HospitalInspections.org

K 012

Based on observation and interview, the facility failed to meet the requirements for construction type on four of thirteen floors.

Findings include:

1. Based on observation on October 3, 2011, at 11:25 a.m. revealed that there is exposed structural steel located in the elevator penthouse in the "T" building.
2. Based on observation on October 4, 2011, at 1:26 p.m. revealed that the rated ceiling assembly is not in tact in room E631 and E631A.
3. Based on observation on October 4, 2011, at 3:05 p.m. revealed that the rated ceiling assembly is not in tact above the ceiling in the corridor near room E521 due to a metal duct not attached properly.
4. Based on observation on October 4, 2011, at 3:29 p.m. revealed that there is exposed structural steel located in room T506.
5. Based on observation on October 4, 2011, at 10:00 a. m. revealed basement structural steel beam above cold water line lacks adequate fire-proof spray.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above items shall be maintained to meet the construction type requirements.

K 012

Based on observation and interview, the facility failed to meet the requirements for construction type on one of five floors.

Findings include:

Observation on October 3, 2011, at 11:40 a. m. revealed that there is unsealed conduit penetrations in the floor assembly of the fourth floor electrical room G486.

Interview with Safety Officer (S. O.) on October 3, 2011 at 11:40 a. m. confirmed the unsealed floor penetrations.

K 012

Based on observation and interview, the facility failed to meet the requirements for construction type on one of seven floors.

Findings include:

1. Observation on October 5, 2011, at 8:20 a. m. revealed that sixth floor has unprotected structural steel outside the pavilion penthouse.

Interview with Safety Officer (S. O.) on October 5, 2011 at 8:20 a. m. confirmed the structural steel beam requires proper fire-proof material.

2. Observation on October 5, 2011, at 8:50 a. m. revealed that sixth floor B wing mechanical penthouse has unsealed electrical conduit for isolation panels through the floor assembly.

Interview with S. O. on October 5, 2011 at 8:50 a. m. confirmed floor penetrations are not sealed.

K 017

Based upon observation and interview, the facility failed to meet the requirements for corridor walls in three locations of thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 12:15 p.m. revealed that there is a penetration in the corridor wall above the ceiling near 1101.
2. Observation on October 4, 2011, at 9:52 a.m. revealed that the corridor wall near room T858 does not continue to the deck above and the smoke compartment is not fully sprinklered.
3. Observation on October 4, 2011, at 10:37 a.m. revealed that there is a penetration in the corridor wall above the ceiling in room T729.

Interview with S. O. on October 6, 2011, at 11:35 a.m. confirmed the above corridors shall meet the requirements.

K 018

Based upon observation and interview, the facility failed to meet the requirements for corridor doors on five of thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 9:00 a.m. revealed that the corridor doors on the eight floor of the tower in CTICU lack positive latching.
2. Observation on October 4, 2011, at 9:01 a.m. revealed that there is plain glass in the corridor doors of CTICU and the smoke compartment is not fully sprinklered.
3. Observation on October 4, 2011, at 1:58 p.m. revealed that patient room door T689 would not latch.
4. Observation on October 4, 2011, at 10:35 a.m. revealed doors to E.D. (main, open 24/7 ambulance area) lack positive latching.
5. Observation on October 4, 2011, at 3:55 p.m. revealed 3E, E306 door to volunteer services lacks positive latching.
6. Observation on October 4, 2011, at 4:15 p.m. revealed 3E, E319 plumbing shop door lacks positive latching.

Interview with S. O. on October 6, 2011, at 11:30 a.m. confirmed the above corridor doors are not maintained to meet the requirements.

K 018

Based upon observation and interview, the facility failed to meet the requirements for corridor doors on four of seven floors.

Findings include:

Observation on October 5, 2011, between 9:00 a. m. and 11:32 a. m. revealed the following corridor doors lack positive latching:
A. Sixth floor 6B bed storage area (9:00 a. m.).
B. Sixth floor waiting room Pav. 6 visitor seating (9:10 a. m.).
C. Fifth floor wound care room #10 (9:45 a. m.).
D. Fifth floor 511/512 patient room, bed obstructing door closure (9:50 a. m.).
E. Fifth floor 522/523 patient room, table and I. V. pole obstructing door closure (9:55 a. m.).
F. Third floor old maternity Pav. 3 room #2, beds obstructing door closure (11:03 a. m.).
G. Second floor laundry services clean linen 2B (11:32 a. m.).

Interview with S. O. on October 5, 2011, at 11:32 a. m. confirmed corridor doors would not positively latch in the frame.

K 018

Based upon observation and interview, the facility failed to meet the requirements for corridor doors on two of five floors.

Findings include:

1. Observation on October 3, 2011, at 11:15 a. m. revealed the fourth floor G403 pharmacy door has unsealed holes.

Interview with S. O. on October 3, 2011, at 11:15 a. m. confirmed corridor door would not resist the passage of smoke.

2. Observation on October 4, 2011, at 9:20 a. m. revealed the basement door to clean linen 0006 (near maintenance storage room 0009) is propped open with a bucket.

Interview with S. O. on October 4, 2011, at 9:20 a. m. confirmed the corridor door was propped open.

K 021

Based upon observation and interview, the facility failed to meet the requirements for doors in exit passageways, stairway enclosures, horizontal exits, smoke barriers or hazardous areas on three of thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 11:25 a.m. revealed that the door the elevator penthouse is being held open by an unauthorized device.
2. Observation on October 3, 2011, at 1:30 p.m. revealed that the door to soiled linen room 1013 did not close and latch tightly in its frame with a self-closing device.
3. Observation on October 4, 2011, at 3:20 p.m. revealed that stair tower door 5F would not latch tightly in its frame with a self-closing device.
4. Observation on October 4, 2011, at 2:45 p.m. revealed O. P. #3, O. P. 304 atrium door to neuroscience office lacks a self-closure.
5. Observation on October 4, 2011, at 11:10 a.m. revealed second floor tower fire doors from tower to outpatient center (horizontal exit doors) lack positive latching.

Interview with S. O. on October 6, 2011, at 11:40 a.m. confirmed the above doors do not meet requirements.

K 025

Based upon observation and interview, the facility failed to meet the requirements for smoke barriers on one of five floors.

Findings include:

Observation on October 3, 2011, between 10:45 a. m. and 11:35 a. m. revealed the following smoke barriers are inadequately sealed:
A. Fourth floor smoke barrier near G-404 has two large unplugged conduits and a portion of the smoke wall removed (10:45 a. m.).
B. Fourth floor smoke barrier G-341 has an unplugged conduit penetration above doors (11:17 a. m.).
C. Fourth floor smoke barrier G-474 has two unplugged conduit penetrations (11:35 a. m.).

Interview with S. O. on October 3, 2011, at 10:45 a. m. confirmed smoke barriers are inadequately sealed.

K 025

Based upon observation and interview, the smoke barriers are constructed to provide at least a one-half hour fire resistance rating on one of thirteen floors.

Findings include:

Based on observation on October 4, 2011, at 1:30 p.m. revealed unsealed conduit penetration in smoke barrier wall at O. P. #1, O. P. 112, above doors.

Interview with S. O. on October 6, 2011, at 10:50 a.m. confirmed the unsealed smoke barrier penetration.

K 027

Based upon observation and interview, the facility failed to meet the requirements for smoke barrier doors in two locations on thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 11:43 a.m. revealed that the smoke barrier door 1230 self-closing device is not working properly due to a broken arm.
2. Observation on October 3, 2011, at 1:55 p.m. revealed that smoke barrier door T936A would not close and latch tightly in its frame with a self-closing device.
3. Observation on October 3, 2011, at 11:25 a.m. revealed second floor tower smoke barrier doors lack positive latching in the frame with latching hardware (next to restroom 260).

Interview with S. O. on October 6, 2011, at 11:45 a.m. confirmed the above smoke barrier doors do not meet requirements.

K 027

Based upon observation and interview, the facility failed to meet the requirements for smoke barrier doors on one of five floors.

Findings include:

Observation on October 5, 2011, at 9:05 a. m. revealed sixth floor smoke barrier doors do not close in the frame at Pav. 6 connecting corridor and B6.

Interview with S. O. on October 5, 2011, at 9:05 a. m. confirmed smoke barrier doors do not close in the frame.

K 027

Based upon observation and interview, the facility failed to meet the requirements for smoke barrier doors on two of five floors.

Findings include:

Observation on October 3, 2011, between 12:05 p. m. and 1:35 p. m. revealed the following smoke barrier doors do not close and latch in the frame with attached latching hardware:
A. Third floor smoke barrier doors G333 (12:05 p. m.).
B. Third floor smoke barrier doors near resident room 353 (12:15 p. m.).
C. Second floor smoke barrier doors G 214 (1:35 p. m.).

Interview with S. O. on October 3, 2011, at 1:35 p. m. confirmed smoke barrier doors do not properly close and latch with the attached hardware.

