six different buildings attached together; and additions were added in 1951, 1956, 1961, 1976, and 1985 on the ground, first, second and third floors. This location provides the following outpatient services: urgent care; hyperbaric and wound care; CT scanner; radiology; anesthesia services; and outpatient day surgery procedures (colonoscopies and dialysis fistula insertions). In addition, the building is also occupied by Health South, a separately certified rehab hospital.

On 2/21/19 between 2:00 PM and 5:00 PM, surveyors, with the Maintenance Supervisor and the Maintenance Director present, observed the following:

a. The first-floor layout was made up of several additions and 90-minute fire doors were present where the 1985, 1956 and 1951 additions met.

b. The second and the third floors were comprised of several additions and no fire barrier separations were observed on either level between any of the following additions: Common wall between the 1961 east Wing and 1956 addition; common wall between the 1956 and the 1951 addition; the common wall between the 1951 addition and the 1956 Central Wing; and the common wall between the 1976 addition and 1985 addition.

During an interview conducted at the time of the observation, the following was stated by the Life Safety Officer for Maine Med:

"a. The 90 minute fire doors, on the first floor, were not part of a fire barrier and were not required.

b. The third floor was designated as business use and no health care operations were conducted at this level; therefore, no smoke barriers or fire barriers were present or designated on the plans. "

A review of the plans, provided by the hospital, confirmed that that the second and third floor were comprised of the same additions. The plans indicated the second floor was designated as Health Care and there are no fire barriers at common walls.

On 2/21/2019, the surveyors were given a Fire Safety Evaluation System (FSES), dated 3/27/14. The FSES was evaluated by a Certified Fire Protection Specialist and he identified the building as a noncombustible Type II (000) based on the buildings construction during the FSES. The FSES, dated 3/27/14, was not approved by the state agency or the Centers for Medicare and Medicaid Services (CMS).

The CMS Survey and Certification Survey letter (17-15- LSC), dated 12/16/16, indicated that as of 11/1/16, facilities would be surveyed for compliance with the 2012 edition of the LSC and if "the FSES is being used to demonstrate compliance with the fire safety requirements, the version of the FSES for Health Care Occupancies and Board and Care Occupancies found in the 2013 edition of the Guide on Alternative Approaches to Life Safety, NFPA 101A must be used". The Brighton campus is required to be a protected non combustible Type II (222) building. However the current designation according to the completed FSES indicated unprotected non combustible Type II (000). The building cannot be an unprotected non combustible building. It shall be a non combustible building.

On 2/25/19 between 10:00 AM and 12:00 PM, the surveyors confirmed these findings with the Supervisor of Maintenance Operations, the Fire Services Supervisor, the Safety Inspector, the Lead Mechanic, and a professional Engineer hired by the facility.

Based on observations and interview the hospital failed to ensure the means of egress was free from all obstructions in four areas at the 22 Bramhall Street location.

Findings:

1. On 2/19/19 between 1:00 PM and 2:30 PM, the following observations were made and confirmed with the hospital's Safety Director and a representative of hospital management at the time of observationons on Level 6 of the Bean wing:

a. A soiled utility cart blocking Patient Room C77 from closing.

b. A soiled utility cart in the corridor near Room 640.

c. A large chair blocking the exit door from being opened in the Atrium space.

2. On 2/19/19 between 1:00 PM and 5:00 PM, surveyors with the Manager of Safety and Emergency Management present, observed two charting computers blocking the egress in and out of the suite rooms at patient Rooms 4712, 4714, and 4730 on Level 4 East Tower.

Based on observations, the hospital failed to ensure exit signs were properly located in the corridor and ensure the means of egress was free from all obstructions in two areas at the 335 Brighton Avenue location.

Findings:

1. On 2/20/19 between 2:00 PM and 5:00 PM, surveyors, with the Safety Supervisor and Operations Supervisor present, observed that an exit sign measured six feet four inches off the floor on floor 2. NFPA 2012 edition Chapter 7 section 7.1.5 indicates projections from the ceiling shall not be less than six feet eight inches.

2. On 2/20/19 between 2:00 PM and 5:00 PM, surveyors, with the Safety Supervisor and Operations Supervisor present, observed computers on wheels and blood pressure carts stored in the corridor near Room 109-A/109-B and 112-A/ 112-B; thus obstructing the means of egress.

Based on observations, the hospital failed to ensure doors would remain in the closed position when released in five areas at the 22 Bramhall Street location.

