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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 protect openings through the floor assembly in multiple locations, on four of nine floors of the facility.

Findings include:

1. Observation on May 29, 2012, at 10:11 AM revealed the floor expansion joint, located by the 4th Floor Heart Center Temporary IT Closet, was not properly sealed.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 10:11 AM confirmed the unsealed expansion joint.

2. Observation on May 29, 2012, at 11:05 AM revealed the double doors, separating the Main Hospital Atrium and the East 2nd Floor Heart Center, would not latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 11:05 AM confirmed the doors would not retract.

3. Observation on May 31, 2012, at 10:00 AM revealed that Basement Mechanical Room B24 was open to an eight story shaft and did not meet the following requirements for a two-hour fire rated shaft enclosure:

a) The room had multiple unsealed penetrations along the West wall;
b) The inactive door, to the double doors, along the West wall, lacked a self-closing device;
c) HVAC ductwork penetrated the two-hour fire rated walls in multiple locations and lacked fire dampers with retaining angles, on both sides of the wall.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:00 AM confirmed the shaft termination room did not meet the requirements for a two-hour fire rated enclosure.

4. Observation on May 31, 2012, at 10:15 AM revealed numerous vertical penetrations through the ceiling of Basement Mechanical Room B9.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:15 AM confirmed the unsealed penetrations.

5. Observation on May 31, 2012, at 11:10 AM revealed numerous vertical penetrations throughout the ceiling of the Basement Central Supply Room.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:10 AM confirmed the unsealed penetrations.

6. Observation on May 31, 2012, at 1:20 PM revealed an unsealed vertical pipe penetration through the ceiling, in the corridor, outside of the double doors to the Basement Laundry.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:20 PM confirmed the unsealed penetration.

7. Observation on May 31, 2012, at 1:35 PM revealed the Basement Laundry was open to an eight story shaft and did not meet the following requirements for a two-hour fire rated shaft enclosure:

a) The room had multiple unsealed penetrations;
b) The facility must verify that all HVAC ductwork which penetrate the walls have fire dampers with retaining angles on both sides of the wall;
c) The facility must verify the integrity and construction of the two-hour fire resistance rating of the laundry room.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:35 PM confirmed the shaft termination room did not meet the requirements for a two-hour fire rated enclosure.

8. Observation on May 31, 2012, at 1:57 PM revealed 3 cored holes in the floor assembly above the suspended ceiling in the 1st floor Gift Shop.

Interview with the Head Electrician on May 31, 2012, at 1:57 PM confirmed the unsealed penetrations.

9. Observation on May 31, 2012, at 2:00 PM revealed the Atrium wall, extending from the 1st floor corridor double doors to the exterior wall by the Lobby Cafe, did not meet the requirements for an Atrium separation. Numerous penetrations existed within the wall, numerous drywall seams were not taped or sealed, the door to the backside of the serving line was not rated and lacked latching hardware and the wall, between the Atrium and the Registration Office, consisted only of one layer of drywall above the suspended ceiling.

Interview with the Head Electrician on May 31, 2012, at 2:00 PM confirmed the wall was incomplete.

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 ensure hazardous areas were protected by smoke resistant partitions, with self-closing and positive latching doors in two locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 31, 2012, at 9:30 AM revealed three penetrations of the 2nd floor Storage Room next to the Imaging Services Control Room, around yellow and white wires, black wires and one silver conduit.

Interview with the Engineering Supervisor on May 31, 2012, at 9:30 AM confirmed the unsealed penetrations and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 31, 2012, between 10:20 AM and 11:10 AM, revealed the following corridor double doors to Basement Storage Rooms required a coordinator adjustment, to properly close and latch in the frame:

a) 10:20 AM, IV Storage Room;
b) 11:10 AM, Central Supply Room.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:10 AM confirmed the doors would not properly close and latch.

3. Observation on May 31, 2012, between 11:09 AM and 2:05 PM, revealed unsealed penetrations in the following locations:

a) 11:09 AM, inside two sleeves, through the West wall of the Basement Central Supply Room;
b) 2:05 PM, numerous penetrations, throughout the Basement Receiving Room.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 2:05 PM 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 maintain the proper fire resistance rating of exit component enclosures in three locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 9:55 AM revealed a penetration of the 5th floor Stairtower, next to Patient Room 545.

Interview with the Engineering Supervisor on May 30, 2012, at 9:55 AM confirmed the unsealed penetration and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 31, 2012, at 8:25 AM revealed penetrations around and beneath a junction box, located on the Stairtower by the entrance to the 2nd floor SICU Hallway, as seen from inside the adjacent Storage Closet.

Interview with the Engineering Supervisor on May 31, 2012, at 8:25 AM confirmed the unsealed penetrations and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on May 31, 2012, at 8:43 AM revealed a penetration of the 2nd floor SICU Stairtower, around the sprinkler pipe.

Interview with the Engineering Supervisor on May 30, 2012, at 8:43 AM confirmed the unsealed penetration 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 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, 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 31, 2012, at 9:40 AM revealed that three oxygen vent pipes, from the Basement Hyperbaric Suite, ran through exit Stair I.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 9:40 AM confirmed the oxygen vent pipes, which ran through Stair I, did not serve Stair I.

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

Findings include:

1. Observation on May 31, 2012, at 1:21 PM revealed a projector screen stored in the 1st floor Cafeteria Stairtower.

Interview with the Head Electrician on May 31, 2012, at 1:21 PM confirmed the storage in the Stairtower and the subsequent correction of the deficiency, at the time of the survey.

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 ensure the sprinkler system was properly installed in five locations, on three of nine floors of the facility.

Findings include:

1. Observation on May 29, 2012, at 10:30 AM revealed the 3rd Floor Heart Center Electrical Closet, opposite the elevator, lacked sprinkler coverage.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 10:30 AM confirmed the lack of sprinkler protection.

2. Observation on May 30, 2012, at 8:47 AM revealed the sprinkler pipe branch beginning in the 4th floor Dumbwaiter Room and terminating in the 4th floor Med Room, was not supported by pipe hangers.

Interview with the Engineering Supervisor on May 30, 2012, at 8:47 AM confirmed the sprinkler pipe was not supported.

3. Observation on May 31, 2012, at 11:10 AM revealed the Basement Central Supply Office, within Central Supply, lacked sprinkler coverage.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:10 AM confirmed the lack of sprinkler protection.

4. Observation on May 31, 2012, at 11:30 AM revealed the Basement Engineering Storage Room by Elevator 3, lacked sprinkler coverage.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:30 AM confirmed the lack of sprinkler protection.

5. Observation on May 31, 2012, at 11:35 AM revealed the Basement Communication Closet within the Bed Storage Room lacked sprinkler coverage.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:35 AM confirmed the lack of sprinkler protection.

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 provide an automatic sprinkler system which was continuously maintained in a reliable operating condition in multiple locations, on nine of nine floors of the facility.

Findings include:

1. Observations on May 29, 2012, between 9:47 AM and 9:50 AM, revealed that items were supported by the sprinkler system in the following locations:

a) 9:47 AM, two large fluorescent light fixtures were suspended from the sprinkler pipe, in the Heart Center 4th Floor Penthouse, between Air Handling Unit's (AHU's) 4 and 12;
b) 9:50 AM, a silver MC cable was tied to the sprinkler hangar, in the Heart Center 4th Floor Penthouse, close to the outside wall, between AHU's 3 and 5.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 9:50 AM confirmed the items were supported by the sprinkler system.

2. Observations on May 29, 2012, at the times and locations listed below, revealed the following sprinkler heads lacked an escutcheon:

a) 10:07 AM, 8th floor South Staff Lounge Closet (one head);
b) 10:49 AM, 8th floor Patient Room 838 (one head);
c) 11:03 AM, 8th floor Kitchenette (one head);
d) 11:22 AM, 8th floor Patient Room 823 (one head);
e) 11:23 AM, 8th floor Patient Room 825 (one head).

Interview with the Engineering Supervisor on May 29, 2012, at 11:23 AM confirmed the missing escutcheons and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on May 29, 2012, at 1:59 PM revealed the 7th floor North Hall Patient Room curtains lacked an upper 18 inches of approved mesh.

Interview with the Engineering Supervisor on May 29, 2012, at 1:59 PM confirmed the curtains did not provide enough clearance to allow the sprinkler system to function properly.

4. Observation on May 29, 2012, at 2:31 PM revealed a light fixture within 12 inches of a sprinkler head, which extended below the deflector of the head, in the 6th floor Nurse Manager's Office.

Interview with the Engineering Supervisor on May 29, 2012, at 2:31 PM confirmed the obstructed sprinkler head.

5. Observations on May 30, 2012, at the times and locations listed below, revealed the following items were supported by the sprinkler system:

a) 8:24 AM, fire alarm wires zip-tied to sprinkler pipe brace, between elevators 2 & 3, on the 6th floor;
b) 9:27 AM, ceiling grid wire tied to sprinkler pipe, by 5th floor Center Nurses' Station.

Interview with the Engineering Supervisor on May 30, 2012, at 9:27 AM confirmed the items were supported by the sprinkler system and the subsequent correction of the deficiency, at the time of the survey.

6. Observations on May 30, 2012, at the times and locations listed below, revealed the following sprinkler heads lacked an escutcheon:

a) 8:35 AM, 6th floor South Storage Room (one head);
b) 9:03 AM, 5th floor South Conference Room (two heads);
c) 1:47 PM, 3rd floor Patient Room 311 (one head);
d) 1:52 PM, 3rd floor East Soiled Linen Room (two heads);
e) 1:53 PM, 3rd floor corridor outside of South Hall Conference Room (one head);
f) 2:15 PM, 3rd floor Patient Room 320 (one head);
g) 2:16 PM, 3rd floor Patient Room 326 (one head);
h) 2:17 PM, 3rd floor Patient Room 327 (one head);
i) 2:29 PM, 3rd floor Dumbwaiter Room (one head).

Interview with the Engineering Supervisor on May 30, 2012, at 2:29 PM confirmed the missing escutcheons and the subsequent correction of the deficiency, at the time of the survey.

7. Observations on May 31, 2012, at the times and locations listed below, revealed the following sprinkler heads lacked an escutcheon:

a) 9:05 AM, 2nd floor Mens OR Changing Room (two heads);
b) 9:14 AM, 2nd floor corridor outside of Stairtower "A" (one head);
c) 9:42 AM, 2nd floor Nuclear Medicine Room 3 (one head);
d) 9:51 AM, 2nd floor Lab Conference Room (one head).

Interview with the Engineering Supervisor on May 31, 2012, at 9:51 AM confirmed the missing escutcheons.

8. Observation on May 31, 2012, at 9:56 AM revealed a ceiling grid wire and one gray wire tied to the sprinkler pipe above the suspended ceiling, by Stairtower "F", on the 2nd floor.

Interview with the Engineering Supervisor on May 31, 2012, at 9:56 AM confirmed the items were supported by the sprinkler system and the subsequent correction of the deficiency, at the time of the survey.

9. Observation on May 31, 2012, at 10:20 AM revealed that wires were attached to the sprinkler pipe, running the length of the Basement IV Storage Room wall.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:20 AM confirmed the wires were supported by the sprinkler system.

10. Observations on May 31, 2012, at the times and locations listed below, revealed the following sprinkler heads lacked an escutcheon:

a) 10:20 AM, 2nd floor Toxicology Room within the Processing Room (one head);
b) 10:46 AM, 2nd floor X-Ray File Room (one head);
c) 10:50 AM, 2nd floor X-Ray Control Room Closet (one head);
d) 11:17 AM, 1st floor Counseling/Consultation Room by the Chapel (one head).

Interview with the Head Electrician on May 31, 2012, at 11:17 AM confirmed the missing escutcheons.

11. Observation on May 31, 2012, at 11:10 AM revealed two sprinkler heads in the Basement Central Supply Room were covered with rags.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:10 AM confirmed the obstructed sprinkler heads.

12. Observation on May 31, 2012, at 1:35 PM revealed that storage and racks were within 18 inches of the sprinkler, located in the Basement Clean Linen Storage Room, located within the Laundry.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:35 PM confirmed the obstructed sprinkler heads.

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 maintain portable fire extinguishers, throughout the facility.

Findings include:

1. Documentation review and interview on May 29, 2012, between 8:00 AM and 9:30 AM, revealed the facility lacked documentation verifying each portable fire extinguisher was inspected monthly, throughout the facility.

Interview with the Engineering Supervisor on May 29, 2012, at 9:30 AM confirmed the lack of documentation.

2. Observation on May 30, 2012, at 10:16 AM revealed the fire extinguisher cabinet on the 5th floor, by Patient Room 530, did not contain a fire extinguisher.

Interview with the Engineering Supervisor on May 30, 2012, at 10:16 AM confirmed the missing fire extinguisher 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 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 maintain means of egress free from obstruction in seven locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 30, 2012, between 10:13 AM and 10:22 AM, revealed WALLaroos at the following times and locations, on the 5th floor, did not fully retract into a closed position:

a) 10:13 AM, outside of Patient Room 527;
b) 10:13 AM, outside of Patient Room 528;
c) 10:15 AM, outside of Patient Room 530;
d) 10:15 AM, outside of Patient Room 531;
e) 10:22 AM, outside of Patient Room 508;
f) 10:22 AM, outside of Patient Room 513.

Interview with the Engineering Supervisor on May 30, 2012, at 10:22 AM confirmed the WALLaroos did not retract and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 31, 2012, at 1:16 PM revealed that patient beds were lined up and stored throughout the Basement Heart Center Connecting Corridor.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:16 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 store soiled linen and trash receptacles greater than 32-gallon capacity when left unattended in three locations, on two of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, between 1:45 PM and 2:50 PM, revealed that trash and soiled linen in excess of 32-gallon capacity were stored outside of a protected hazardous storage area, in the following locations:

a) 1:45 PM, four soiled linen bins, exceeding 32-gallon capacity, were stored in the 2nd Floor Gastro Intestinal Services (GIS) alcove, by Endo Procedure Room 2;
b) 2:49 PM, a large trash bin was stored in the small exiting corridor, by the 1st Floor EKG Department;
c) 2:50 PM, a large red biohazard bin and stacks of empty cardboard boxes were stored in the 1st Floor Emergency Room (ER) suite, across from ER Storage.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 2:50 PM confirmed that trash and soiled linen were not properly stored.

Based on observation and interview, the facility failed to properly store mobile soiled linen receptacles greater than 32-gallon capacity when left unattended in four locations, on four of nine floors of the the facility.

Findings include:

1. Observation on May 29, 2012, at 1:31 PM revealed a 95-gallon paper trash receptacle, located in the 7th floor Dumbwaiter Room, across from the Nurses' Station.

Interview with the Engineering Supervisor on May 29, 2012, at 1:31 PM confirmed the oversize receptacle and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 30, 2012, at 10:39 AM revealed a 50-gallon trash receptacle, located in the 4th floor South Hall Staff Lounge.

Interview with the Engineering Supervisor on May 30, 2012, at 10:39 AM confirmed the oversize receptacle and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on May 31, 2012, at 10:46 AM revealed that a blue 95-gallon paper trash receptacle was stored in the Basement corridor, outside of Electrical Room B17.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:46 AM confirmed the receptacle was stored in the corridor, outside of a hazardous storage area.

4. Observation on May 31, 2012, at 1:59 PM revealed a 95-gallon paper trash receptacle, located in the 1st floor Registration Area.

Interview with the Head Electrician on May 31, 2012, at 1:59 PM confirmed the receptacle was oversized.

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.

Based on observation and interview, it was determined the facility failed to maintain electrical equipment, wiring and vault enclosures in eleven locations, on six of nine floors of the facility.

Findings include:

1. Observation on May 29, 2012, at 9:55 AM revealed the corridor double doors to the small Electrical Vault, located in the 4th Floor Heart Center Penthouse, would not properly close and latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 9:55 AM confirmed the doors would not properly close and latch in the frame.

2. Observation on May 29, 2012, at 10:00 AM revealed the following deficiencies to the two-hour fire rated Main Electrical Switchgear Vault, located in the 4th Floor Heart Center Penthouse:

a) the single door to the room required a closure adjustment, to properly close and latch in the frame;
b) the double doors to the room had a broken coordinator, the latches on both doors were stuck and there was a gap greater than 1/8 inch at the meeting edges of the doors;
c) the door and frame to the South air intake room, which is open to the Main Electrical Switchgear Vault, lack fire resistance labels and a door closure.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 10:00 AM confirmed the doors would not properly close and latch in the frame and the missing fire resistance labels on the door and door frame.

3. Observation on May 29, 2012, at 10:16 AM revealed that a coffee machine was plugged into a surge protector in the 8th floor TCU Nurse Manager's Office.

Interview with the Engineering Supervisor on May 29, 2012, at 10:16 AM confirmed the improper use of a surge protector and the subsequent correction of the deficiency, at the time of the survey.

4. Observation on May 30, 2012, at 10:06 AM revealed an unsealed penetration of the two-hour fire rated Electrical Vault, located on the Ground Floor of the Heart Center, around a conduit by exhaust ductwork and the Vault double doors required a closure adjustment, to properly close and latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 10:06 AM confirmed the unsealed penetration and the required closure adjustment.

5. Observation on May 30, 2012, at 1:16 PM revealed a junction box without a cover plate, between elevators 2 and 3, on the 3rd floor.

Interview with the Engineering Supervisor on May 30, 2012, at 1:16 PM confirmed the lack of a cover plate and the subsequent correction of the deficiency, at the time of the survey.

6. Observation on May 31, 2012, at 8:25 AM revealed a junction box without a cover plate, located by the Stairtower, in the entrance to the 2nd floor SICU Hallway.

Interview with the Engineering Supervisor on May 31, 2012, at 8:25 AM confirmed the lack of a cover plate and the subsequent correction of the deficiency, at the time of the survey.

7. Observation on May 31, 2012, at 10:15 AM revealed that numerous electrical junction boxes, within Basement Mechanical Room B9, lacked cover plates.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:15 AM confirmed the lack of a cover plates.

8. Observation on May 31, 2012, at 10:51 AM revealed the following deficiencies to the two-hour fire rated Electrical Vault Room B17, located in the Basement:

a) the corridor double doors to Vault B17 would not properly close and latch;
b) there was an open ended six-inch conduit and unsealed penetrations around conduits on the back wall.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:51 AM confirmed the doors would not properly close and latch and the unsealed penetrations.

9. Observation on May 31, 2012, at 11:15 AM revealed a receptacle multiplier was used supplying power to a coffee pot, water cooler and printer, in the Basement Materials Management Office.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:15 AM confirmed the use of a receptacle multiplier.

10. Observation on May 31, 2012, at 11:45 AM revealed that an extension cord was used for a large refrigerator, in the Basement Therapy Services Staff Work Area.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:45 AM confirmed the use of the extension cord.

11. Observation on May 31, 2012, at 1:57 PM revealed two junction boxes without cover plates in the 1st floor Gift Shop, between the cashier desk and the flower refrigerator.

Interview with the Head Electrician on May 31, 2012, at 1:57 PM confirmed the lack of cover plates.

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 protect openings through the floor assembly in multiple locations, on four of nine floors of the facility.

Findings include:

1. Observation on May 29, 2012, at 10:11 AM revealed the floor expansion joint, located by the 4th Floor Heart Center Temporary IT Closet, was not properly sealed.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 10:11 AM confirmed the unsealed expansion joint.

2. Observation on May 29, 2012, at 11:05 AM revealed the double doors, separating the Main Hospital Atrium and the East 2nd Floor Heart Center, would not latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 11:05 AM confirmed the doors would not retract.

3. Observation on May 31, 2012, at 10:00 AM revealed that Basement Mechanical Room B24 was open to an eight story shaft and did not meet the following requirements for a two-hour fire rated shaft enclosure:

a) The room had multiple unsealed penetrations along the West wall;
b) The inactive door, to the double doors, along the West wall, lacked a self-closing device;
c) HVAC ductwork penetrated the two-hour fire rated walls in multiple locations and lacked fire dampers with retaining angles, on both sides of the wall.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:00 AM confirmed the shaft termination room did not meet the requirements for a two-hour fire rated enclosure.

4. Observation on May 31, 2012, at 10:15 AM revealed numerous vertical penetrations through the ceiling of Basement Mechanical Room B9.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:15 AM confirmed the unsealed penetrations.

5. Observation on May 31, 2012, at 11:10 AM revealed numerous vertical penetrations throughout the ceiling of the Basement Central Supply Room.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:10 AM confirmed the unsealed penetrations.

6. Observation on May 31, 2012, at 1:20 PM revealed an unsealed vertical pipe penetration through the ceiling, in the corridor, outside of the double doors to the Basement Laundry.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:20 PM confirmed the unsealed penetration.

7. Observation on May 31, 2012, at 1:35 PM revealed the Basement Laundry was open to an eight story shaft and did not meet the following requirements for a two-hour fire rated shaft enclosure:

a) The room had multiple unsealed penetrations;
b) The facility must verify that all HVAC ductwork which penetrate the walls have fire dampers with retaining angles on both sides of the wall;
c) The facility must verify the integrity and construction of the two-hour fire resistance rating of the laundry room.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:35 PM confirmed the shaft termination room did not meet the requirements for a two-hour fire rated enclosure.

8. Observation on May 31, 2012, at 1:57 PM revealed 3 cored holes in the floor assembly above the suspended ceiling in the 1st floor Gift Shop.

Interview with the Head Electrician on May 31, 2012, at 1:57 PM confirmed the unsealed penetrations.

9. Observation on May 31, 2012, at 2:00 PM revealed the Atrium wall, extending from the 1st floor corridor double doors to the exterior wall by the Lobby Cafe, did not meet the requirements for an Atrium separation. Numerous penetrations existed within the wall, numerous drywall seams were not taped or sealed, the door to the backside of the serving line was not rated and lacked latching hardware and the wall, between the Atrium and the Registration Office, consisted only of one layer of drywall above the suspended ceiling.

Interview with the Head Electrician on May 31, 2012, at 2:00 PM confirmed the wall was incomplete.

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 ensure hazardous areas were protected by smoke resistant partitions, with self-closing and positive latching doors in two locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 31, 2012, at 9:30 AM revealed three penetrations of the 2nd floor Storage Room next to the Imaging Services Control Room, around yellow and white wires, black wires and one silver conduit.

Interview with the Engineering Supervisor on May 31, 2012, at 9:30 AM confirmed the unsealed penetrations and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 31, 2012, between 10:20 AM and 11:10 AM, revealed the following corridor double doors to Basement Storage Rooms required a coordinator adjustment, to properly close and latch in the frame:

a) 10:20 AM, IV Storage Room;
b) 11:10 AM, Central Supply Room.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:10 AM confirmed the doors would not properly close and latch.

3. Observation on May 31, 2012, between 11:09 AM and 2:05 PM, revealed unsealed penetrations in the following locations:

a) 11:09 AM, inside two sleeves, through the West wall of the Basement Central Supply Room;
b) 2:05 PM, numerous penetrations, throughout the Basement Receiving Room.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 2:05 PM 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 maintain the proper fire resistance rating of exit component enclosures in three locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 30, 2012, at 9:55 AM revealed a penetration of the 5th floor Stairtower, next to Patient Room 545.

Interview with the Engineering Supervisor on May 30, 2012, at 9:55 AM confirmed the unsealed penetration and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 31, 2012, at 8:25 AM revealed penetrations around and beneath a junction box, located on the Stairtower by the entrance to the 2nd floor SICU Hallway, as seen from inside the adjacent Storage Closet.

Interview with the Engineering Supervisor on May 31, 2012, at 8:25 AM confirmed the unsealed penetrations and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on May 31, 2012, at 8:43 AM revealed a penetration of the 2nd floor SICU Stairtower, around the sprinkler pipe.

Interview with the Engineering Supervisor on May 30, 2012, at 8:43 AM confirmed the unsealed penetration 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 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, 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 31, 2012, at 9:40 AM revealed that three oxygen vent pipes, from the Basement Hyperbaric Suite, ran through exit Stair I.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 9:40 AM confirmed the oxygen vent pipes, which ran through Stair I, did not serve Stair I.

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

Findings include:

1. Observation on May 31, 2012, at 1:21 PM revealed a projector screen stored in the 1st floor Cafeteria Stairtower.

Interview with the Head Electrician on May 31, 2012, at 1:21 PM confirmed the storage in the Stairtower and the subsequent correction of the deficiency, at the time of the survey.

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 ensure the sprinkler system was properly installed in five locations, on three of nine floors of the facility.

Findings include:

1. Observation on May 29, 2012, at 10:30 AM revealed the 3rd Floor Heart Center Electrical Closet, opposite the elevator, lacked sprinkler coverage.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 10:30 AM confirmed the lack of sprinkler protection.

2. Observation on May 30, 2012, at 8:47 AM revealed the sprinkler pipe branch beginning in the 4th floor Dumbwaiter Room and terminating in the 4th floor Med Room, was not supported by pipe hangers.

Interview with the Engineering Supervisor on May 30, 2012, at 8:47 AM confirmed the sprinkler pipe was not supported.

3. Observation on May 31, 2012, at 11:10 AM revealed the Basement Central Supply Office, within Central Supply, lacked sprinkler coverage.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:10 AM confirmed the lack of sprinkler protection.

4. Observation on May 31, 2012, at 11:30 AM revealed the Basement Engineering Storage Room by Elevator 3, lacked sprinkler coverage.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:30 AM confirmed the lack of sprinkler protection.

5. Observation on May 31, 2012, at 11:35 AM revealed the Basement Communication Closet within the Bed Storage Room lacked sprinkler coverage.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:35 AM confirmed the lack of sprinkler protection.

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 provide an automatic sprinkler system which was continuously maintained in a reliable operating condition in multiple locations, on nine of nine floors of the facility.

Findings include:

1. Observations on May 29, 2012, between 9:47 AM and 9:50 AM, revealed that items were supported by the sprinkler system in the following locations:

a) 9:47 AM, two large fluorescent light fixtures were suspended from the sprinkler pipe, in the Heart Center 4th Floor Penthouse, between Air Handling Unit's (AHU's) 4 and 12;
b) 9:50 AM, a silver MC cable was tied to the sprinkler hangar, in the Heart Center 4th Floor Penthouse, close to the outside wall, between AHU's 3 and 5.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 9:50 AM confirmed the items were supported by the sprinkler system.

2. Observations on May 29, 2012, at the times and locations listed below, revealed the following sprinkler heads lacked an escutcheon:

a) 10:07 AM, 8th floor South Staff Lounge Closet (one head);
b) 10:49 AM, 8th floor Patient Room 838 (one head);
c) 11:03 AM, 8th floor Kitchenette (one head);
d) 11:22 AM, 8th floor Patient Room 823 (one head);
e) 11:23 AM, 8th floor Patient Room 825 (one head).

Interview with the Engineering Supervisor on May 29, 2012, at 11:23 AM confirmed the missing escutcheons and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on May 29, 2012, at 1:59 PM revealed the 7th floor North Hall Patient Room curtains lacked an upper 18 inches of approved mesh.

Interview with the Engineering Supervisor on May 29, 2012, at 1:59 PM confirmed the curtains did not provide enough clearance to allow the sprinkler system to function properly.

4. Observation on May 29, 2012, at 2:31 PM revealed a light fixture within 12 inches of a sprinkler head, which extended below the deflector of the head, in the 6th floor Nurse Manager's Office.

Interview with the Engineering Supervisor on May 29, 2012, at 2:31 PM confirmed the obstructed sprinkler head.

5. Observations on May 30, 2012, at the times and locations listed below, revealed the following items were supported by the sprinkler system:

a) 8:24 AM, fire alarm wires zip-tied to sprinkler pipe brace, between elevators 2 & 3, on the 6th floor;
b) 9:27 AM, ceiling grid wire tied to sprinkler pipe, by 5th floor Center Nurses' Station.

Interview with the Engineering Supervisor on May 30, 2012, at 9:27 AM confirmed the items were supported by the sprinkler system and the subsequent correction of the deficiency, at the time of the survey.

6. Observations on May 30, 2012, at the times and locations listed below, revealed the following sprinkler heads lacked an escutcheon:

a) 8:35 AM, 6th floor South Storage Room (one head);
b) 9:03 AM, 5th floor South Conference Room (two heads);
c) 1:47 PM, 3rd floor Patient Room 311 (one head);
d) 1:52 PM, 3rd floor East Soiled Linen Room (two heads);
e) 1:53 PM, 3rd floor corridor outside of South Hall Conference Room (one head);
f) 2:15 PM, 3rd floor Patient Room 320 (one head);
g) 2:16 PM, 3rd floor Patient Room 326 (one head);
h) 2:17 PM, 3rd floor Patient Room 327 (one head);
i) 2:29 PM, 3rd floor Dumbwaiter Room (one head).

Interview with the Engineering Supervisor on May 30, 2012, at 2:29 PM confirmed the missing escutcheons and the subsequent correction of the deficiency, at the time of the survey.

7. Observations on May 31, 2012, at the times and locations listed below, revealed the following sprinkler heads lacked an escutcheon:

a) 9:05 AM, 2nd floor Mens OR Changing Room (two heads);
b) 9:14 AM, 2nd floor corridor outside of Stairtower "A" (one head);
c) 9:42 AM, 2nd floor Nuclear Medicine Room 3 (one head);
d) 9:51 AM, 2nd floor Lab Conference Room (one head).

Interview with the Engineering Supervisor on May 31, 2012, at 9:51 AM confirmed the missing escutcheons.

8. Observation on May 31, 2012, at 9:56 AM revealed a ceiling grid wire and one gray wire tied to the sprinkler pipe above the suspended ceiling, by Stairtower "F", on the 2nd floor.

Interview with the Engineering Supervisor on May 31, 2012, at 9:56 AM confirmed the items were supported by the sprinkler system and the subsequent correction of the deficiency, at the time of the survey.

9. Observation on May 31, 2012, at 10:20 AM revealed that wires were attached to the sprinkler pipe, running the length of the Basement IV Storage Room wall.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:20 AM confirmed the wires were supported by the sprinkler system.

10. Observations on May 31, 2012, at the times and locations listed below, revealed the following sprinkler heads lacked an escutcheon:

a) 10:20 AM, 2nd floor Toxicology Room within the Processing Room (one head);
b) 10:46 AM, 2nd floor X-Ray File Room (one head);
c) 10:50 AM, 2nd floor X-Ray Control Room Closet (one head);
d) 11:17 AM, 1st floor Counseling/Consultation Room by the Chapel (one head).

Interview with the Head Electrician on May 31, 2012, at 11:17 AM confirmed the missing escutcheons.

11. Observation on May 31, 2012, at 11:10 AM revealed two sprinkler heads in the Basement Central Supply Room were covered with rags.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:10 AM confirmed the obstructed sprinkler heads.

12. Observation on May 31, 2012, at 1:35 PM revealed that storage and racks were within 18 inches of the sprinkler, located in the Basement Clean Linen Storage Room, located within the Laundry.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:35 PM confirmed the obstructed sprinkler heads.

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 maintain portable fire extinguishers, throughout the facility.

Findings include:

1. Documentation review and interview on May 29, 2012, between 8:00 AM and 9:30 AM, revealed the facility lacked documentation verifying each portable fire extinguisher was inspected monthly, throughout the facility.

Interview with the Engineering Supervisor on May 29, 2012, at 9:30 AM confirmed the lack of documentation.

2. Observation on May 30, 2012, at 10:16 AM revealed the fire extinguisher cabinet on the 5th floor, by Patient Room 530, did not contain a fire extinguisher.

Interview with the Engineering Supervisor on May 30, 2012, at 10:16 AM confirmed the missing fire extinguisher 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 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 maintain means of egress free from obstruction in seven locations, on two of nine floors of the facility.

Findings include:

1. Observation on May 30, 2012, between 10:13 AM and 10:22 AM, revealed WALLaroos at the following times and locations, on the 5th floor, did not fully retract into a closed position:

a) 10:13 AM, outside of Patient Room 527;
b) 10:13 AM, outside of Patient Room 528;
c) 10:15 AM, outside of Patient Room 530;
d) 10:15 AM, outside of Patient Room 531;
e) 10:22 AM, outside of Patient Room 508;
f) 10:22 AM, outside of Patient Room 513.

Interview with the Engineering Supervisor on May 30, 2012, at 10:22 AM confirmed the WALLaroos did not retract and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 31, 2012, at 1:16 PM revealed that patient beds were lined up and stored throughout the Basement Heart Center Connecting Corridor.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 1:16 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 store soiled linen and trash receptacles greater than 32-gallon capacity when left unattended in three locations, on two of three floors of the facility.

Findings include:

1. Observation on May 30, 2012, between 1:45 PM and 2:50 PM, revealed that trash and soiled linen in excess of 32-gallon capacity were stored outside of a protected hazardous storage area, in the following locations:

a) 1:45 PM, four soiled linen bins, exceeding 32-gallon capacity, were stored in the 2nd Floor Gastro Intestinal Services (GIS) alcove, by Endo Procedure Room 2;
b) 2:49 PM, a large trash bin was stored in the small exiting corridor, by the 1st Floor EKG Department;
c) 2:50 PM, a large red biohazard bin and stacks of empty cardboard boxes were stored in the 1st Floor Emergency Room (ER) suite, across from ER Storage.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 2:50 PM confirmed that trash and soiled linen were not properly stored.

Based on observation and interview, the facility failed to properly store mobile soiled linen receptacles greater than 32-gallon capacity when left unattended in four locations, on four of nine floors of the the facility.

Findings include:

1. Observation on May 29, 2012, at 1:31 PM revealed a 95-gallon paper trash receptacle, located in the 7th floor Dumbwaiter Room, across from the Nurses' Station.

Interview with the Engineering Supervisor on May 29, 2012, at 1:31 PM confirmed the oversize receptacle and the subsequent correction of the deficiency, at the time of the survey.

2. Observation on May 30, 2012, at 10:39 AM revealed a 50-gallon trash receptacle, located in the 4th floor South Hall Staff Lounge.

Interview with the Engineering Supervisor on May 30, 2012, at 10:39 AM confirmed the oversize receptacle and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on May 31, 2012, at 10:46 AM revealed that a blue 95-gallon paper trash receptacle was stored in the Basement corridor, outside of Electrical Room B17.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:46 AM confirmed the receptacle was stored in the corridor, outside of a hazardous storage area.

4. Observation on May 31, 2012, at 1:59 PM revealed a 95-gallon paper trash receptacle, located in the 1st floor Registration Area.

Interview with the Head Electrician on May 31, 2012, at 1:59 PM confirmed the receptacle was oversized.

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.

Based on observation and interview, it was determined the facility failed to maintain electrical equipment, wiring and vault enclosures in eleven locations, on six of nine floors of the facility.

Findings include:

1. Observation on May 29, 2012, at 9:55 AM revealed the corridor double doors to the small Electrical Vault, located in the 4th Floor Heart Center Penthouse, would not properly close and latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 9:55 AM confirmed the doors would not properly close and latch in the frame.

2. Observation on May 29, 2012, at 10:00 AM revealed the following deficiencies to the two-hour fire rated Main Electrical Switchgear Vault, located in the 4th Floor Heart Center Penthouse:

a) the single door to the room required a closure adjustment, to properly close and latch in the frame;
b) the double doors to the room had a broken coordinator, the latches on both doors were stuck and there was a gap greater than 1/8 inch at the meeting edges of the doors;
c) the door and frame to the South air intake room, which is open to the Main Electrical Switchgear Vault, lack fire resistance labels and a door closure.

Interview with the Safety and Emergency Management Coordinator on May 29, 2012, at 10:00 AM confirmed the doors would not properly close and latch in the frame and the missing fire resistance labels on the door and door frame.

3. Observation on May 29, 2012, at 10:16 AM revealed that a coffee machine was plugged into a surge protector in the 8th floor TCU Nurse Manager's Office.

Interview with the Engineering Supervisor on May 29, 2012, at 10:16 AM confirmed the improper use of a surge protector and the subsequent correction of the deficiency, at the time of the survey.

4. Observation on May 30, 2012, at 10:06 AM revealed an unsealed penetration of the two-hour fire rated Electrical Vault, located on the Ground Floor of the Heart Center, around a conduit by exhaust ductwork and the Vault double doors required a closure adjustment, to properly close and latch in the frame.

Interview with the Safety and Emergency Management Coordinator on May 30, 2012, at 10:06 AM confirmed the unsealed penetration and the required closure adjustment.

5. Observation on May 30, 2012, at 1:16 PM revealed a junction box without a cover plate, between elevators 2 and 3, on the 3rd floor.

Interview with the Engineering Supervisor on May 30, 2012, at 1:16 PM confirmed the lack of a cover plate and the subsequent correction of the deficiency, at the time of the survey.

6. Observation on May 31, 2012, at 8:25 AM revealed a junction box without a cover plate, located by the Stairtower, in the entrance to the 2nd floor SICU Hallway.

Interview with the Engineering Supervisor on May 31, 2012, at 8:25 AM confirmed the lack of a cover plate and the subsequent correction of the deficiency, at the time of the survey.

7. Observation on May 31, 2012, at 10:15 AM revealed that numerous electrical junction boxes, within Basement Mechanical Room B9, lacked cover plates.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:15 AM confirmed the lack of a cover plates.

8. Observation on May 31, 2012, at 10:51 AM revealed the following deficiencies to the two-hour fire rated Electrical Vault Room B17, located in the Basement:

a) the corridor double doors to Vault B17 would not properly close and latch;
b) there was an open ended six-inch conduit and unsealed penetrations around conduits on the back wall.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 10:51 AM confirmed the doors would not properly close and latch and the unsealed penetrations.

9. Observation on May 31, 2012, at 11:15 AM revealed a receptacle multiplier was used supplying power to a coffee pot, water cooler and printer, in the Basement Materials Management Office.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:15 AM confirmed the use of a receptacle multiplier.

10. Observation on May 31, 2012, at 11:45 AM revealed that an extension cord was used for a large refrigerator, in the Basement Therapy Services Staff Work Area.

Interview with the Safety and Emergency Management Coordinator on May 31, 2012, at 11:45 AM confirmed the use of the extension cord.

11. Observation on May 31, 2012, at 1:57 PM revealed two junction boxes without cover plates in the 1st floor Gift Shop, between the cashier desk and the flower refrigerator.

Interview with the Head Electrician on May 31, 2012, at 1:57 PM confirmed the lack of cover plates.