K 029

Based upon observation and interview, the facility failed to meet the requirements for hazardous areas in one location on thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 9:02 a.m. revealed that room T812 is being used for storage and corridor doors have plain glass and lack positive latching with a self-closing device.
2. Observation on October 4, 2011, at 10:16 a.m. revealed first floor tower E.D. soiled holding door lacks positive latching.
3. Observation on October 4, 2011, at 10:17 a.m. revealed first floor tower E.D. dirty utility room door 155 lacks positive latching.
4. Observation on October 4, 2011, at 11:55 a.m. revealed second floor doors 280 to "the barn" storage area lack positive latching due to one door not remaining latched so the other door may close in the frame.
5. Observation on October 4, 2011, at 1:17 p.m. revealed O. P. #1, O. P. 107 door to gift shop storage lacks positive latching.
6. Observation on October 4, 2011, at 1:20 p.m. revealed O. P. #1, O. P. 111A door to gift shop storage lacks positive latching.
7. Observation on October 4, 2011, at 2:50 p.m. revealed O. P. #1, O.P. 358 storage room door lacks a self closure.
8. Observation on October 4, 2011, at 3:52 p.m. revealed 3E, E 301 storage room door lacks positive latching.

Interview with S. O. on October 6, 2011, at 11:20 a.m. confirmed the above hazardous areas do not meet requirements.

K 029

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on three of five floors.

Findings include:

1. Observation on October 3, 2011, at 1:40 p. m. revealed second floor mechanical room doors G274 lack positive latching with the coordinator.

Interview with S. O. on October 3, 2011, at 1:40 p. m. confirmed the doors lack positive latching with a coordinator.

2. Observation on October 4, 2011, between 9:05 a. m. and 9:40 am revealed the following hazardous area doors lack positive latching:
A. First floor door to electrical room G 167 AB (9:05 a. m.).
B. Basement dirty linen 0006 door (near maintenance storage room 0009), propped open with a bucket (9:20 a. m.).
C. Basement elevator equipment room 0007 (9:30 a. m.).
D. Basement medial records 0003 (9:40 a. m.).

Interview with S. O. on October 4, 2011, at 9:40 a. m. confirmed the hazardous area doors lack positive latching.

K 029

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on two of seven floors.

Findings include:

Observation on October 5, 2011, between 11:20 a. m. and 3:00 p. m. revealed the following hazardous area corridor doors lack positive latching:
A. Second floor radiology storage room 00-44, doors lack positive latching with coordinator (11:20 a. m.).
B. Second floor E. D. storage room door across from room 4 (1:13 p. m.).
C. Ground floor storage room door Pav. lower level old chemo room (2:32 p. m.).
D. Ground floor radiation oncology storage suite Pav. lower level (2:35 p. m.).
E. Ground floor B wing lower level environmental storage room, closure is removed (3:00 p. m.).

Interview with S. O. on October 5, 2011, at 3:00 p. m. confirmed the hazardous area doors lack positive latching in the frame.

K 033

Based upon observation and interview, the facility failed to meet the requirements for stair tower construction on one of five floors.

Findings include:

Observation on October 3, 2011, between 11:10 a. m. and 11:32 a. m. revealed the following stair towers lack two-hour construction:
A. Fourth floor stair tower G 424 has large hole with cable, as well as an unsealed sprinkler pipe penetration (11:10 a. m.).
B. Fourth floor stair tower G 466 has two holes above the door (11:32 a. m.).

Interview with S. O. on October 3, 2011, at 11:32 a. m. confirmed the above stair towers lack the required two-hour fire rated construction.

K 033

Based upon observation and interview, the facility failed to meet the requirements for stair tower construction on two of seven floors.

Findings include:

1. Observation on October 5, 2011, at 10:10 a. m. revealed fourth floor stair tower #2 doors lack positive latching with a coordinator.

Interview with S. O. on October 5, 2011, at 10:10 a. m. confirmed stair tower doors lack positive latching.

2. Observation on October 5, 2011, at 11:00 a. m. revealed third floor stair tower #1 has unsealed conduit penetrations.

Interview with S. O. on October 5, 2011, at 11:00 a. m. confirmed stair tower has unsealed conduit penetrations.

K 034

Based upon observation and interview, the facility failed to meet the requirements for stair towers in three locations on thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 11:25 a.m. revealed that there is storage of equipment in the stair tower leading to the elevator penthouse in the "T" building.
2. Observation on October 4, 2011, at 11:55 a.m. revealed that there is storage of equipment in the stair tower at F713.
3. Observation on October 4, 2011, at 10:04 a.m. revealed stair tower A door to basement lacks a self-closure.

Interview with S. O. on October 6, 2011, at 11:05 a.m. confirmed the above items shall be maintained to meet the construction requirements of a two-hour fire rated stair tower.

K 038

Based upon observation and interview, the facility failed to meet the requirements for exit access on five of thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 9:06 a.m. revealed that there is a sign on door T816 stating "not an exit" which would create a dead-end corridor.
2. Observation on October 4, 2011, at 11:35 a.m. revealed that there is a thumb latch on patient room door E717.
3. Observation on October 4, 2011, at 11:46 a.m. revealed that there is no over-ride device located on stair tower door E743 for the special locking arrangement.
4. Observation on October 4, 2011, at 3:55 p.m. revealed that there is no over-ride device located on fourth floor stair tower door "B" for the special locking arrangement.
5. Observation on October 4, 2011, at 4:05 a.m. revealed that there is a thumb latch located on the interior slide door OP443A.
6. Observation on October 4, 2011, at 11:30 a.m. revealed fire exit stair tower door in purchasing/materials management has no over-ride device for the special locking arrangement.

Interview with S. O. on October 6, 2011, at 11:50 a.m. confirmed the above locations shall meet the requirements for required exits.

K 038

Based upon observation and interview, the facility failed to meet the requirements for exit access on two of five floors.

Findings include:

1. Observation on October 3, 2011, at 11:15 a. m. revealed fourth floor pharmacy doors can be locked against egress at G403 and G435.

Interview with S. O. on October 3, 2011, at 11:15 a. m. confirmed corridor doors can be locked against egress.

2. Observation on October 4, 2011, at 9:35 a. m. revealed a "not an exit" sign is required on the first floor door of stair tower B to direct exiting from the location of basement travel to second floor.

Interview with S. O. on October 4, 2011, at 11:15 a. m. confirmed first floor stair tower door requires "not an exit" sign with a directional to indicate exiting via the second floor.

Based upon documentation review and interview, the facility failed to meet the requirements for battery pack lighting on one of thirteen floors.

Findings include:

1. Documentation review on October 6, 2011, at 9:00 a.m. revealed that the facility lacks documentation that the battery pack lighting in the emergency department is being inspected 1 1/2 hours annually.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for battery pack lighting..

K 047

Based upon observation and interview, the facility failed to meet the requirements for emergency lighting on three of thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 9:22 a.m. revealed that there is an exit sign above the double doors on the eighth floor directing exiting through the medical ICU suite.
2. Observation on October 4, 2011, at 10:45 a.m. revealed there is an exit sign directing egress through a storage room near room T772.
3. Observation on October 4, 2011, at 1:57 p.m. revealed that there is an exit sign missing at the double doors leading into CTICU on the sixth floor.
4. Observation on October 4, 2011, at 1:15 p.m. revealed a burned-out exit sign near O. P. #1, O. P. 103 A (door to the outside).

Interview with S. O. on October 6, 2011, at 11:55 a.m. confirmed the above locations shall meet lighting requirements.

K 051

Based on observation and interview, the facility failed to to meet the requirements for the fire alarm systems for the entire facility.

Findings include:

1. Observation on October 4, 2011, at 1:20 p.m. revealed that there is a smoke detector located above the ceiling in the corridor of 7E near room E714.
2. Observation on October 4, 2011, at 2:28 p.m. revealed that the pull station located in room OP544 is being blocked with shelving.
3. Observation on October 4, 2011, at 5:01 p.m. revealed that the fire alarm panel in the security office (E410) is in trouble status.

Interview with S. O. on October 6, 2011, at 12:00 p.m. confirmed the fire alarm system shall be in normal operational status.

K 051

Based on observation and interview, the facility failed to to meet the requirements for the fire alarm systems for the entire facility.

Findings include:

1. Observation on October 5, 2011, at 10:30 a. m. revealed the third floor C wing/snack shop (near aspen room) corridor has a smoke detector hanging from the base.

Interview with S. O. on October 5, 2011, at 10:30 a. m. confirmed the smoke detector is detached from the base.

2. Observation on October 5, 2011, at 11:30 a. m. revealed the fire alarm panel is in trouble status (twelve trouble signals).

Interview with S. O. on October 5, 2011, at 11:30 a. m. confirmed the fire alarm is not in normal status.

K 056

Based upon observation and interview, the facility failed to meet the requirements for sprinkler installation on five of thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 10:37 a.m. revealed that the ceiling tile is not in tact in room T729 which could prevent the sprinkler protection from functioning properly.
2. Observation on October 4, 2011, at 11:25 a.m. revealed that the ceiling tile is not in tact in the stair tower E742 which could prevent the sprinkler protection from functioning properly.
3. Observation on October 4, 2011, at 11:36 a.m. revealed that the sprinkler head is not installed properly in room E736.
4. Observation on October 4, 2011, at 11:58 a.m. revealed that there is storage within 18 inches of the sprinkler head in room F722.
5. Observation on October 4, 2011, at 11:59 a.m. revealed that the ceiling tile is not in tact in stair tower F713 which could prevent the sprinkler protection from functioning properly.
6. Observation on October 4, 2011, at 3:15 p.m. revealed that there are wires attached to sprinkler piping in the construction area of 5F.
7. Observation on October 4, 2011, at 3:29 p.m. revealed that there are sprinkler heads installed too far from the ceiling in room T506.
8. Observation on October 4, 2011, at 3:30 p.m. revealed that there are sprinkler heads installed too far from the ceiling in electrical room located in T508 corridor.
9. Observation on October 4, 2011, at 3:33 p.m. revealed that telecommunication room T557 lacks sprinkler protection.
10. Observation on October 4, 2011, at 3:43 p.m. revealed that the closet in room T566A lacks sprinkler protection.
11. Observation on October 4, 2011, at 3:45 p.m. revealed that ceiling tile in room T567 is not in tact and could prevent the sprinkler protection from functioning properly.
12. Observation on October 4, 2011, at 4:40 p.m. revealed that fourth closet by E403B lacks sprinkler protection.
13. Observation on October 4, 2011, at 1:50 p.m revealed O. P. #1, O. P. 172 and 173 patient access closets lack sprinkler protection.
14. Observation on October 4, 2011, at 2:10 p.m. revealed O. P. #2, O. P. 263 old cardiac rehab gym lacks sprinkler coverage.

Interview with S. O. on October 6, 2011, at 10:25 a.m. confirmed the above areas have deficiencies that would alter sprinkler coverage and/or compromise the area to be protected by sprinkler coverage.

K 062

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on four of thirteen floors.

Findings include:

1. Based on observation on October 4, 2011, between 10:10 a.m. and 4:10 p.m. revealed facility has ceiling removed at the following locations, which may delay activation of the fire sprinkler heads:
A. First floor tower ceiling tile removed in portico to the E.D./E.R. entrance (10:10 a.m.).
B. First floor tower monolithic ceiling removed in E.D. 115 electrical closet (10:11 a.m.).
C. O. P. #3, O. P. 336 ceiling tile removed in soiled utility room (2:47 p.m.).
D. 3E, E318 five monolithic ceiling openings in electrical room (4:10 p.m.).

Interview with S. O. on October 6, 2011, at 10:45 a.m. confirmed removed ceilings may delay activation of fire sprinkler heads.

2. Based on observation on October 4, 2011, at 1:32 p.m. revealed O. P. #1 alcove across from room O.P. 139 has boxes stored within 18" of the fire sprinkler head.

Interview with S. O. on October 6, 2011, at 10:40 a.m. confirmed items within 18" of the fire sprinkler head.

K 062

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on three of five floors.

Findings include:

1. Observation on October 3, 2011, at 2:00 p. m. revealed second floor unassigned room G236 has five ceiling tile removed and may delay activation of the fire sprinkler system.

Interview with S. O. on October 3, 2011, at 2:00 p. m. confirmed the ceiling tile is removed.

2. Observation on October 4, 2011, at 8:55 a. m. revealed first floor print shop G 176 has boxes stored directly below fire sprinkler head.

Interview with S. O. on October 4, 2011, at 8:55 a. m. confirmed the sprinkler head does not have 18" required distance from other items.

3. Observation on October 4, 2011, at 9:00 a. m. revealed first floor Siamese connection for the fire department (located outside the building at the loading dock) has a large amount of sediment that needs removed behind the protective caps.

Interview with S. O. on October 4, 2011, at 9:00 a. m. confirmed the sprinkler connection is not free of obstructions.

4. Observation on October 4, 2011, at 9:10 a. m. revealed first floor maintenance storage area is missing three ceiling tile and may delay activation of the fire sprinkler system.

Interview with S. O. on October 4, 2011, at 9:10 a. m. confirmed the ceiling tile is removed.

5. Observation on October 4, 2011, at 9:25 a. m. revealed basement elevator equipment room 0007 has two sprinkler escutcheons missing.

Interview with S. O. on October 4, 2011, at 9:25 a. m. confirmed the missing sprinkler escutcheons.

K 062

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on two of seven floors.

Findings include:

Observation on October 5, 2011, between 11:45 a. m. and 2:30 p. m. revealed the following areas have ceiling tile removed and may delay the activation of the fire sprinkler heads.
A. Second floor MRI (11:45 a. m.).
B. Second floor Cath Lab soiled utility room, monolithic ceiling removed as well as ceiling tile (11:47 a. m.).
C. Second floor X-Ray old Nuclear Med. room (12:55 p. m.).
D. Ground floor Pav. old tumor registry room. If ceiling tile is permanently removed, fire sprinkler heads need changed to upright-type heads (2:30 p. m.).

Interview with S. O. on October 5, 2011, at 2:30 p. m. confirmed the ceiling is removed.

K 064

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers, on one of five floors.

Findings include:

Observation on October 3, 2011, at 2:05 p. m. revealed the fire extinguisher in second floor room G265 kitchen is not properly mounted.

Interview with S. O. on October 3, 2011, at 2:05 p. m. confirmed the fire extinguisher is not properly mounted.

K 064

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers, on one of seven floors.

Findings include:

Observation on October 5, 2011, at 10:35 a. m. revealed the fire extinguisher in third floor minor procedure room #1 is not properly mounted.

Interview with S. O. on October 5, 2011, at 10:35 a. m. confirmed the fire extinguisher is not properly mounted.

K 066

Based on observation and interview, the facility failed to meet the requirements for smoking regulations in one location throughout the facility.

Findings include:

Observation on October 4, 2011, at 2:30 p.m. revealed that there was a member of the maintenance staff smoking in the sixth floor mechanical room in the OP building. There was a smell of smoke and evidence of cigarette butts in the area. This is not an approved smoking area per the facility's smoking policy.

Interview with S. O. on October 6, 2011, at 10:20 a.m. confirmed the facility did not adhere to the approved smoking policy.

Based upon observation and interview, the facility failed to meet the requirements for fire dampers for the entire facility

Findings include:

1. Observation and documentation review on October 6, 2011, at 9:00 a.m. revealed that the fire damper report dated November 2006 has deficiencies noted for 4th floor FDSA 4004 (Rm 457) and 12th floor FDRA (Rm 1220). Facility needs to verify these issues have been corrected.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for fire dampers.

Based upon observation and interview, the facility failed to meet the requirements for fire dampers for the entire facility.

Findings include:

1. Observation and documentation review on October 6, 2011, at 9:00 a.m. revealed that the fire damper report dated May 2007 for the 4th floor FDSA 254 (Oncology Manager) has a discrepancy listed. Facility must verify this issue was corrected.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for fire dampers.

K 069

Based on observation and interview, the facility failed to meet the requirements for cooking equipment/facilities in one location.

Findings include:

Observation on October 4, 2011, at 3:50 p.m. revealed that the kitchen ansul system lacks monthly inspections.

Interview with S. O. on October 6, 2011, at 10:15 a.m. confirmed the facility lacks monthly inspections on the hood suppression system.

K 070

Based upon observation and interview, it was determined the facility failed to monitor the portable space heating devices in the administrative areas on one of seven floors.

Findings include:

Observation on October 5, 2011, at 8:40 a. m. revealed facility shall verify the portable heater used in the sixth floor B6 administrative assistant office is U. L. listed.

Interview with S. O. on October 5, 2011, at 8:40 a. m. confirmed the heater shall be U. L. listed.

K 072

Based upon observation and interview, the facility failed to meet requirements for means of egress on four of thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 11:05 a.m. revealed that the cross-over corridor at the end of the hall on the fourteenth floor in palliative care is being blocked by various pieces of furniture.
2. Observation on October 3, 2011, at 2:21 p.m. revealed that wall-mounted charting station at LDRP 15 is not self-closing when left in the open position.
3. Observation on October 4, 2011, at 9:53 a.m. revealed that there is storage of equipment on the seventh floor in the operating room corridors.
4. Observation on October 4, 2011, at 11:24 a.m. revealed that there is storage of equipment on the seventh floor in the corridor near the on-call rooms in the OP building.
5. Observation on October 4, 2011, at 11:45 a.m. revealed that there are computers on wheels with chairs being stored in the corridor near room E731. This is creating a nurses' station in the corridor.
6. Observation on October 4, 2011, at 10:05 a.m. revealed first floor exit from E. D. waiting room 107A (glass hallway) has outside shrubs that need trimmed back to allow exit access.
7. Observation on October 4, 2011, at 10:55 a.m. revealed first floor X-ray department has a portable X-ray machine stored within the corridor.

Interview with S. O. on October 6, 2011, at 11:10 a.m. confirmed the means of egress shall be maintained throughout the facility.

K 072

Based upon observation and interview, the facility failed to meet requirements for means of egress on one of seven floors.

Findings include:

Observation on October 5, 2011, at 8:30 a. m. revealed sixth floor corridor outside pharmacy has housekeeping trash cans stored in the corridor blocking clear corridor width.

Interview with S. O. on October 5, 2011, at 8:30 a. m. confirmed the above corridor is not clear to width.

K 072

Based upon observation and interview, the facility failed to meet requirements for means of egress on two of five floors.

Findings include:

Observation on October 3, 2011, between 11:27 a. m. and 1:45 p. m. revealed the following locations have items blocking clear corridor width:
A. Fourth floor corridors near G 453 and G 470, chairs (11:27 a. m.).
B. Second floor corridor outside of freight elevator, large amount of boxes and pallets (1:45 p. m.).

Interview with S. O. on October 3, 2011, at 1:45 p. m. confirmed the above corridors are not clear to width.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on two of thirteen floors.

Findings include:

1. Based on observation on October 4, 2011, at 11:40 a..m. revealed second floor tower medical gas storage in back of purchasing department has medical gas cylinders that are not designated as full or empty.
2. Based on observation on October 4, 2011 at 2:25 p.m. revealed O. P. #2, O. P. 229 respiratory therapy has an overabundance of oxygen cylinders considered "in-use" (15 cylinders).
3. Based on observation on October 6, 2011, at 9:25 p.m. revealed there are oxygen cylinders in excess of 300 cubic feet being stored in room TC-211 and the electrical outlets/switches are not sixty inches above the floor and the oxygen is being stored within five feet of combustibles.

Interview with S. O. on October 6, 2011, at 10:35 a.m. confirmed medical gas shall be stored in accordance with regulations and the subsequent correction of item #2 only at the time of the survey.

K 077

Based upon observation and interview, the facility failed to meet the requirements for piped in medical gas on seven floors of thirteen.

Findings include:

1. Observation on October 3, 2011, at 12:18 p.m. revealed that the eleventh floor medical gas alarm panel for medical air is not labeled "not in use" and the gauge is reading zero and the panel is not in alarm status.
2. Observation on October 3, 2011, at 1:30 p.m. revealed that the tenth floor medical gas alarm panel for medical air is not labeled "not in use" and the gauge is reading zero and the panel is not in alarm status.
3. Observation on October 4, 2011, at 9:10 a.m. revealed that the medical gas shut-off located in eight floor STICU lacks labeling.
4. Observation on October 4, 2011, at 9:20 a.m. revealed that the oxygen medical gas shut-off located in the main corridor near T862 lacks labeling.
5. Observation on October 4, 2011, at 9:51 a.m. revealed that the air medical gas shut-off located in the corridor near room T851 lacks labeling.
6. Observation on October 4, 2011, at 10:35 a.m. revealed that the seventh floor medical gas shut-offs located in the operating room corridor are being blocked by equipment.
7. Observation on October 4, 2011, at 2:50 p.m. revealed that the fifth floor medical air dew point monitor located in the mechanical room exceeds 39 degrees Fahrenheit.
8. Observation on October 4, 2011, at 10:20 a.m. revealed E.D. department has a large cart blocking medical gas shut-off valves outside of 164 corridor.
9. Observation on October 4, 2011, at 3:50 p.m. revealed 3E medical gas shut-off valves are not labeled "out of service" in corridor across from E 301.

Interview with S. O. on October 6, 2011, at 11:25 a.m. confirmed the above piped-in medical gas deficiencies shall be addressed.

K 077

Based upon observation and interview, the piped in medical gas system does not comply with regulations on one of seven floors.

Findings include:

Observation on October 5, 2011, at 1:00 p. m. revealed second floor radiology corridor has an X-ray machine parked in front of the medical gas shut-off valves.

Interview with S. O. on October 5, 2011, at 1:00 p. m. confirmed the medical gas shut-off valves are obstructed, and the subsequent correction of this item during the survey.

Based upon observation and documentation review, the facility failed to comply with regulations for anesthetizing locations for one operating room in the operating room compartment.

Findings include:

1. Observation and documentation review on October 6, 2011, at 9:00 a.m. revealed that the humidity levels for operating room #6 are well below the 35% requirement for months November 2010 through April 2011.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for anesthetizing locations.

Based upon observation and documentation review, the facility failed to comply with regulations for anesthetizing locations for one operating room in the operating room compartment.

Findings include:

1. Observation and documentation review on October 6, 2011, at 9:00 a.m. revealed the facility lacked documentation for humidity levels for anesthetizing locations (operating room compartment) from August 1, 2010, to May 11, 2011.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for anesthetizing locations.

K 104

Based upon observation and interview, the facility failed to meet the requirements for heating ventilation and air conditioning ducts in two locations on thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 2:05 p.m. revealed that the facility needs to verify that there is a smoke damper in the duct work above the ceiling at door T936A.
2. Observation on October 3, 2011, at 2:21 p.m. revealed that the facility needs to verify that an access panel for the smoke damper is in the duct work above the ceiling at T922 near T939A.

Interview with S. O. on October 6, 2011, at 10:10 a.m. confirmed the heating, ventilation and air conditioning units do not meet requirements.

K 130

28 Pa. Code ? 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. ? 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal, State and Local laws and regulations on one of five floors.

Findings include:

Observation on October 3, 2011, at 11:30 a. m. revealed fourth floor stand pipe access within stair tower G 466 has broken glass.

Interview with S. O. on October 3, 2011, at 11:30 a. m. confirmed the broken glass within the stair tower stand pipe access.

K 130

28 Pa. Code ? 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. ? 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal, State and Local laws and regulations on one of seven floors.

Findings include:

Observation on October 5, 2011, at 12:00 p. m. revealed the chapel has an unattended lit candle.

Interview with S. O. on October 5, 2011, at 12:00 p. m. confirmed candle was left unattended in the chapel.

K 130

28 Pa. Code ? 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. ? 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal, State and Local laws and regulations on one of thirteen floors.

Findings include:

Observation on October 4, 2011, at 3:30 p. m. revealed facility has a lab renovation/expansion under construction. Due to the construction, the facility has areas that are "safety-compromised" (smoke detectors out of service, removed ceiling tile, exposed wiring, use of extension cords, etc.). Facility shall verify a policy is in place to keep the construction areas safe during renovations until completion.

Interview with S. O. on October 6, 2011, at 10:20 a.m. confirmed the facility shall have a safety policy in place for all renovated areas.

K 143

Based upon observation and interview, oxygen transfilling locations and/or procedures failed to meet regulations on one of seven floors.

Findings include:

Observation on October 5, 2011, at 3:05 p. m. revealed ground floor liquid oxygen transfilling room on B1 lacks a "no smoking" and "oxygen transfilling in progress" sign outside the room.

Interview with S. O. on October 5, 2011, at 3:05 p. m. confirmed lack of signs outside the oxygen transfilling location.

Based upon documentation review and interview, the facility failed to meet the requirements for generators in one location for the entire building.

Findings include:

1. Observation on October 6, 2011, at 9:40 a.m. revealed that the facility lacks documentation that the remote annunciator for the generators meets the requirements of NFPA 99, Section 3-4.1.1.15. Note: The facility must also ensure the responsible staff is aware of these requirements.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item shall be maintained to meet generator requirements.

Based upon observation and interview, the facility failed to meet the requirements for electrical wiring and/or equipment on nine of thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 10:47 a.m. revealed that there are appliances plugged into a six-plug extension in the nurses' lounge, room 1451.
2. Observation on October 4, 2011, at 9:05 a.m. revealed that there is romex cable being used for the television amplifier in room T813.
3. Observation on October 4, 2011, at 10:32 a.m. revealed that there is medical equipment plugged into a surge protector in room T727.
4. Observation on October 4, 2011, at 11:05 a.m. revealed that there is exposed wiring at the clock location in women's locker room OP783.
5. Observation on October 4, 2011, at 11:56 a.m. revealed that there is storage in front of the electrical panels in room F707.
6. Observation on October 4, 2011, at 1:20 p.m. revealed that there is an open junction box above the ceiling in the corridor near room E714.
7. Observation on October 4, 2011, at 11:30 a.m. revealed that electrical panels (N-1 & N-2) on 7E corridor walls were found unlocked.
8. Observation on October 4, 2011, at 10:15 a.m. revealed first floor supply E.D. 131-A has a coffee pot that need the cord replaced (insulation gone to expose wiring).
9. Observation on October 4, 2011, at 11:13 a.m. revealed second floor purchasing office (pharmacy order placement) has a surge protector plugged into another surge protector.
10. Observation on October 4, 2011, at 11:15 a.m. revealed second floor pharmacy unpacking area has a surge protector plugged into another surge protector.
11. Observation on October 4, 2011, at 11:35 a.m. revealed purchasing/materials management has a microwave and coffee pot plugged into a surge protector.
12. Observation on October 4, 2011, at 11:50 a.m. revealed "the barn" storage area door 280 has electrical panels blocked with shelving and boxes.
13. Observation on October 4, 2011, at 11:57 a.m. revealed office 275 has a microwave and refrigerator plugged into a surge protector.
14. Observation on October 4, 2011, at 1:45 p.m. revealed O. P. #1, O. P. 118 has electrical panels blocked with ladders, wheelchairs, and shelving.
15. Observation on October 4, 2011, at 2:20 p.m. revealed O. P. #2, O. P. 214 cardiac holter monitoring room has a refrigerator, microwave, and coffee pot plugged into a surge protector.
16. Observation on October 4, 2011, at 2:30 p.m. revealed O. P. #2, O. P. 206 respiratory is utilizing a hospital grade extension cord.
17. Observation on October 4, 2011, at 3:05 p.m. revealed third floor tower 304A lab office has an extension cord plugged into a surge protector.
18. Observation on October 4, 2011, at 3:15 p.m. revealed third floor tower 305 lab area has two refrigerators plugged into a surge protector.
19. Observation on October 4, 2011, at 3:20 p.m. revealed third floor tower micro-biology has a surge protector plugged into another surge protector.
20. Observation on October 4, 2011, at 3:25 p.m. revealed third floor tower lab 332 has a ladder stored in front of electrical panel.
21. Observation on October 4, 2011, at 3:32 p.m. revealed third floor tower T-371 has a laundry cart and I. V. poles stored in front of electrical panels.
22. Observation on October 4, 2011, at 3:35 p.m. revealed third floor tower support services T-385A has a surge protector plugged into another surge protector.
23. Observation on October 4, 2011, at 3:54 p.m. revealed two open junction boxes by sprinkler main in 3E, E-307.
24. Observation on October 4, 2011, at 3:57 p.m. revealed 3E, E-308 volunteer services has two coffee pots plugged into a surge protector.
25. Observation on October 4, 2011, at 4:06 p.m. revealed 3E, E-316 plumbing shop is utilizing a hospital grade extension cord.
26. Observation on October 4, 2011, at 4:15 p.m. revealed 3E, E-319 plumbing shop has a toaster plugged into a surge protector and two permanently mounted surge protectors.
27. Observation on October 6, 2011, at 9:25 a.m. revealed there is an extension cord being used on the second floor trauma building in room TC-211.

Interview with S. O. on October 6, 2011, at 11:15 a.m. confirmed the above electrical deficiencies shall be addressed.

K 147

Based upon observation and interview, the facility failed to meet the requirements for electrical wiring and/or equipment on one of five floors.

Findings include:

Observation on October 3, 2011, between 11:20 a. m. and 11:25 a. m. revealed the following electrical deficiencies:
A. Fourth floor office G 448 has a microwave oven plugged into a surge protector (11:20 a. m.).
B. Fourth floor area G 453 has a surge protector plugged into another surge protector (11:25 a. m.).

Interview with S. O. on October 3, 2011, at 11:25 a. m. confirmed the above items shall be plugged directly into a wall receptacle.

K 147

Based upon observation and interview, the facility failed to meet the requirements for electrical wiring and/or equipment on two of seven floors.

Findings include:

Observation on October 5, 2011, between 1:05 p. m. and 2:25 p. m. revealed the following electrical deficiencies:
A. Second floor E. D. bay #4 has temporary lighting above the ceiling tile (1:05 p. m.).
B. Second floor police department office has a microwave, refrigerator, and coffee pot plugged into a surge protector.
C. First floor dietary office, clerk area is utilizing an extension cord (1:45 p. m.).
D. First floor business office, cashier area has a coffee pot plugged into a surge protector (2:25 pm).

Interview with S. O. on October 5, 2011, at 2:25 p. m. confirmed the above electrical deficiencies.

K 211

Based upon observation and interview, the facility failed to meet the requirements for alcohol based hand sanitizers (ABHS) in one location for the entire facility.

Findings include:

Observation on October 4, 2011, at 4:05 p.m. revealed that there is an alcohol based hand sanitizer installed over carpeting in room T467 and the smoke compartment is not fully sprinklered.

Interview with S. O. on October 6, 2011, at 10:55 a.m. confirmed the alcohol based hand sanitizer is installed over carpet.

K 012

Based on observation and interview, the facility failed to meet the requirements for construction type on four of thirteen floors.

Findings include:

1. Based on observation on October 3, 2011, at 11:25 a.m. revealed that there is exposed structural steel located in the elevator penthouse in the "T" building.
2. Based on observation on October 4, 2011, at 1:26 p.m. revealed that the rated ceiling assembly is not in tact in room E631 and E631A.
3. Based on observation on October 4, 2011, at 3:05 p.m. revealed that the rated ceiling assembly is not in tact above the ceiling in the corridor near room E521 due to a metal duct not attached properly.
4. Based on observation on October 4, 2011, at 3:29 p.m. revealed that there is exposed structural steel located in room T506.
5. Based on observation on October 4, 2011, at 10:00 a. m. revealed basement structural steel beam above cold water line lacks adequate fire-proof spray.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above items shall be maintained to meet the construction type requirements.

K 012

Based on observation and interview, the facility failed to meet the requirements for construction type on one of five floors.

Findings include:

Observation on October 3, 2011, at 11:40 a. m. revealed that there is unsealed conduit penetrations in the floor assembly of the fourth floor electrical room G486.

Interview with Safety Officer (S. O.) on October 3, 2011 at 11:40 a. m. confirmed the unsealed floor penetrations.

K 012

Based on observation and interview, the facility failed to meet the requirements for construction type on one of seven floors.

Findings include:

1. Observation on October 5, 2011, at 8:20 a. m. revealed that sixth floor has unprotected structural steel outside the pavilion penthouse.

Interview with Safety Officer (S. O.) on October 5, 2011 at 8:20 a. m. confirmed the structural steel beam requires proper fire-proof material.

2. Observation on October 5, 2011, at 8:50 a. m. revealed that sixth floor B wing mechanical penthouse has unsealed electrical conduit for isolation panels through the floor assembly.

Interview with S. O. on October 5, 2011 at 8:50 a. m. confirmed floor penetrations are not sealed.

K 017

Based upon observation and interview, the facility failed to meet the requirements for corridor walls in three locations of thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 12:15 p.m. revealed that there is a penetration in the corridor wall above the ceiling near 1101.
2. Observation on October 4, 2011, at 9:52 a.m. revealed that the corridor wall near room T858 does not continue to the deck above and the smoke compartment is not fully sprinklered.
3. Observation on October 4, 2011, at 10:37 a.m. revealed that there is a penetration in the corridor wall above the ceiling in room T729.

Interview with S. O. on October 6, 2011, at 11:35 a.m. confirmed the above corridors shall meet the requirements.

K 018

Based upon observation and interview, the facility failed to meet the requirements for corridor doors on five of thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 9:00 a.m. revealed that the corridor doors on the eight floor of the tower in CTICU lack positive latching.
2. Observation on October 4, 2011, at 9:01 a.m. revealed that there is plain glass in the corridor doors of CTICU and the smoke compartment is not fully sprinklered.
3. Observation on October 4, 2011, at 1:58 p.m. revealed that patient room door T689 would not latch.
4. Observation on October 4, 2011, at 10:35 a.m. revealed doors to E.D. (main, open 24/7 ambulance area) lack positive latching.
5. Observation on October 4, 2011, at 3:55 p.m. revealed 3E, E306 door to volunteer services lacks positive latching.
6. Observation on October 4, 2011, at 4:15 p.m. revealed 3E, E319 plumbing shop door lacks positive latching.

Interview with S. O. on October 6, 2011, at 11:30 a.m. confirmed the above corridor doors are not maintained to meet the requirements.

K 018

Based upon observation and interview, the facility failed to meet the requirements for corridor doors on four of seven floors.

Findings include:

Observation on October 5, 2011, between 9:00 a. m. and 11:32 a. m. revealed the following corridor doors lack positive latching:
A. Sixth floor 6B bed storage area (9:00 a. m.).
B. Sixth floor waiting room Pav. 6 visitor seating (9:10 a. m.).
C. Fifth floor wound care room #10 (9:45 a. m.).
D. Fifth floor 511/512 patient room, bed obstructing door closure (9:50 a. m.).
E. Fifth floor 522/523 patient room, table and I. V. pole obstructing door closure (9:55 a. m.).
F. Third floor old maternity Pav. 3 room #2, beds obstructing door closure (11:03 a. m.).
G. Second floor laundry services clean linen 2B (11:32 a. m.).

Interview with S. O. on October 5, 2011, at 11:32 a. m. confirmed corridor doors would not positively latch in the frame.

K 018

Based upon observation and interview, the facility failed to meet the requirements for corridor doors on two of five floors.

Findings include:

1. Observation on October 3, 2011, at 11:15 a. m. revealed the fourth floor G403 pharmacy door has unsealed holes.

Interview with S. O. on October 3, 2011, at 11:15 a. m. confirmed corridor door would not resist the passage of smoke.

2. Observation on October 4, 2011, at 9:20 a. m. revealed the basement door to clean linen 0006 (near maintenance storage room 0009) is propped open with a bucket.

Interview with S. O. on October 4, 2011, at 9:20 a. m. confirmed the corridor door was propped open.

K 021

Based upon observation and interview, the facility failed to meet the requirements for doors in exit passageways, stairway enclosures, horizontal exits, smoke barriers or hazardous areas on three of thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 11:25 a.m. revealed that the door the elevator penthouse is being held open by an unauthorized device.
2. Observation on October 3, 2011, at 1:30 p.m. revealed that the door to soiled linen room 1013 did not close and latch tightly in its frame with a self-closing device.
3. Observation on October 4, 2011, at 3:20 p.m. revealed that stair tower door 5F would not latch tightly in its frame with a self-closing device.
4. Observation on October 4, 2011, at 2:45 p.m. revealed O. P. #3, O. P. 304 atrium door to neuroscience office lacks a self-closure.
5. Observation on October 4, 2011, at 11:10 a.m. revealed second floor tower fire doors from tower to outpatient center (horizontal exit doors) lack positive latching.

Interview with S. O. on October 6, 2011, at 11:40 a.m. confirmed the above doors do not meet requirements.

K 025

Based upon observation and interview, the facility failed to meet the requirements for smoke barriers on one of five floors.

Findings include:

Observation on October 3, 2011, between 10:45 a. m. and 11:35 a. m. revealed the following smoke barriers are inadequately sealed:
A. Fourth floor smoke barrier near G-404 has two large unplugged conduits and a portion of the smoke wall removed (10:45 a. m.).
B. Fourth floor smoke barrier G-341 has an unplugged conduit penetration above doors (11:17 a. m.).
C. Fourth floor smoke barrier G-474 has two unplugged conduit penetrations (11:35 a. m.).

Interview with S. O. on October 3, 2011, at 10:45 a. m. confirmed smoke barriers are inadequately sealed.

K 025

Based upon observation and interview, the smoke barriers are constructed to provide at least a one-half hour fire resistance rating on one of thirteen floors.

Findings include:

Based on observation on October 4, 2011, at 1:30 p.m. revealed unsealed conduit penetration in smoke barrier wall at O. P. #1, O. P. 112, above doors.

Interview with S. O. on October 6, 2011, at 10:50 a.m. confirmed the unsealed smoke barrier penetration.

K 027

Based upon observation and interview, the facility failed to meet the requirements for smoke barrier doors in two locations on thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 11:43 a.m. revealed that the smoke barrier door 1230 self-closing device is not working properly due to a broken arm.
2. Observation on October 3, 2011, at 1:55 p.m. revealed that smoke barrier door T936A would not close and latch tightly in its frame with a self-closing device.
3. Observation on October 3, 2011, at 11:25 a.m. revealed second floor tower smoke barrier doors lack positive latching in the frame with latching hardware (next to restroom 260).

Interview with S. O. on October 6, 2011, at 11:45 a.m. confirmed the above smoke barrier doors do not meet requirements.

K 027

Based upon observation and interview, the facility failed to meet the requirements for smoke barrier doors on one of five floors.

Findings include:

Observation on October 5, 2011, at 9:05 a. m. revealed sixth floor smoke barrier doors do not close in the frame at Pav. 6 connecting corridor and B6.

Interview with S. O. on October 5, 2011, at 9:05 a. m. confirmed smoke barrier doors do not close in the frame.

K 027

Based upon observation and interview, the facility failed to meet the requirements for smoke barrier doors on two of five floors.

Findings include:

Observation on October 3, 2011, between 12:05 p. m. and 1:35 p. m. revealed the following smoke barrier doors do not close and latch in the frame with attached latching hardware:
A. Third floor smoke barrier doors G333 (12:05 p. m.).
B. Third floor smoke barrier doors near resident room 353 (12:15 p. m.).
C. Second floor smoke barrier doors G 214 (1:35 p. m.).

Interview with S. O. on October 3, 2011, at 1:35 p. m. confirmed smoke barrier doors do not properly close and latch with the attached hardware.

K 029

Based upon observation and interview, the facility failed to meet the requirements for hazardous areas in one location on thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 9:02 a.m. revealed that room T812 is being used for storage and corridor doors have plain glass and lack positive latching with a self-closing device.
2. Observation on October 4, 2011, at 10:16 a.m. revealed first floor tower E.D. soiled holding door lacks positive latching.
3. Observation on October 4, 2011, at 10:17 a.m. revealed first floor tower E.D. dirty utility room door 155 lacks positive latching.
4. Observation on October 4, 2011, at 11:55 a.m. revealed second floor doors 280 to "the barn" storage area lack positive latching due to one door not remaining latched so the other door may close in the frame.
5. Observation on October 4, 2011, at 1:17 p.m. revealed O. P. #1, O. P. 107 door to gift shop storage lacks positive latching.
6. Observation on October 4, 2011, at 1:20 p.m. revealed O. P. #1, O. P. 111A door to gift shop storage lacks positive latching.
7. Observation on October 4, 2011, at 2:50 p.m. revealed O. P. #1, O.P. 358 storage room door lacks a self closure.
8. Observation on October 4, 2011, at 3:52 p.m. revealed 3E, E 301 storage room door lacks positive latching.

Interview with S. O. on October 6, 2011, at 11:20 a.m. confirmed the above hazardous areas do not meet requirements.

K 029

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on three of five floors.

Findings include:

1. Observation on October 3, 2011, at 1:40 p. m. revealed second floor mechanical room doors G274 lack positive latching with the coordinator.

Interview with S. O. on October 3, 2011, at 1:40 p. m. confirmed the doors lack positive latching with a coordinator.

2. Observation on October 4, 2011, between 9:05 a. m. and 9:40 am revealed the following hazardous area doors lack positive latching:
A. First floor door to electrical room G 167 AB (9:05 a. m.).
B. Basement dirty linen 0006 door (near maintenance storage room 0009), propped open with a bucket (9:20 a. m.).
C. Basement elevator equipment room 0007 (9:30 a. m.).
D. Basement medial records 0003 (9:40 a. m.).

Interview with S. O. on October 4, 2011, at 9:40 a. m. confirmed the hazardous area doors lack positive latching.

K 029

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on two of seven floors.

Findings include:

Observation on October 5, 2011, between 11:20 a. m. and 3:00 p. m. revealed the following hazardous area corridor doors lack positive latching:
A. Second floor radiology storage room 00-44, doors lack positive latching with coordinator (11:20 a. m.).
B. Second floor E. D. storage room door across from room 4 (1:13 p. m.).
C. Ground floor storage room door Pav. lower level old chemo room (2:32 p. m.).
D. Ground floor radiation oncology storage suite Pav. lower level (2:35 p. m.).
E. Ground floor B wing lower level environmental storage room, closure is removed (3:00 p. m.).

Interview with S. O. on October 5, 2011, at 3:00 p. m. confirmed the hazardous area doors lack positive latching in the frame.

K 033

Based upon observation and interview, the facility failed to meet the requirements for stair tower construction on one of five floors.

Findings include:

Observation on October 3, 2011, between 11:10 a. m. and 11:32 a. m. revealed the following stair towers lack two-hour construction:
A. Fourth floor stair tower G 424 has large hole with cable, as well as an unsealed sprinkler pipe penetration (11:10 a. m.).
B. Fourth floor stair tower G 466 has two holes above the door (11:32 a. m.).

Interview with S. O. on October 3, 2011, at 11:32 a. m. confirmed the above stair towers lack the required two-hour fire rated construction.

K 033

Based upon observation and interview, the facility failed to meet the requirements for stair tower construction on two of seven floors.

Findings include:

1. Observation on October 5, 2011, at 10:10 a. m. revealed fourth floor stair tower #2 doors lack positive latching with a coordinator.

Interview with S. O. on October 5, 2011, at 10:10 a. m. confirmed stair tower doors lack positive latching.

2. Observation on October 5, 2011, at 11:00 a. m. revealed third floor stair tower #1 has unsealed conduit penetrations.

Interview with S. O. on October 5, 2011, at 11:00 a. m. confirmed stair tower has unsealed conduit penetrations.

K 034

Based upon observation and interview, the facility failed to meet the requirements for stair towers in three locations on thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 11:25 a.m. revealed that there is storage of equipment in the stair tower leading to the elevator penthouse in the "T" building.
2. Observation on October 4, 2011, at 11:55 a.m. revealed that there is storage of equipment in the stair tower at F713.
3. Observation on October 4, 2011, at 10:04 a.m. revealed stair tower A door to basement lacks a self-closure.

Interview with S. O. on October 6, 2011, at 11:05 a.m. confirmed the above items shall be maintained to meet the construction requirements of a two-hour fire rated stair tower.

K 038

Based upon observation and interview, the facility failed to meet the requirements for exit access on five of thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 9:06 a.m. revealed that there is a sign on door T816 stating "not an exit" which would create a dead-end corridor.
2. Observation on October 4, 2011, at 11:35 a.m. revealed that there is a thumb latch on patient room door E717.
3. Observation on October 4, 2011, at 11:46 a.m. revealed that there is no over-ride device located on stair tower door E743 for the special locking arrangement.
4. Observation on October 4, 2011, at 3:55 p.m. revealed that there is no over-ride device located on fourth floor stair tower door "B" for the special locking arrangement.
5. Observation on October 4, 2011, at 4:05 a.m. revealed that there is a thumb latch located on the interior slide door OP443A.
6. Observation on October 4, 2011, at 11:30 a.m. revealed fire exit stair tower door in purchasing/materials management has no over-ride device for the special locking arrangement.

Interview with S. O. on October 6, 2011, at 11:50 a.m. confirmed the above locations shall meet the requirements for required exits.

K 038

Based upon observation and interview, the facility failed to meet the requirements for exit access on two of five floors.

Findings include:

1. Observation on October 3, 2011, at 11:15 a. m. revealed fourth floor pharmacy doors can be locked against egress at G403 and G435.

Interview with S. O. on October 3, 2011, at 11:15 a. m. confirmed corridor doors can be locked against egress.

2. Observation on October 4, 2011, at 9:35 a. m. revealed a "not an exit" sign is required on the first floor door of stair tower B to direct exiting from the location of basement travel to second floor.

Interview with S. O. on October 4, 2011, at 11:15 a. m. confirmed first floor stair tower door requires "not an exit" sign with a directional to indicate exiting via the second floor.

Based upon documentation review and interview, the facility failed to meet the requirements for battery pack lighting on one of thirteen floors.

Findings include:

1. Documentation review on October 6, 2011, at 9:00 a.m. revealed that the facility lacks documentation that the battery pack lighting in the emergency department is being inspected 1 1/2 hours annually.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for battery pack lighting..

K 047

Based upon observation and interview, the facility failed to meet the requirements for emergency lighting on three of thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 9:22 a.m. revealed that there is an exit sign above the double doors on the eighth floor directing exiting through the medical ICU suite.
2. Observation on October 4, 2011, at 10:45 a.m. revealed there is an exit sign directing egress through a storage room near room T772.
3. Observation on October 4, 2011, at 1:57 p.m. revealed that there is an exit sign missing at the double doors leading into CTICU on the sixth floor.
4. Observation on October 4, 2011, at 1:15 p.m. revealed a burned-out exit sign near O. P. #1, O. P. 103 A (door to the outside).

Interview with S. O. on October 6, 2011, at 11:55 a.m. confirmed the above locations shall meet lighting requirements.

K 051

Based on observation and interview, the facility failed to to meet the requirements for the fire alarm systems for the entire facility.

Findings include:

1. Observation on October 4, 2011, at 1:20 p.m. revealed that there is a smoke detector located above the ceiling in the corridor of 7E near room E714.
2. Observation on October 4, 2011, at 2:28 p.m. revealed that the pull station located in room OP544 is being blocked with shelving.
3. Observation on October 4, 2011, at 5:01 p.m. revealed that the fire alarm panel in the security office (E410) is in trouble status.

Interview with S. O. on October 6, 2011, at 12:00 p.m. confirmed the fire alarm system shall be in normal operational status.

K 051

Based on observation and interview, the facility failed to to meet the requirements for the fire alarm systems for the entire facility.

Findings include:

1. Observation on October 5, 2011, at 10:30 a. m. revealed the third floor C wing/snack shop (near aspen room) corridor has a smoke detector hanging from the base.

Interview with S. O. on October 5, 2011, at 10:30 a. m. confirmed the smoke detector is detached from the base.

2. Observation on October 5, 2011, at 11:30 a. m. revealed the fire alarm panel is in trouble status (twelve trouble signals).

Interview with S. O. on October 5, 2011, at 11:30 a. m. confirmed the fire alarm is not in normal status.

K 056

Based upon observation and interview, the facility failed to meet the requirements for sprinkler installation on five of thirteen floors.

Findings include:

1. Observation on October 4, 2011, at 10:37 a.m. revealed that the ceiling tile is not in tact in room T729 which could prevent the sprinkler protection from functioning properly.
2. Observation on October 4, 2011, at 11:25 a.m. revealed that the ceiling tile is not in tact in the stair tower E742 which could prevent the sprinkler protection from functioning properly.
3. Observation on October 4, 2011, at 11:36 a.m. revealed that the sprinkler head is not installed properly in room E736.
4. Observation on October 4, 2011, at 11:58 a.m. revealed that there is storage within 18 inches of the sprinkler head in room F722.
5. Observation on October 4, 2011, at 11:59 a.m. revealed that the ceiling tile is not in tact in stair tower F713 which could prevent the sprinkler protection from functioning properly.
6. Observation on October 4, 2011, at 3:15 p.m. revealed that there are wires attached to sprinkler piping in the construction area of 5F.
7. Observation on October 4, 2011, at 3:29 p.m. revealed that there are sprinkler heads installed too far from the ceiling in room T506.
8. Observation on October 4, 2011, at 3:30 p.m. revealed that there are sprinkler heads installed too far from the ceiling in electrical room located in T508 corridor.
9. Observation on October 4, 2011, at 3:33 p.m. revealed that telecommunication room T557 lacks sprinkler protection.
10. Observation on October 4, 2011, at 3:43 p.m. revealed that the closet in room T566A lacks sprinkler protection.
11. Observation on October 4, 2011, at 3:45 p.m. revealed that ceiling tile in room T567 is not in tact and could prevent the sprinkler protection from functioning properly.
12. Observation on October 4, 2011, at 4:40 p.m. revealed that fourth closet by E403B lacks sprinkler protection.
13. Observation on October 4, 2011, at 1:50 p.m revealed O. P. #1, O. P. 172 and 173 patient access closets lack sprinkler protection.
14. Observation on October 4, 2011, at 2:10 p.m. revealed O. P. #2, O. P. 263 old cardiac rehab gym lacks sprinkler coverage.

Interview with S. O. on October 6, 2011, at 10:25 a.m. confirmed the above areas have deficiencies that would alter sprinkler coverage and/or compromise the area to be protected by sprinkler coverage.

K 062

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on four of thirteen floors.

Findings include:

1. Based on observation on October 4, 2011, between 10:10 a.m. and 4:10 p.m. revealed facility has ceiling removed at the following locations, which may delay activation of the fire sprinkler heads:
A. First floor tower ceiling tile removed in portico to the E.D./E.R. entrance (10:10 a.m.).
B. First floor tower monolithic ceiling removed in E.D. 115 electrical closet (10:11 a.m.).
C. O. P. #3, O. P. 336 ceiling tile removed in soiled utility room (2:47 p.m.).
D. 3E, E318 five monolithic ceiling openings in electrical room (4:10 p.m.).

Interview with S. O. on October 6, 2011, at 10:45 a.m. confirmed removed ceilings may delay activation of fire sprinkler heads.

2. Based on observation on October 4, 2011, at 1:32 p.m. revealed O. P. #1 alcove across from room O.P. 139 has boxes stored within 18" of the fire sprinkler head.

Interview with S. O. on October 6, 2011, at 10:40 a.m. confirmed items within 18" of the fire sprinkler head.

K 062

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on three of five floors.

Findings include:

1. Observation on October 3, 2011, at 2:00 p. m. revealed second floor unassigned room G236 has five ceiling tile removed and may delay activation of the fire sprinkler system.

Interview with S. O. on October 3, 2011, at 2:00 p. m. confirmed the ceiling tile is removed.

2. Observation on October 4, 2011, at 8:55 a. m. revealed first floor print shop G 176 has boxes stored directly below fire sprinkler head.

Interview with S. O. on October 4, 2011, at 8:55 a. m. confirmed the sprinkler head does not have 18" required distance from other items.

3. Observation on October 4, 2011, at 9:00 a. m. revealed first floor Siamese connection for the fire department (located outside the building at the loading dock) has a large amount of sediment that needs removed behind the protective caps.

Interview with S. O. on October 4, 2011, at 9:00 a. m. confirmed the sprinkler connection is not free of obstructions.

4. Observation on October 4, 2011, at 9:10 a. m. revealed first floor maintenance storage area is missing three ceiling tile and may delay activation of the fire sprinkler system.

Interview with S. O. on October 4, 2011, at 9:10 a. m. confirmed the ceiling tile is removed.

5. Observation on October 4, 2011, at 9:25 a. m. revealed basement elevator equipment room 0007 has two sprinkler escutcheons missing.

Interview with S. O. on October 4, 2011, at 9:25 a. m. confirmed the missing sprinkler escutcheons.

K 062

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on two of seven floors.

Findings include:

Observation on October 5, 2011, between 11:45 a. m. and 2:30 p. m. revealed the following areas have ceiling tile removed and may delay the activation of the fire sprinkler heads.
A. Second floor MRI (11:45 a. m.).
B. Second floor Cath Lab soiled utility room, monolithic ceiling removed as well as ceiling tile (11:47 a. m.).
C. Second floor X-Ray old Nuclear Med. room (12:55 p. m.).
D. Ground floor Pav. old tumor registry room. If ceiling tile is permanently removed, fire sprinkler heads need changed to upright-type heads (2:30 p. m.).

Interview with S. O. on October 5, 2011, at 2:30 p. m. confirmed the ceiling is removed.

K 064

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers, on one of five floors.

Findings include:

Observation on October 3, 2011, at 2:05 p. m. revealed the fire extinguisher in second floor room G265 kitchen is not properly mounted.

Interview with S. O. on October 3, 2011, at 2:05 p. m. confirmed the fire extinguisher is not properly mounted.

K 064

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers, on one of seven floors.

Findings include:

Observation on October 5, 2011, at 10:35 a. m. revealed the fire extinguisher in third floor minor procedure room #1 is not properly mounted.

Interview with S. O. on October 5, 2011, at 10:35 a. m. confirmed the fire extinguisher is not properly mounted.

K 066

Based on observation and interview, the facility failed to meet the requirements for smoking regulations in one location throughout the facility.

Findings include:

Observation on October 4, 2011, at 2:30 p.m. revealed that there was a member of the maintenance staff smoking in the sixth floor mechanical room in the OP building. There was a smell of smoke and evidence of cigarette butts in the area. This is not an approved smoking area per the facility's smoking policy.

Interview with S. O. on October 6, 2011, at 10:20 a.m. confirmed the facility did not adhere to the approved smoking policy.

Based upon observation and interview, the facility failed to meet the requirements for fire dampers for the entire facility

Findings include:

1. Observation and documentation review on October 6, 2011, at 9:00 a.m. revealed that the fire damper report dated November 2006 has deficiencies noted for 4th floor FDSA 4004 (Rm 457) and 12th floor FDRA (Rm 1220). Facility needs to verify these issues have been corrected.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for fire dampers.

Based upon observation and interview, the facility failed to meet the requirements for fire dampers for the entire facility.

Findings include:

1. Observation and documentation review on October 6, 2011, at 9:00 a.m. revealed that the fire damper report dated May 2007 for the 4th floor FDSA 254 (Oncology Manager) has a discrepancy listed. Facility must verify this issue was corrected.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for fire dampers.

K 069

Based on observation and interview, the facility failed to meet the requirements for cooking equipment/facilities in one location.

Findings include:

Observation on October 4, 2011, at 3:50 p.m. revealed that the kitchen ansul system lacks monthly inspections.

Interview with S. O. on October 6, 2011, at 10:15 a.m. confirmed the facility lacks monthly inspections on the hood suppression system.

K 070

Based upon observation and interview, it was determined the facility failed to monitor the portable space heating devices in the administrative areas on one of seven floors.

Findings include:

Observation on October 5, 2011, at 8:40 a. m. revealed facility shall verify the portable heater used in the sixth floor B6 administrative assistant office is U. L. listed.

Interview with S. O. on October 5, 2011, at 8:40 a. m. confirmed the heater shall be U. L. listed.

K 072

Based upon observation and interview, the facility failed to meet requirements for means of egress on four of thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 11:05 a.m. revealed that the cross-over corridor at the end of the hall on the fourteenth floor in palliative care is being blocked by various pieces of furniture.
2. Observation on October 3, 2011, at 2:21 p.m. revealed that wall-mounted charting station at LDRP 15 is not self-closing when left in the open position.
3. Observation on October 4, 2011, at 9:53 a.m. revealed that there is storage of equipment on the seventh floor in the operating room corridors.
4. Observation on October 4, 2011, at 11:24 a.m. revealed that there is storage of equipment on the seventh floor in the corridor near the on-call rooms in the OP building.
5. Observation on October 4, 2011, at 11:45 a.m. revealed that there are computers on wheels with chairs being stored in the corridor near room E731. This is creating a nurses' station in the corridor.
6. Observation on October 4, 2011, at 10:05 a.m. revealed first floor exit from E. D. waiting room 107A (glass hallway) has outside shrubs that need trimmed back to allow exit access.
7. Observation on October 4, 2011, at 10:55 a.m. revealed first floor X-ray department has a portable X-ray machine stored within the corridor.

Interview with S. O. on October 6, 2011, at 11:10 a.m. confirmed the means of egress shall be maintained throughout the facility.

K 072

Based upon observation and interview, the facility failed to meet requirements for means of egress on one of seven floors.

Findings include:

Observation on October 5, 2011, at 8:30 a. m. revealed sixth floor corridor outside pharmacy has housekeeping trash cans stored in the corridor blocking clear corridor width.

Interview with S. O. on October 5, 2011, at 8:30 a. m. confirmed the above corridor is not clear to width.

K 072

Based upon observation and interview, the facility failed to meet requirements for means of egress on two of five floors.

Findings include:

Observation on October 3, 2011, between 11:27 a. m. and 1:45 p. m. revealed the following locations have items blocking clear corridor width:
A. Fourth floor corridors near G 453 and G 470, chairs (11:27 a. m.).
B. Second floor corridor outside of freight elevator, large amount of boxes and pallets (1:45 p. m.).

Interview with S. O. on October 3, 2011, at 1:45 p. m. confirmed the above corridors are not clear to width.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on two of thirteen floors.

Findings include:

1. Based on observation on October 4, 2011, at 11:40 a..m. revealed second floor tower medical gas storage in back of purchasing department has medical gas cylinders that are not designated as full or empty.
2. Based on observation on October 4, 2011 at 2:25 p.m. revealed O. P. #2, O. P. 229 respiratory therapy has an overabundance of oxygen cylinders considered "in-use" (15 cylinders).
3. Based on observation on October 6, 2011, at 9:25 p.m. revealed there are oxygen cylinders in excess of 300 cubic feet being stored in room TC-211 and the electrical outlets/switches are not sixty inches above the floor and the oxygen is being stored within five feet of combustibles.

Interview with S. O. on October 6, 2011, at 10:35 a.m. confirmed medical gas shall be stored in accordance with regulations and the subsequent correction of item #2 only at the time of the survey.

K 077

Based upon observation and interview, the facility failed to meet the requirements for piped in medical gas on seven floors of thirteen.

Findings include:

1. Observation on October 3, 2011, at 12:18 p.m. revealed that the eleventh floor medical gas alarm panel for medical air is not labeled "not in use" and the gauge is reading zero and the panel is not in alarm status.
2. Observation on October 3, 2011, at 1:30 p.m. revealed that the tenth floor medical gas alarm panel for medical air is not labeled "not in use" and the gauge is reading zero and the panel is not in alarm status.
3. Observation on October 4, 2011, at 9:10 a.m. revealed that the medical gas shut-off located in eight floor STICU lacks labeling.
4. Observation on October 4, 2011, at 9:20 a.m. revealed that the oxygen medical gas shut-off located in the main corridor near T862 lacks labeling.
5. Observation on October 4, 2011, at 9:51 a.m. revealed that the air medical gas shut-off located in the corridor near room T851 lacks labeling.
6. Observation on October 4, 2011, at 10:35 a.m. revealed that the seventh floor medical gas shut-offs located in the operating room corridor are being blocked by equipment.
7. Observation on October 4, 2011, at 2:50 p.m. revealed that the fifth floor medical air dew point monitor located in the mechanical room exceeds 39 degrees Fahrenheit.
8. Observation on October 4, 2011, at 10:20 a.m. revealed E.D. department has a large cart blocking medical gas shut-off valves outside of 164 corridor.
9. Observation on October 4, 2011, at 3:50 p.m. revealed 3E medical gas shut-off valves are not labeled "out of service" in corridor across from E 301.

Interview with S. O. on October 6, 2011, at 11:25 a.m. confirmed the above piped-in medical gas deficiencies shall be addressed.

K 077

Based upon observation and interview, the piped in medical gas system does not comply with regulations on one of seven floors.

Findings include:

Observation on October 5, 2011, at 1:00 p. m. revealed second floor radiology corridor has an X-ray machine parked in front of the medical gas shut-off valves.

Interview with S. O. on October 5, 2011, at 1:00 p. m. confirmed the medical gas shut-off valves are obstructed, and the subsequent correction of this item during the survey.

Based upon observation and documentation review, the facility failed to comply with regulations for anesthetizing locations for one operating room in the operating room compartment.

Findings include:

1. Observation and documentation review on October 6, 2011, at 9:00 a.m. revealed that the humidity levels for operating room #6 are well below the 35% requirement for months November 2010 through April 2011.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for anesthetizing locations.

Based upon observation and documentation review, the facility failed to comply with regulations for anesthetizing locations for one operating room in the operating room compartment.

Findings include:

1. Observation and documentation review on October 6, 2011, at 9:00 a.m. revealed the facility lacked documentation for humidity levels for anesthetizing locations (operating room compartment) from August 1, 2010, to May 11, 2011.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item existed for anesthetizing locations.

K 104

Based upon observation and interview, the facility failed to meet the requirements for heating ventilation and air conditioning ducts in two locations on thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 2:05 p.m. revealed that the facility needs to verify that there is a smoke damper in the duct work above the ceiling at door T936A.
2. Observation on October 3, 2011, at 2:21 p.m. revealed that the facility needs to verify that an access panel for the smoke damper is in the duct work above the ceiling at T922 near T939A.

Interview with S. O. on October 6, 2011, at 10:10 a.m. confirmed the heating, ventilation and air conditioning units do not meet requirements.

K 130

28 Pa. Code ? 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. ? 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal, State and Local laws and regulations on one of five floors.

Findings include:

Observation on October 3, 2011, at 11:30 a. m. revealed fourth floor stand pipe access within stair tower G 466 has broken glass.

Interview with S. O. on October 3, 2011, at 11:30 a. m. confirmed the broken glass within the stair tower stand pipe access.

K 130

28 Pa. Code ? 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. ? 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal, State and Local laws and regulations on one of seven floors.

Findings include:

Observation on October 5, 2011, at 12:00 p. m. revealed the chapel has an unattended lit candle.

Interview with S. O. on October 5, 2011, at 12:00 p. m. confirmed candle was left unattended in the chapel.

K 130

28 Pa. Code ? 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. ? 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal, State and Local laws and regulations on one of thirteen floors.

Findings include:

Observation on October 4, 2011, at 3:30 p. m. revealed facility has a lab renovation/expansion under construction. Due to the construction, the facility has areas that are "safety-compromised" (smoke detectors out of service, removed ceiling tile, exposed wiring, use of extension cords, etc.). Facility shall verify a policy is in place to keep the construction areas safe during renovations until completion.

Interview with S. O. on October 6, 2011, at 10:20 a.m. confirmed the facility shall have a safety policy in place for all renovated areas.

K 143

Based upon observation and interview, oxygen transfilling locations and/or procedures failed to meet regulations on one of seven floors.

Findings include:

Observation on October 5, 2011, at 3:05 p. m. revealed ground floor liquid oxygen transfilling room on B1 lacks a "no smoking" and "oxygen transfilling in progress" sign outside the room.

Interview with S. O. on October 5, 2011, at 3:05 p. m. confirmed lack of signs outside the oxygen transfilling location.

Based upon documentation review and interview, the facility failed to meet the requirements for generators in one location for the entire building.

Findings include:

1. Observation on October 6, 2011, at 9:40 a.m. revealed that the facility lacks documentation that the remote annunciator for the generators meets the requirements of NFPA 99, