HospitalInspections.org

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. COMPLETE

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: COMPLETE

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. COMPLETE

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. COMPLETE

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. COMPLETE

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.


*** Observation on October 2, 2012, at 9:15 AM items 1. through 5. COMPLETED, the double doors under item 6. would not properly close and latch in the frame.

Interview with the Director of Engineering on October 2, 2012, at 9:15 AM confirmed the doors would not properly close and latch.***

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. COMPLETED

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. COMPLETED

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: COMPLETED

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. COMPLETED

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. COMPLETED

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. COMPLETED

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. COMPLETED

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.


*** Observation on October 2, 2012, 10:45 AM confirmed items 1, 2, 3, 4, 5, 6, 8, above were COMPLETED. Item 7. the Basement Laundry open to an eight story shaft, was not completed. Item 9. Atrium wall did not have a plan of corection entered.

Interview with the Director of Engineering on October 2, 2012, at 10:45 AM confirmed that Items 7. and 9. are still not corrected.***

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.


*** Observation on October 2, 2012, 10:40 AM soiled linen bin was still stored directly in front of the fire extinguisher cabinet.

Interview with the Director of Engineering on October 2, 2012, at 10:40 AM confirmed the
obstruction of the fire extinguisher cabinet.***

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.


*** Observation on October 2, 2012, 11:10 AM OR 9 and 10 connecting corridor, still has storage throughout.

Interview with the Engineering Supervisor on October 2, 2012, at 11:10 AM confirmed the corridor's storage.***

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. COMPLETED

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. COMPLETED

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.

*** Observation on October 2, 2012, 10:45 AM confirmed items 1. and 3. were COMPLETED. The 50-gallon trash receptacle under item 2. is still located in the 4th floor South Hall Staff Lounge. The 95-gallon paper trash receptacle under item 4, is still located in the 1st floor Registration Area.

Interview with the Director of Engineering on October 2, 2012, at 10:45 AM confirmed that Items 2 and 4 are still not corrected.***

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. COMPLETED

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; COMPLETED
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. COMPLETED

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. COMPLETED

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. COMPLETED

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. COMPLETED

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: COMPLETED

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. COMPLETED

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. COMPLETED

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. COMPLETED

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

*** Observation on October 2, 2012, 11:30 AM items 1, 2a, 3, 5, 6, 7, 8, 9, 10, 11 are COMPLETED. Doors under item 2b and 2c still are deficient. Vault doors under item 4 are still deficient (penetration was sealed).

Interview with the Engineering Supervisor on October 2, 2012, at 11:30 AM confirmed that items 2b, 2c and 4 were not completed.***