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Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of common walls and communicating door openings in nine locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 2:20 PM revealed an unsealed penetration around a pneumatic tube, located above the 1st Floor corridor double doors, separating the Main Building and the ER/OPS Building, across from Elevator 15, on both sides of the wall.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 2:20 PM confirmed the unsealed penetration.

2. Observation on May 30, 2012, between 2:14 PM and 2:45 PM, revealed the following communicating door openings in the two-hour fire rated building separation, required an adjustment to properly close and latch in the frame:

a) 2:14 PM, the single door, leading to the 1st Floor Emergency Room Waiting Area vending machines and restrooms, would not properly close and latch;
b) 2:20 PM, the corridor double doors, across from 1st Floor Elevator 15, required a latch adjustment;
c) 2:39 PM, the single door, leading to the 1st Floor Employee Health Department, would not properly close and latch;
d) 2:45 PM, the corridor double doors, at the rear Emergency Room Hallway outside of the EKG Department, would not properly close and latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 2:45 PM confirmed the doors required an adjustment.

3. Observation on May 31, 2012, at 11:06 AM revealed a penetration, around a green MC cable above the door to the Convent by the Lounge, on the 1st floor.

Interview with the Head Electrician on May 31, 2012, at 11:06 AM confirmed the unsealed penetration and the subsequent correction of the deficiency, at the time of the survey.

4. Observation on May 31, 2012, at 1:15 PM revealed unsealed penetrations, around various conduits and piping above the suspended ceiling in the Basement Electrical Room, by Rehab Services Management Office.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:15 PM confirmed the unsealed penetrations.

5. Observation on May 31, 2012, at 1:18 PM revealed the Basement cross-corridor double doors, separating the Main Building from the Education Building, would not latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:18 PM confirmed the doors would not latch.

6. Observation on May 31, 2012, at 2:18 PM revealed the Basement Tunnel cross-corridor double doors, separating the Main Building from the Powerhouse, would not properly close and latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 2:18 PM confirmed the doors would not properly close and latch.

Based on observation and interview, it was determined the facility failed to maintain latching hardware for corridor doors in three locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 31, 2012, at 10:15 AM revealed the door to the 2nd floor Lab Office, across from the Processing Room, required a latching adjustment, to properly close and latch in the frame.

Interview with the Head Electrician on May 31, 2012, at 10:15 AM confirmed the door would not latch and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 31, 2012, at 10:15 AM revealed the double doors, to Basement Mechanical Room B9, required a coordinator and latching adjustment, to properly close and latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:15 AM confirmed the door would not properly close and latch in the frame.

3. Observation on May 31, 2012, at 10:18 AM revealed the door, to the 2nd floor Processing Room, required a latching adjustment, to properly close and latch in the frame.

Interview with the Head Electrician on May 31, 2012, at 10:18 AM confirmed the door would not latch and the subsequent correction of the deficiency, at the time of the survey.

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating for one shaft, on one of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 10:59 AM revealed the access panel to the Ground Floor duct and pipe chase, located in the serving area, lacked a fire resistance rating and was not self-closing.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 10:59 AM confirmed the access panel lacked a fire resistance rating and the panel was not self-closing.

Based on observation and interview, it was determined the facility failed to clearly identify access to exits by readily visible signs in one location, on one of nine floors of the facility.

Findings include:

1. Observation on May 31, 2012, at 9:15 AM revealed the exit sign, at the entrance to the 2nd floor SICU Hallway, contained a lit chevron directing egress in the wrong direction.

Interview with the Engineering Supervisor on May 31, 2012, at 9:15 AM confirmed the incorrect chevron and the subsequent correction of the deficiency, at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in eight locations, on three of nine floors of the facility.

Findings include:

1. Observation on May 29, 2012, at 11:10 AM revealed the smoke barrier wall, separating the atrium and the 2nd Floor West Heart Center, located above the corridor double doors, was not complete to the column at the exterior wall and not properly sealed at the deck over to the I-beam.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 11:10 AM confirmed the wall was not complete.

2. Observation on May 29, 2012, at 11:35 AM revealed the wall, in the 2nd floor Men's Locker Room, was not sealed at the deck or around an I beam and joints behind the I beam were not taped and sealed.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 11:35 AM confirmed the unsealed penetrations.

3. Observation on May 30, 2012, at 9:08 AM revealed a penetration around and inside a black cast iron pipe along the corridor wall, across from the 1st floor Cath Lab Staff Lounge, in the Heart Center.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 9:08 AM confirmed the unsealed penetration.

4. Observation on May 30, 2012, at 9:15 AM revealed a penetration around a sprinkler pipe on both sides of the corridor wall of the 1st floor Cath Lab 3 Room, across from the EP Storage 2 CRM Products Room, in the Heart Center.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 9:15 AM confirmed the unsealed penetration.

5. Observation on May 30, 2012, at 9:35 AM revealed penetrations above the 2nd floor cross corridor double doors around a black wire and an approximately 1/2 inch penetration outside Cath Lab 1, on the Equipment 1 side, in the Heart Center.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 9:35 AM confirmed the unsealed penetrations.

6. Observation on May 30, 2012, at 9:40 AM revealed a penetration of the 1st floor Equipment 1 Cath Lab around red and blue cables for a Coolix 2200A machine, at floor level, in the Heart Center.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 9:40 AM confirmed the unsealed penetration.

7. Observation on May 30, 2012, at 11:20 AM revealed a penetration by the 4th floor North Hall Soiled Linen Room around gray wires.

Interview with the Engineering Supervisor on May 30, 2012, at 11:20 AM confirmed the unsealed penetration and the subsequent correction of the deficiency, at the time of the survey.

8. Observation on May 30, 2012, at 2:04 PM revealed penetrations around the medical air line and around a group of yellow and blue wires within the 3rd floor North Hall Clean Utility Room.

Interview with the Engineering Supervisor on May 30, 2012, at 2:04 PM confirmed the unsealed penetrations and the subsequent correction of the deficiency, at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier door openings in one location, on one of nine floors of the facility.

Findings include:

1. Observation on May 29, 2012, at 1:32 PM revealed the double doors at the Atrium, by the Heart Center 1st floor Electrical Data Closet, would not properly close and latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 1:32 PM confirmed the doors were obstructed from closing by the brushguard.

Based on observation and interview, it was determined the facility failed to maintain one-hour fire rated construction for hazardous areas in one location, on one of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 11:20 AM revealed numerous unsealed penetrations in the Basement Ceramic Room/Personal Storage.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 11:20 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of exit components to provide a continuous path of escape in three locations, on one of three floors.
Findings include:

1. Observation on May 31, 2012, between 8:23 AM and 8:49 AM, revealed the following unsealed penetrations of the Basement protected passageway for Stair's H and G:

a) 8:23 AM, the drywall was not sealed to the deck and drywall joints were not sealed or taped behind the I beam, located above the single door, leading the the Hyperbaric Suite;
b) 8:30 AM, around an I beam and an expansion joint, approximately halfway down the corridor, between the Mechanical Room and the Security Corridor doorway;
c) 8:49 AM, around the topside of a group of conduits and the wall was not properly sealed at the corrugated deck, located above the Mechanical Room doorway, on the corridor side.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 8:49 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to ensure that stairways used as exits, were not used for any purpose that has the potential to interfere with egress in one location, on one of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 11:24 AM revealed that a full trash bag was stored in the 1st Floor Stair Landing, of Stair BB.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 11:24 AM confirmed that trash was stored in the exiting stair-tower.

Based on observation and interview, the facility failed to ensure that exit signs were displayed with continuous illumination and that doors, that are neither an exit nor a way of exit access, which could be mistaken for an exit, are clearly marked with appropriate signage in three locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 29, 2012, at 1:40 PM revealed the single door to the Courtyard outside of the Atrium in the connecting corridor, between the Education Building and the Heart Center, lacked signage indicating it is not an exit door.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 1:40 PM confirmed the lack of signage.

2. Observation on May 30, 2012, at 1:32 PM revealed the exit sign in the 3rd floor Storage Room, by the medical gas shut off valves, was not lit.

Interview with the Engineering Supervisor on May 30, 2012, at 1:32 PM confirmed the sign was not lit and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on May 31, 2012, at 1:30 PM revealed two Courtyard doors, on either side of the 1st floor Receptionist Desk, lack signage indicating they are not exit doors.

Interview with the Head Electrician on May 31, 2012, at 1:30 PM confirmed the doors lacked signage.

Based on observation and interview, it was determined the facility failed to ensure the sprinkler system provided complete coverage in one location, on one of three floors of the facility.

Findings include:

1. Observation on May 31, 2012, at 9:15 AM revealed the Basement Mechanical Room lacked sprinkler coverage under HVAC ductwork (approximately 5 feet in width), between the large air handler and the Safety corridor wall.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 9:15 AM confirmed the lack of sprinkler coverage.

Based on observation and interview, it was determined the facility failed to maintain unobstructed sprinkler coverage in one location, on one of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 2:41 PM revealed storage within 18 inches of the sprinkler head in the 1st Floor ER Suite closet, outside of Exam Room 29.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 2:41 PM confirmed obstructed sprinkler coverage.

Based on observation and interview, it was determined the facility failed to maintain clear and unobstructed access to portable fire extinguishers in one location, on one of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 2:51 PM revealed that a mobile soiled linen bin was stored directly in-front of the fire extinguisher cabinet, outside of the Emergency Department Clean Linen Room.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 2:51 PM confirmed the fire extinguisher was obstructed.

Based on observation and interview, it was determined the facility failed to properly install Heating, Ventilating, and Air Conditioning (HVAC) system ductwork through fire-rated walls in numerous locations, on one of nine floors.

Findings include:

1. Observation on May 30, 2012, between 1:22 PM and 1:32 PM, revealed that HVAC ductwork throughout the 2nd Floor combination two-hour fire rated building separation and smoke barrier wall, between the Main Hospital (Component 01) and the ER/OPS Building (Component 23), lacked fire dampers and retaining angles.

Interview with the Safety and Emergency Management Coordinator May 30, 2012, at 1:32 PM confirmed the missing fire dampers and retaining angles.

Based on observation and interview, it was determined the facility failed to properly maintain linen and trash chutes in three locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 10:31 AM revealed the Rubbish Chute, in the 5th floor East Hall Janitor Closet, would not retract and latch into the frame.

Interview with the Engineering Supervisor on May 30, 2012, at 10:31 AM confirmed the door would not retract and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 31, 2012, between 1:30 PM and 2:00 PM, revealed the soiled linen and rubbish chute discharge rooms were not maintained in the following locations:

a) 1:30 PM, around two conduits in the Basement corridor, outside of the rubbish chute discharge room, on the left side of the door;
b) 1:35 PM, the door to the soiled linen chute discharge room was propped open with a wooden brush;
c) 2:00 PM, there were unsealed penetrations to the rubbish chute discharge room, along the shared laundry chemical storage room wall.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 2:00 PM confirmed the soiled linen and rubbish chute discharge room deficiencies.

Based on observation and interview, it was determined the facility failed to maintain means of egress free from obstructions in one location, on one of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 1:40 PM revealed that OR 9 and 10 connecting corridor, located on the 2nd Floor, had storage throughout.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 1:40 PM confirmed the corridor obstructions.

Based on observation and interview, it was determined the facility failed to properly store soiled linen and trash receptacles greater than 32-gallon capacity when left unattended in four locations, on two of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, between 10:50 AM and 11:30 AM, revealed that trash and soiled linen, in excess of 32-gallon capacity, was stored outside of a protected hazardous storage area, in the following locations:

a) 10:50 AM, a 95-gallon blue paper recycle bin was stored in the Ground Floor corridor, outside of Acute Care Services Social Work and Therapy Office;
b) 11:05 AM, numerous filled trash bags were stored in the Ground Floor Waiting Room Telephone Alcove;
c) 11:26 AM, three soiled laundry bins were stored together, exceeding 32-gallon capacity, outside of the 1st Floor Men's and Women's Restroom, in the Sunset Room;
d) 11:30 AM, three soiled laundry bins were stored together, exceeding 32-gallon capacity, outside of Room 131.1, in the Sunrise Room.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 11:30 AM confirmed that trash and soiled linen were not properly stored.

Based on observation and interview, it was determined the facility failed to properly maintain medical gas storage areas in one location, on one of nine floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 9:30 AM revealed a metal cylinder rack containing 8 oxygen cylinders, was stored in the 5th floor Clean Linen Room, which did not meet the requirements for oxygen storage.

Interview with the Engineering Supervisor on May 30, 2012, at 9:30 AM confirmed the improper storage of oxygen and the subsequent correction of the deficiency, at the time of the survey.

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

Findings include:

1. Observation on May 31, 2012, at 11:35 AM revealed the medical gas lines, located in the Communication Closet, within the the Basement Bed Storage room, were not labeled.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:35 AM confirmed the missing labels.

2. Observation on May 31, 2012, at 1:20 PM revealed that small steel metal tubes were hanging off the medical gas lines, in the Basement corridor, outside of the Laundry double doors.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:20 PM confirmed that dissimilar metal was in direct contact with the medical gas piping.

3. Observation on May 31, 2012, at 2:10 PM revealed the oxygen pipe labeling, located throughout the Basement Receiving Room, was not color coded properly. The piping had yellow labels indicating oxygen.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 2:10 PM confirmed the inaccurate labels.

Based on observation and interview, it was determined the facility failed to maintain the proper use of surge protectors and temporary wiring in three locations, on one of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, between 10:54 AM and 11:03 AM, revealed that electrical wiring was not properly used, in the following locations:

a) 10:54 AM, two surge protectors were connected together (daisy-chained) at the back office cubical, located in the Ground Floor Acute Care Services Office;
b) 11:00 AM, an extension cord was used for a copier machine, in the Ground Floor Medical Records Suite, at the front reception desk;
c) 11:03 AM, an extension cord and surge protector were daisy-chained at the front office cubical, located in the Ground Floor Medical Records Suite.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 11:03 AM confirmed the improper use of a surge protectors and extension cords.