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Based on observation and interview, the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations and accesses are in accordance with Chapter 7, and continuously maintained free of all obstructions to full use in case of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect ALL occupants in the event of an evacuation in an emergency situation.

The following observations were made:

On 11-13-17
At Approximately 3:05 PM - While on tour with Facility Plant Operations Manager observed in East Tower Basement Corridor near MEDICAL RECORDS E0004 combustible storage in the corridor.

On 11-14-17
At approximately 09:56 AM - While on tour with Facility Plant Operations Manager observed in South Tower 6th Floor Corridor near Medical education the use and storage of a 90 Gallon trash receptacle.

At approximately 10:55 AM- While on tour with Facility Plant Operations Manager observed in South Tower 3rd Floor the use of 5 x WORKSTATION ON WHEELS ("WOW") carts as permanent work stations. These carts were observed with nursing staff sitting in chairs plugged in to the wall of the corridor. The corridor width is 6 feet and when WOW carts are utilized the width was narrowed to 3- 4 feet of free clearance.

On 11-15-17
At approximately 11:09 AM - While on tour with Facility Plant Operations Manager observed in Medical Office Building Exits from Stairwell "B" from the Main Hospital; the 3rd Bank of exit doors to the West, the last westerly door failed to open under the required pounds of force necessary to open for an emergency exit.

All observations were witnessed and confirmed by the Facility Plant Operations Manager at the time of observation.

Based on observation and interview, the facility failed to ensure that Stairways and Smokeproof enclosures used as exits are in accordance with 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 Chapter 7, and continuously maintained free of all obstructions to full use in case of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect ALL occupants in the event of an evacuation resulting in the use of stairwells and exit doors.

The following observations were made:

On 11-13-17
At approximately 10:45 AM - While on tour with Facility Plant Operations Manager observed in STAIRWELL "K" the storage of a cleaning cart under the stairs.

On 11-15-17
At approximately 11:06 AM - While on tour with Facility Plant Operations Manager observed in STAIRWELL "B" 1st floor the doors to the stairwell failed to close to a positive latch. (Both doors).

At approximately 11:07 AM - While on tour with Facility Plant Operations Manager observed in STAIRWELL "F" 1st floor door to the stairwell failed to close to a positive latch.

At approximately 1:35 PM - While on tour with Facility Plant Operations Manager observed in STAIRWELL "H" 1st floor the storage of 3 inch conduits in the stairwell on the floor.

At approximately 2:22 PM - While on tour with Facility Plant Operations Manager observed in STAIRWELL "D" 1st floor the storgage of elevator referbishing material stored in the horizntal exit from the stairwell.

All observations were witnessed and confirmed by the facilities Plant Operations Manager at the time of observation.

Based upon observation, records review and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect ALL occupants in the event of required protection of the room and surrounding rooms per the construction of the building and the life safety plans.

Findings Include:
On 11/13/2017 at approximately 3:05 PM the following observations were made:

On 11-13-17
At approximately 3:05 PM - While on tour with Facility Plant Operations Manager observed in East Tower Basement Fire Pump Room was not finished in accordance with the life safety drawings and observation of unfinished wall to the deck. Penetrations were observed at the wall to deck ripple which was not properly sealed.

At approximately 3:07 PM - While on tour with Facility Plant Operations Manager observed in East Tower Basement Electrical room E0024 was not finished in accordance with the life safety drawings and observation of unfinished wall to the deck. Penetrations were observed at the wall to deck ripple which was not properly sealed.

At approximately 3:09 PM - While on tour with Facility Plant Operations Manager observed in East Tower Basement Electrical room E0018 was not finished in accordance with the life safety drawings and observation of unfinished wall to the deck. Penetrations were observed at the wall to deck ripple which was not properly sealed.

All observations were witnessed and confirmed by the manager of Plant Operations at the time of observation.

Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect ALL occupants in the event of a fire and sprinkler activation is required resulting in delay or possible failure to activate sprinkler protection at all.

Findings Include:
On 11-13-17 at approximately 10:00 AM the following observations were made:

On 11-13-17
At approximately 10:00 AM - While on tour with Facility Plant Operations Manager observed in EAST TOWER 3rd FLOOR STAIRWELL "K" in the stairwell a sprinkler head thru the drywall ceiling with a water stain around the head. Verification at the time could not prove the stain was not coming from the sprinkler.

At approximately 11:30 AM - While on tour with Facility Plant Operations Manager observed in EAST TOWER 2nd FLOOR ICU EAST LOW-SIDE quick response sprinkler heads mixed with standard response heads installed in the same smoke zone.

At approximately 2:35 PM - While on tour with Facility Plant Operations Manager observed in EAST TOWER BASEMENT ROOM E0031 multiple ceiling tiles removed from the ceiling plane preventing sprinkler coverage to operate as designed.

On 11-14-17
At approximately 09:28 AM - While on tour with Facility Plant Operations Manager observed in SOUTH TOWER 6th FLOOR MEDICAL EDUCATION MANAGERS OFFICE partial sprinkler coverage of the same smoke zone resulting in inadequate sprinkler coverage of the same smoke zone.

On 11-15-17
At approximately 10:53 AM - While on tour with Facility Plant Operations Manager observed in WEST TOWER 1st FLOOR PHYSICIANS LIBRARY 4 sprinkler heads that are installed with a higher temperature rating then the remainder of sprinkler heads in the room.

At approximately 11:22 AM - While on tour with Facility Plant Operations Manager observed in SOUTH TOWER 1st FLOOR EMERGENCY TRIAGE AREA a sprinkler eschution missing.

At approximately 11:36 AM - While on tour with Facility Plant Operations Manager observed in SOUTH TOWER 1st FLOOR EMERGENCY ROOM CORRIDOR by ROOM S1036 wiring wrapped around the sprinkler pipe above ceiling.

At approximately 1:10 PM - While on tour with Facility Plant Operations Manager observed in MRI EQUIPMENT ROOM 1st FLOOR ceiling tiles removed preventing the sprinkler coverage in the room to activate as designed.

At approximately 1:44 PM - While on tour with Facility Plant Operations Manager observed in LAB PATHOLOGY Ceiling tiles removed in the area and sprinkler heads covered in excessive dust and dirt.

All observations were witnessed and confirmed by the Facility Plant Operations Manager at the time of observation.

Based upon observation, records review and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect 6 occupants in the event of evacuation of occupants.

Findings Include:
On 11-14-17 at approximately 1:58 PM the following observations were made:

While on tour with Facility Plant Operations Manager observed in SURGERY CENTER 1st Floor in the BULK STORAGE room. A corridor wall door that was blocked by material and inaccessible for use.

This was observed and confirmed by the Facility Manager of Plant operations at the time of observation.

Based upon observation, records review and interview, the facility failed to ensure that smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5 as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect ALL occupants in the event of fire and the use of sheltering in place and the use of building separation to provide life safety.

Findings Include:
On 11-13-17 at approximately 9:00 AM the following observations were made:

On 11-13-17
At approximately 09:35 AM - While on tour with Facility Plant Operations Manager observed in East Tower 3rd Floor in ROOM 3056 after review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a single penetration through the smoke barrier wall above ceiling, of a duct that was not sealed.

At Approximately 09:40 AM - While on tour with Facility Plant Operations Manager observed in East Tower 3rd Floor above Smoke Barrier Doors ceiling upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a single penetration through the smoke barrier wall above ceiling, of a duct that was not sealed.

At approximately 9:50 AM - While on tour with Facility Plant Operations Manager observed in East Tower 3rd Floor Smoke Barrier wall down the STERILE CORRIDOR upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed of multiple penetrations through the smoke barrier wall above ceiling.

At approximately 10:30 AM - While on tour with Facility Plant Operations Manager observed in East Tower 2nd Floor EXAM ROOM "E" upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a single penetration through the smoke barrier wall above ceiling, of a 4" to 5" hole through the structural support steel not sealed.

At approximately 10:32 AM - While on tour with Facility Plant Operations Manager observed in East Tower 2nd Floor RESTROOM E2118 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a single penetration through the smoke barrier wall above ceiling, of a sprinkler pipe that was not sealed.

At approximately 10:34 AM - While on tour with Facility Plant Operations Manager observed in East Tower 2nd Floor EXAM ROOM "F" upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a multiple penetrations through the smoke barrier wall above ceiling, of (5) pipes not sealed.

At approximately 10:35 AM - While on tour with Facility Plant Operations Manager observed in East Tower 2nd Floor above smoke barrier doors E2004 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a single penetration through the smoke barrier wall above ceiling, of a 4 inch pipe that was not sealed.

At approximately 10:55 AM - While on tour with Facility Plant Operations Manager observed in East Tower 2nd Floor ROOM E2060 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed of several penetrations through the smoke barrier wall above ceiling, 3 penetrations around conduits wiring and pipes that was not fire stopped.

At approximately 10:57 AM - While on tour with Facility Plant Operations Manager observed in East Tower 2nd Floor ROOM E2052 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a single penetration through the smoke barrier wall above ceiling, of a wire conduit that was not fire stopped.

At approximately 11:05 AM - While on tour with Facility Plant Operations Manager observed in East Tower 1st Floor above the Smoke barrier doors E 1001 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed of a couple of penetrations through the smoke barrier wall above ceiling, 2 penetrations that were not sealed.

At approximately 1:30 PM - While on tour with Facility Plant Operations Manager observed in Heart Center Main Corridor Behind Nuclear Medicine rooms 3,4,5 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed of multiple penetrations through the smoke barrier wall above ceiling.

On 11-14-17
At approximately 10:08 AM - While on tour with Facility Plant Operations Manager observed in South Tower 5th Floor near room 504 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a single penetration through the smoke barrier wall above ceiling, a conduit that was not sealed.

At approximately 10:25 AM - While on tour with Facility Plant Operations Manager observed in South Tower 4th Floor behind the Pharmacy upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed of multiple penetrations through the smoke barrier wall above ceiling, that was not sealed.

At approximately 11:24 AM - While on tour with Facility Plant Operations Manager observed in South Tower 2nd Floor near room 2015 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a single penetration through the smoke barrier wall above ceiling, of a hole through the wall was not sealed.

On 11-15-17
At approximately 11:30 AM - While on tour with Facility Plant Operations Manager observed in Emergency room Smoke barrier wall above doors to Triage upon review of the Life safety drawings and inspection of the floors smoke barrier wall, it was observed of multiple penetrations through the smoke barrier wall above ceiling, of conduits and pipes that are not sealed.

At approximately 11:33 AM - While on tour with Facility Plant Operations Manager observed in Smoke Barrier Wall across from S1036 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed multiple penetrations through the smoke barrier wall above ceiling, the wall was not sealed to the deck.

At approximately 11:41 AM - While on tour with Facility Plant Operations Manager observed in Smoke Barrier Wall between S1037 and the main corridor upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed multiple penetrations through the smoke barrier wall above ceiling, the wall was not sealed to the deck above.

At approximately 11:49 AM - While on tour with Facility Plant Operations Manager observed in Smoke Barrier Wall above the smoke barrier doors in the main hall and the corridor doors to fast track upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed a single penetration through the smoke barrier wall above ceiling, of a conduit not sealed.

At approximately 1:22 PM - While on tour with Facility Plant Operations Manager observed in Radiology Office upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed the wall does not comply with smoke barrier construction.

At approximately 1:30 PM - While on tour with Facility Plant Operations Manager observed in X-Ray across from X-Ray "F" upon review of the Life safety drawings and inspection of the floors smoke barrier wall, it was observed the wall does not meet the requirements of smoke barrier construction.

At approximately 1:58 PM - While on tour with Facility Plant Operations Manager observed Smoke Barrier Wall near STAFF ELEVATOR #10 upon review of the Life safety drawings and inspection of the floors smoke barrier wall it was observed the wall was not in compliance with a smoke barrier construction wall requirements. Included the corridor door to to DIAGNOSTIC IMAGING was not compliant with smoke door requirements.

All observations were witnessed and confirmed by the Facility Plant Operation Manager at the time of observation.

Based upon observation, records review and interview, the facility failed to ensure that smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5 as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect ALL occupants in the event of fire and the use of sheltering in place and the use of building seperation to provide life safety.

Findings Include:
On 11-14-17 at approximately 1:15PM: the following observations were made:

At approximately 1:16 PM - While on tour with Facility Plant Operations Manager observed in 2nd Floor Surgery Center near the PHARMACY CLEAN CORRIDOR upon review of the Life safety drawings and inspection of the wall it was observed of multiple penetrations through the smoke barrier wall above ceiling, above the smoke barrier doors that was not fire stopped.

At approximately 1:19 PM - While on tour with Facility Plant Operations Manager observed in 2nd Floor Surgery Center in PRE-OP UNIT CORRIDOR across from COMMUNICATION CLOSET upon review of the life safety drawings and inspection of the wall it was observed above ceiling through the smoke barrier wall of a couple of penetrations through the wall that was not firestopped.

At approximately 1:38 PM - While on tour with Facility Plant Operations Manager observed in 1st Floor Surgery Center near the STAFF LOUNGE upon review of the Life safety drawings and inspection of the wall it was observed above ceiling the Smoke Barrier wall was not finished to the deck.

Observation of all deficiencies were witnessed and confirmed by the Facility Manager of Plant Operations.

Based upon observation and interview, the facility failed to ensure that power receptacles comply with the requirements of 6.3.2.2.6.2(F) and 6.3.2.4.2 of NFPA 99. This deficient practice could affect ALL occupants in the event of electrical fires created by shorts, and failure of the electrical circuit.

Findings Include:

On 11-13-17
At approximately 10:05 AM- While on tour with Facility Plant Operations Manager observed in South Tower 5th Floor Room 504 observed an electrical outlet near the patient bed that was loose in the wall and moved freely in the wall.

At approximately 10:06 AM- While on tour with Facility Plant Operations Manager observed in South Tower 5 th floor Room 504 Observed an emergency electrical plug that had a cracked outlet near the patient bed.

At approximately 10:45 AM - While on tour with Facility Plant Operations Manager observed in West Tower 4th Floor in the corridor near room 486 observed an electrical outlet that was loose in the wall and moved freely.

At approximately 10:46 AM- While on tour with Facility Plant Operations Manager observed in West Tower 4th Floor in the corridor across from Stairwell "A" an electrical outlet that was loose in the wall and moved freely.

On 11-15-17
At approximately 10:34 AM- While on tour with Facility Plant Operations Manager observed in West Tower 1st floor Medical Records observed an overloaded circuit turning a two outlet into a twelve outlet with daisy chained surge protectors.

All observations were observed and confirmed by the Facility Plant Operations Manager at the time of observation.

Based upon observation, records review and interview, the facility failed to ensure that storage of nonflammable gasses meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99. This deficient practice could affect ALL occupants in the event of a fire and the uncontrolled failure of the pressurized vessels becoming high pressured shrapnel.

Findings Include:
On 11-14-17 at approximately 1:58PM: the following observations were made:

At approximatley 1:58 PM- While on tour with Facility Plant Operations Manager observed in Surgery Center 1st Floor Bulk Storage room near receiving observed the storage of 12 x E-Cylinder oxygen tanks in the room with combustible storage. The room was sprinkled however distance and signage was not met.

This was also observed and confirmed by the Facilities Plant Manager.