Findings:

1. On 2/19/19 between 1:00 PM and 3:00 PM, surveyors with the Safety Management Manager observed the following:

a. A 90-minute Fire rated door did not latch when closed at door number FS701 in the Sub-Basement corridor.

b. A 90-minute fire rated door did not latch when closed at door number FB118 in the Basement level.

c. A 90-minute fire rated door did not latch when closed at door number FD106 in Basement level.

d. A 90-minute fire rated door did not latch when closed at door number F2301 on second floor.

e. A 90-minute Fire rated door did not latch when closed at door number R9 Bean wing to Sullivan wing.

Based on observations, the hospital failed to ensure doors latched and closed in three areas at the 22 Bramhall Street location.

Findings:

1. On 2/19/19 between 1:00 p.m. and 1:30 p.m., surveyors, with the Safety Director present, observed the following on Level 6 of the Bean wing in the critical care area:

a. The sliding glass door did not latch when closed at Room 6081.

b. The sliding glass door did not latch when closed at Room 6084.

c. The automatic sliding door did not latch when closed at Room 6085.

Based on observations, the hospital failed to ensure that hazardous rooms had required fire ratings, self closing doors, and/or no penetrations in the fire walls in eight areas at the 22 Bramhall Street location.

Findings:

1. On 02/19/19 between 1:00 PM and 5:00 PM, surveyors, with the Safety Director-Emergency Management present, observed the following:


A. Four approximately 3" x 6" sections of sheetrock had been cut away from an area above the duct work on the exterior of the elevator machine room in Bean Building Level 4.

B. A large diameter hole penetrating the two hour fire rated floor ceiling assembly located above air handler number 72 in the Bean Building.



2. On 02/19/19 between 1:00 PM and 5:00 PM, surveyors, with the Director of Safety-Emergency Management present, observed the door was held open by a rolling cart and there was no self-closing hardware on storage room S0009 door in the Richards Building sub-basement.

3. On 02/19/19 between 1:00 PM and 5:00 PM, surveyors, with Director of Safety-Emergency Management present, observed the following:

a. A twelve inch pipe penetration sealed with unapproved spray foam through the deck at East Tower Floor 5 penthouse areas Electrical Panel DPE4 461.

b. The fire rating tag was obscured with paint at OB/Triage medication room 2806 in the East Tower Floor 2.

4. On 03/19/19 between 1:00 PM and 5:00 PM, surveyors. with Regulatory and Compliance Manager present, observed there was no self-closing hardware on door G511 of the NDF Building Supplies Room.

Based on observation, the hospital failed ensure that sprinkler coverage was installed or maintained in seven areas at the 22 Bramhall Street location.

Findings:

1. On 2/19/19 between 1:00 PM and 5:00 PM, surveyor, with the Facility Director present, observed the following:

a. The track/rail system mounted to the ceiling in all patient rooms was obstructing the side wall sprinkler head spray pattern on level 3 in the Richards Building.

b. No sprinkler coverage in kitchen closets G115, G116, and G117 at the ground level of the Richards Building.

c. Sprinkler heads installed to close in proximity over the Pharmacy breakroom table in the NDF building.

d. Boxes were found within 18 inches of the sprinkler head that would cause an obstruction of the sprinkler heads water development pattern in room G556 of the NDF building.

2. On 2/19/19 between 1:00 PM and 5:00 PM, surveyors, with the Facility Maintenance worker present, observed unprotected CVPC sprinkler pipe in nine information technology closets located in the Richards Building.

Based on observations, the hospital failed to ensure that sprinkler head was installed tightly in one area at the 84 Campus Drive Scarborough location.

Finding:

On 2/20/19 between 9:00 AM and 10:30 AM, surveyors, with the hospital's Life Safety Inspector present, observed that a sprinkler head escutcheon plate located in the locker room did not fit tightly against the sheetrock ceiling, exposing an approximately half inch gap/hole.

Based on observation, the hospital failed to ensure fire extinguishers were inspected in one location at the 22 Bramhall St location.

Finding:

On 02/19/19 between 1:00 PM and 2:00 PM, a surveyor, with the Manager of Safety and Emergency Management present, observed two fire extinguishers that did not have monthly inspections completed on the East Wing floor 5.

Based on observations, the hospital failed to ensure doors that opened to the corridor were able to be latched and resist the passage of smoke in ten areas at the 22 Bramhall Street location.

Findings:

1. On 02/19/19 between 1:00 PM and 3:00 PM, surveyors, with the facility maintenance worker present, observed the catherization lab door number 306 did not positively latch.

2. On 02/19/19 between 1:00 PM and 3:00 PM, survyeyor, with the Fire Services Director present, observed the electrical room door, located across from Room 2076, would not latch on Bean Building level 2.

3. On 02/19/19 between 1:00 PM and 4:00 PM, surveyors, with the Director of Safety-Emergency Management present, observed the following:

a. Patients room doors 4712, 4714, 4716, 4730, and 4740 were obstructed by wall mounted computers preventing the doors from closing on Floor 4 of the East Tower.

b. Patient room door 4720 had a gap at the top of the door that exceeded a half inch on Floor 4 of the East Tower.

c. Patient room door 1064 was obstructed by a computer cart preventing the door from closing on Floor 1 of the East Tower.

Based on observations, the hospital failed to maintain smoke barriers to resist the passage of smoke in three locations at the 335 Brighton Avenue location.

Findings:

1. On 02/20/19 between 2:00 PM and 5:00 PM, a surveyor, with the Safety Supervisor and Operation Supervisor present, observed the following:

a. Smoke barrier doors have a 3/8 inch gap or greater where the door leaves meet near rooms 2020-A and 2020-B.

b. Smoke barrier doors have a 3/8 inch gap or greater where the door leaves meet near rooms 207-A and 207-B.

c. Smoke barrier doors have 3/8 inch gap or greater where the door leaves meet on level 1 near room 116-A.

Based on record review and interview, the hospital failed to ensure that fire doors were in compliance with NFPA 80 The Standard for Fire Doors and Other Opening Protective for 43 of 187 doors.

Findings:

On 2/19/19 between 1:00 PM and 5:00 PM, a surveyor reviewed the fire door inspection report, dated September 2018, which identified 187 doors not in compliance with NFPA 80 The Standard for Fire Doors and Other Opening Protective. As of 2/19/19, 43 doors had not been repaired to meet the standard.

This finding was confirmed, in an interview with the Regulatory and Compliance Manager, on 2/19/19 at the time of the record review.

Based on interviews and record reviews, the hospital failed to ensure that piped in gas and vacuum systems had been installed and maintained at the 22 Bramhall Street location.

Findings:

On 2/19/19 between 1:00 PM and 5:00 PM, a surveyor, with the Regulatory Compliance Manager present, reviewed the Medical Gas inspection report, dated 5/17/18. At the time of the record review, an interview with the Regulatory Compliance Manager confirmed that the following items identified on the report had not yet been corrected:

FOR COMPLIANCE DISCREPENCIES:

A. IN THE BEAN BUILDING:

1. In the clinical engineering (sub-basement), the nitrogen outlet was not supplied through a zone valve and there was no dedicated WAGD inlets installed in this location.

2. In the ASU, the zone valves, located across from the nurse's station, have no wall intervening between the valves and the Outlets/inlets they control.

3. In the special procedures (Ground Floor), there was no area alarm located for Special Procedures Room.

B. IN THE NDF BUILDING:

1. In MRI area, the alarm, located to the left of the MRI entrance, did not have separate visual indicators for each condition monitored.

2. In the Interventional Radiology, there was no area alarm located for IR Holding Room.

3. In Radiation/Oncology, zone valves, located across from Stairway 14, had no pressure/vacuum indicators on the station outlet/inlet side of the zone valves.

C. IN THE PAVILION BUILDINGS:

1. In Women's OBGYN, the oxygen zone valve, located right of Room 1318, had no pressure indicator on the station outlet side of the zone valve and all vacuum inlets in this department were not supplied through a zone valve.

2. In Echo and Stress, the zone valves, located left of Room 2106, had no pressure/vacuum indicators on the station outlet/inlet side of the zone valves; had threaded connections on each side of the zone valve; the oxygen zone valve was not a quarter turn valve; and had painted piping.

3. In Medical Surgical (P2C), all vacuum inlets in this department are not supplied through a zone valve.

4. In Simulation Lab, the area alarm, located right of Room 3204, did not have a separate visual indicators for each condition monitored.

5. In Ace Unit (P3CD), the oxygen zone valve, located right of Room 3321A, had no pressure indicator on the station outlet side of the zone valve; had threaded connections on each side of the zone valve; and all vacuum inlets in this department were not supplied through a zone valve.

6. In Pulmonary, the zone valves, located left of Room 4200, had no pressure/vacuum indicators on the station outlet/inlet side of the zone valves; had threaded connections on each side of the zone valve; and had painted piping.

7. In Short Stay, all vacuum inlets in this department were not supplied through a zone valve

8. In Dialysis, the area alarm, located at the nurse's station, did not have separate visual indicators for each condition monitored.

D. IN THE RICHARDS BUILDING

1. In Pedi ED/ACU, the area alarm, located right of K3, did not have separate visual indicators for each condition monitored and there was no area alarm located for the zone valve located left of the nurse's station.

2. In R-1, the zone valves, located right of 1163, had no pressure/vacuum indicators on the station outlet/inlet side of the zone valves; had threaded connections on each side of the zone valve; and had painted piping.

3. In R-5, the zone valves, located across from 506, had no pressure/vacuum indicators on the station outlet/inlet side of the zone valves; had threaded connections on each side of the zone valve; had painted piping; and the oxygen zone valve was not a quarter turn valve.

4. In R-7, zone valves, located right of 7165, had no pressure/vacuum indicators on the station outlet/inlet side of the zone valves; had threaded connections on each side of the zone valve; and had painted piping.

5. In the Catheterization Lab, zone valves, located left of 8150, were not immediately located outside the room they control; had no pressure indicator on the station outlet side of the oxygen zone valve; had painted piping on the oxygen zone valve; and had threaded connections on each side of the oxygen zone valve. In addition, the medical air zone valve, located right of 8150, was not immediately locate outside the room it controls.

6. In CICU, the area alarm, located right of nurse's station, did not have separate visual indicators for each condition monitored and zone valves, located right of Nurse's desk check in, had no pressure/vacuum indicators on the station outlet/inlet side of the zone valves.

7. In R-9, an oxygen zone valve, located left of Room 9131, had a 0-200 psig gauge installed which did not have the normal operating pressure within the middle third of the total range.

FOR MASTER ALARMS AND SOURCES:

1. In the oxygen supply system the following was noted:

a. The source valve, located on the oxygen bulk pad, did not consist of three pieces permitting in-line serviceability.

b. The source valves on the oxygen bulk pad that isolate the oxygen supply did not consist of three pieces permitting in-line serviceability.

c. An oxygen check valve, located on the main line piping, that enters the CSD stairwell had threaded connections.

d. An oxygen check valve, located on the main line piping, that enters the Old Boiler Room has threaded connections.

e. Piping that enters the Old Boiler Room is painted.

f. Final line gauge located in the Housekeeping Closet ceiling in the Bean Building, sub-basement is not readable from a standing position.

2. At EOSC 1 (Outside of CSD), an oxygen check valve, located on the emergency piping that enter the CSD Stairwell, had threaded connections.

3. At EOSC 2 (Old Boiler Room), an oxygen check valve, on the emergency piping that enters the Old Boiler Room, had threaded connections and the emergency oxygen supply connection was installed at an inaccessible location for emergency vehicles.

4. For the nitrous oxide supply system, there was no source valve installed at the nitrous oxide bulk pad and all turns, offsets, and other changes in direction to the pressure relief piping were bent and not brazed with wrought copper capillary fittings.

5. For the Medical Air Compressor (Room 4000), the medical air high pressure emergency reserve cannot be in the same room as vacuum pumps, medical air compressors, WAGD sources, Instrument air compressor sources, or any other compressor, vacuum pump, or electrically powered machinery; the medical air high pressure emergency reserve system had no alarm provided to monitor the operation or condition of the source supply; and the medical air intake, located on the roof, was not located a minimum of 25 feet from existing plumbing vents.

6. In the Vacuum Pump (Room 4000), the vacuum exhaust piping was not installed with compliant tubing and downstream of a future valve at the vacuum pump was a cap that is soft-soldered and not brazed.

IN THE BEAN BUILDING

1. In the Clinical Engineering (Sub-Basement Floor) area, oxygen zone valves, located across from Clinical Engineering leaks at the stem in the on and off position.

2. In the ASU area, an oxygen zone valve, located across from nurse's station, leaked at the stem in the on and off position.

3. In the Surgical Services (Basement Floor) area, an oxygen zone valve, located right of B074, leaked at the stem in the on and off position

4. In Operating Room 1, an oxygen zone valve, located right of B075 leaked at the stem in the on and off position.

5. In Operating Room 2, during the 10-minute standing pressure test, vacuum lost 3" Hg; the 1st vacuum inlet on ceiling 1 leaked at the end of the hose; the 2nd vacuum inlet on ceiling 1 leaked at the end of the hose; and the 3rd vacuum inlet on ceiling 1 leaked at the end of the hose.

6. In Operating Room 3, an oxygen zone valve, located left of OR 3, leaked at the stem in the on and off position; the medical air zone valve, located left of OR 3, leaked at the stem in the on and off position and at the gauge port; and the medical air outlet on ceiling 1 leaked at the end of the hose.

7. In Operating Room 7, an oxygen zone valve, located across from OR 7, leaked at the stem in the on and off position; the 2nd vacuum inlet on ceiling 2 leaked at the ceiling and at the end of the hose; and the 3rd vacuum inlet on ceiling 2 leaked at the ceiling and at the end of the hose.

8. In Operating Room 8, and oxygen zone valve, located across from B062, leaked at the stem in the on and off position.

9. In OR Holding, an oxygen zone valve, located left of B040, leaked at the stem in the on and off position.

10. In Operating Room 9, an oxygen zone valve located right of OR 9 leaked at the stem in the on and off position and the nitrous oxide zone valve, located right of OR 9 leaked at the gauge port.

11. In Operating Room 10, an oxygen zone valve, located right of OR 10, leaked at the stem in the on and off position and the medical air zone valve, located right of OR 10, leaked at the gauge port.

12. In Operating Room 11, an oxygen zone valve, located left of OR 12, leaked at the stem in the on and off position and the medical air zone valve, located left of OR 12, leaked at the gauge port.

13. In Operating Room 12, an oxygen zone valve, located across from holding, leaked at the stem in the on and off position and medical air zone valve, located across from holding, leaked at the gauge port.

14. In Operating Room 13, an oxygen and medical air zone valves, located right of OR 12, leak at the stem in the on and off position; the 1st vacuum inlet on ceiling 1 leaks at the end of the hose; and 2nd vacuum inlet on ceiling 1 leaks at the end of the hose.

15. In Operating Room 14, an oxygen zone valve, located right of OR 14, leaked at the stem in the on position.

16. In Operating Room 15, an oxygen zone valve, located left of OR 16, leaked at the stem in the on and off position.

17. In Operating Room 16, an oxygen and medical air zone valve, located left of OR 16, leaked at the stem in the on and off position.

18. In Operating Room 17, an oxygen zone valve, located right of OR 16, leaked at the stem in the on and off position; the 1st vacuum inlet on the ceiling leaked at the ceiling and at the end of the hose; and 2nd vacuum inlet on the ceiling leaked at the ceiling and at the end of the hose.

19. In Operating Room 18, an oxygen zone valve, located across from the viewing room, leaked at the stem in the on and off position and the 2nd vacuum inlet leaked at the end of the hose.

20. In Operating Room 19, an oxygen zone valve, located right of OR 19, leaked at the stem in the on and off position; the medical air zone valve, located right of OR 19, leaked at the stem in the on and off position and at the gauge port; and the WAGD inlet on ceiling 2 leaked at the end of the hose.

21. In Operating Room 20, during the 10-minute standing pressure test, vacuum/WAGD lost 23" Hg and the nitrogen panel on the boom had a defective regulator knob.

22. In the Special Procedures (Ground Floor) area, an oxygen zone valve, located right of entrance to CU 3, leaked at the stem in the on and off position.

23. In the CICU area, the medical air and oxygen zone valves, located across from G019, leaks at the stem in the on and off position. In 1012, the 1st vacuum inlet leaked and had a low flow of 2.0 scfm and the 2nd vacuum inlet leaked.

24. In the ICU 2 area, the oxygen zone valve, located across from G027, leaked at the stem in the on and off position.

25. In the SCU 3 area, the oxygen zone valve, located across from G044, leaked at the stem in the on and off position. In 1033, the 2nd vacuum inlet leaked.

26. In the SCU 4 area, in 1045, the 3rd vacuum inlet leaked and the 4th vacuum inlet leaked. In addition, in 1047, the 2nd vacuum inlet leaked.

27. In the Surgical Services (2nd Floor) area, in Operating Room 24, the 1st vacuum inlet on the ceiling leaked at the end of the hose and the 2nd vacuum inlet on the ceiling leaked at the end of the hose.

28. In the Barbara Bush Children's area, the oxygen zone valve, located across from 632, leaked at the gauge port.

IN THE EAST TOWER:

1. In the Emergency Department area, in A3, the 2nd vacuum inlet leaked; in B17, the 2nd vacuum inlet leaked; in B21, the 2nd vacuum inlet leaked; and in B22, the 1st vacuum inlet leaked.

2. In C-Section/Triage, in 2863, the 1st oxygen outlet on the wall drops 13 psig at 3.5 scfm, the 1st vacuum inlet on the ceiling leaked at the end of the hose, and the 2nd vacuum inlet on the ceiling leaks at the end of the hose; and in 2867, the 1st vacuum inlet on the ceiling leaked at the ceiling and at the end of the hose and the 2nd vacuum inlet on the ceiling leaked at the ceiling leaks at the end of the hose.

IN THE NDF BUILDING:

1. In the Nuclear Medicine area, in B327, the vacuum inlet on the ceiling leaked at the end of the hose.

2. In the Ultrasound area, the oxygen zone valve, located right of B472, leaked at the left flange.

3. In the Radiology area, in X-Ray 4, during the 10-minute standing pressure test, the vacuum/WAGD lost 22" Hg and in ENDORAD 0, during the 10-minute standing pressure test, the vacuum lost 24" Hg.

4. In the Interventional Radiology area, in IR Room 2, the 2nd vacuum inlet on the ceiling leaked at the ceiling and at the end of the hose and in IR Room 3, the 1st vacuum inlet on the ceiling leaked at the ceiling and at the end of the hose.

5. In Radiology/Oncology area, the oxygen zone valve located across from stairway 14 leaked at both flanges.

6. In RADCU area, the oxygen zone valve located right of B462 leaked at the stem in the off position.

PAVILION BUILDINGS:

1. In the Women's OBGYN area, the oxygen zone valve, located right of Room 1318, leaked at the stem in the on and off position.

2. In Medical Surgical (P2B) area, in 2403, the oxygen outlet had a defective faceplate and the vacuum inlet leaked.

3. In the Medical Surgical (P2C) area, in 256, 266, 276 and 281, the vacuum inlet leaked. In addition, in 281, there was a low flow of 1.75 scfm.

4. In Ace Unit (P3CD) area, in 360, the 1st and the 2nd vacuum inlet leaked; in 393 and 395, the vacuum inlet leaked; and in 3416, the vacuum inlet had a low flow of 2.5 scfm.

5. In the Pulmonary area, the oxygen zone valve, located left of 4200, leaked at the stem in the on and off position.

6. In the Short Stay area, in 472, the vacuum inlet leaked and had a low flow of 1.75 scfm; in 478, the vacuum inlet had a low flow of 2.25 scfm; and in 482, the vacuum inlet leaked and had a low flow of 2.5 scfm.

IN THE RICHARDS BUILDING

1. In the Pedi ED/ACU, in C25, the oxygen outlet leaked; and in K2, the 1st vacuum inlet had a low flow of 1.5 scfm and the 2nd vacuum inlet has a low flow of 1.75 scfm.

2. In Level R-1, the following was noted:

a. In 116, 118, 120, 124 the 1st vacuum inlet leaked.

b. In 101, 105, 110, and 114, the 2nd vacuums leaked.

c. In 107, 111, 112, 117, and 119, the 1st vacuum inlet and the 2nd vacuum inlet leaked.

3. In Level R-2, the following was noted:

a. In 201, the oxygen outlet drops 11 psig at 3.5 scfm.

b. In 202, the oxygen outlet drops 20 psig at 3.5 scfm.

c. In 211, the oxygen outlet drops 10 psig at 3.5 scfm.

d. In 212, the oxygen outlet drops 10 psig at 3.5 scfm.

e. In 214, the oxygen outlet drops 12 psig at 3.5 scfm.

f. In 216, the oxygen outlet drops 14 psig at 3.5 scfm.

g. In 217, the oxygen outlet drops 20 psig at 3.5 scfm.

h. In 218, the 1st vacuum inlet had a low flow of 2.0 scfm and the oxygen outlet drops 9 psig at 3.5 scfm.

i. In 219, the oxygen outlet drops 9 psig at 3.5 scfm.

j. In 220, the 1st vacuum inlet leaked.

k. In 223, the oxygen outlet drops 12 psig at 3.5 scfm.

l. In 224, the oxygen outlet drops 16 psig at 3.5 scfm.

m. In 225, the oxygen outlet drops 15 psig at 3.5 scfm.

n. In 226, the oxygen outlet drops 15 psig at 3.5 scfm.

o. In 227, the oxygen outlet drops 10 psig at 3.5 scfm.

4. In Level R-3, the following was noted:

a. In 301, the oxygen outlet drops 11 psig at 3.5 scfm.

b. In 304, the oxygen outlet drops 10 psig at 3.5 scfm.

c. In 305, the oxygen outlet drops 10 psig at 3.5 scfm.

d. In 306, the oxygen outlet leaks and drops 10 psig at 3.5 scfm.

e. In 307, the oxygen outlet leaks and drops 14 psig at 3.5 scfm.

f. In 309, the 3rd oxygen outlet leaks and drops 15 psig at 3.5 scfm.
g. In 310, the oxygen outlet drops 20 psig at 3.5 scfm.

h. In 311, the oxygen outlet drops 15 psig at 3.5 scfm.

i. In 312, the oxygen outlet drops 10 psig at 3.5 scfm and the 2nd vacuum inlet leaks

j. In 314, the oxygen outlet leaks and drops 35 psig at 3.5 scfm.

k. In 315, the oxygen outlet drops 15 psig at 3.5 scfm.

l. In 316, the oxygen outlet drops 12 psig at 3.5 scfm.

m. In 317, the oxygen outlet leaks 50 psig.

n. In 318, the oxygen outlet drops 12 psig at 3.5 scfm.

o. In 319, the oxygen outlet leaks 50 psig.

p. In 320, the oxygen outlet drops 14 psig at 3.5 scfm.

q. In 321, the oxygen outlet drops 12 psig at 3.5 scfm.

r. In 323, the 3rd vacuum inlet leaked.

s. In 325, the 3rd vacuum inlet leaks, and the 2nd and 4th oxygen outlets leaked.

5. In Level R-4, the following was noted:

a. In 410, the oxygen outlet leaks and drops 25 psig at 3.5 scfm.

b. In 411, the oxygen outlet leaks and drops 12 psig at 3.5 scfm.

c. In 412, the 1st vacuum inlet leaked and the oxygen outlet drops 12 psig at 3.5 scfm.

d. In 415, the oxygen outlet drops 10 psig at 3.5 scfm.

e. In 417, the oxygen outlet leaks and drops 10 psig at 3.5 scfm.

f. In 418, the oxygen outlet drops 10 psig at 3.5 scfm.

g. In 419, the oxygen outlet drops 13 psig at 3.5 scfm.

h. In 420, the oxygen outlet leaks drops 20 psig at 3.5 scfm.

i. In 421, the oxygen outlet drops 10 psig at 3.5 scfm.

j. In 422, the 2nd vacuum inlet leaked.

k. In 427, the 1st vacuum inlet leaked and had a low flow of 2.0 scfm; the 4th vacuum inlet leaked; and the 4th oxygen outlet leaks.

6. In Level R-5, the following was noted:

a. In 501, the 1st oxygen outlet leaked.

b. In 504, the oxygen outlet leaked.

c. In 510, the oxygen outlet leaked and drops 20 psig at 3.5 scfm.

d. In 511, the oxygen outlet drops 16 psig at 3.5 scfm.

e. In 512, the oxygen outlet drops 20 psig at 3.5 scfm.

f. In 514, the oxygen outlet drops 11 psig at 3.5 scfm.

g. In 515, the oxygen outlet drops 20 psig at 3.5 scfm.

h. In 516, the oxygen outlet drops 15 psig at 3.5 scfm.

i. In 519, the oxygen outlet drops 12 psig at 3.5 scfm.

j. In 520, the oxygen outlet leaks and drops 15 psig at 3.5 scfm.

k. In 521, the oxygen outlet drops 21 psig at 3.5 scfm.

l. In 524, the 2nd vacuum inlet leaks.

m. In 5123, the oxygen outlet drops 20 psig at 3.5 scfm.

n. In 5133, the oxygen outlet drops 13 psig at 3.5 scfm.

7. In Level R-6, in 615, the 2nd vacuum inlet leaked.

8. In Level R-7, the following was noted:

a. In 702, the oxygen outlet leaked and drops 15 psig at 3.5 scfm.

b. In 703, the 1st vacuum inlet leaked and the oxygen outlet leaked and drops 15 psig at 3.5 scfm.

c. In 705, the oxygen outlet leaked and the 2nd vacuum inlet leaked.

d. In 706, the oxygen outlet leaked and drops 50 psig at 3.5 scfm.

e. In 707, the 1st vacuum inlet leaked.

f. In 709, the oxygen outlet leaked and drops 10 psig at 3.5 scfm.

g. In 710, the oxygen outlet leaked and drops 10 psig at 3.5 scfm.

h. In 711, the oxygen outlet drops 10 psig at 3.5 scfm.

i. In 712, the oxygen outlet drops 10 psig at 3.5 scfm.

j. In 714, the oxygen outlet leaked and the 2nd vacuum inlet leaked.

k. In 715, the 1st vacuum inlet leaked and the oxygen outlet leaked and drops 16 psig at 3.5 scfm.

l. In 719, the oxygen outlet leaked and drops 12 psig at 3.5 scfm.

m. In 720, the oxygen outlet leaked and drops 8 psig at 3.5 scfm and the 2nd vacuum inlet leaks.

n. In 722, the 1st vacuum inlet leaked and the oxygen outlet drops 10 psig at 3.5 scfm.

o. In 723, the oxygen outlet leaked and the 2nd vacuum inlet leaked.

p. In 725, the oxygen outlet leaked.

q. In 726, the oxygen outlet leaked and drops 10 psig at 3.5 scfm.

r. In 727, the oxygen outlet leaked and drops 20 psig at 3.5 scfm.

s. In 7125, the 1st oxygen outlet leaked and drops 10 psig at 3.5 scfm; the 3rd vacuum inlet had no registered flow; and the 2nd oxygen outlet drops 30 psig at 3.5 scfm.

9. In the Catheterization Lab area the following was noted;

a. In EP Lab 1, the oxygen zone valve, located right of 8169, leaked at the stem in the off position and the medical air zone valve, located right of 8169, had a defective gauge.

b. In Cath Lab 2, the oxygen zone valve, located left of 8150, leaked at both flanges and the medical air zone valve, located right of 8150, leaked at the right flange.

c. In Cath Lab 5, the 1st vacuum inlet on the ceiling leaked at the ceiling and at the end of the hose.

d. In EP Lab 6, the oxygen zone valve, located right of EP Lab 6, leaked at the stem in the off position.

10. In the CICU area, the following was noted:

a. In the area alarm, located right of nurse's station, needed the oxygen low pressure alarm adjusted to 48 psig. Currently, the oxygen low pressure alarms at 42 psig.

b. The oxygen zone valve, located right of nurse's desk, leaked at the stem in the on and off position.

c. In 902, the 1st vacuum and 2nd vacuum inlets leaked.

d. In 903, the 1st vacuum and the 2nd vacuum inlets leaked and the 2nd medical air outlet leaked.

e. In 904,911, and 912. the 2nd vacuum inlets leaked.

f. In 906, the 1st medical air outlet leaked and the 1st vacuum and the 2nd vacuum inlets leaked

11. In Level R-9, the following was noted:

a. In 914, 916, 917, the 1st vacuum inlets leaked.

b. In 917, the 1st and the 2nd oxygen outlets leaked

c. In 918, the 1st vacuum inlet leaked and had a low flow of 2.75 scfm and the 2nd vacuum inlet leaked.

d. In 919, the oxygen outlet leaked; the 1st vacuum inlet leaked and had a low flow of 1.25 scfm; and the 2nd vacuum inlet leaked.

e. In 920, the 1st and 2nd oxygen outlets leaked and and the 1st vacuum inlet leaks.

f. In 921, the 1st vacuum inlet leaked and had a low flow of 2.25 scfm and the 2nd vacuum inlet leaked.

g. In 923, the 1st and 2nd vacuum inlet leaked and the. 2nd oxygen outlet leaked.

h. In 924, the 2nd oxygen outlet leaked 50 psig.

12. In the EP Lab area, the zone valves, located left of EP Lab, had an outlet leak in the on and off position, had a broken window; and the vacuum inlet on the ceiling leaked at the end of the hose.

13. In the oxygen supply system, the service valve on the pad that controls the main line piping entering the Boiler Room leaked; there were multiple threaded fittings in the Bulk Pad that leaked; and both sides of the threaded check valve that was located on the main line piping in the CSD stairwell leaked.

14. In the EOSC 2 (Outside Old Boiler Room) area, the threaded check valve, located on the emergency piping, leaked and was defective and the check valve did not hold pressure.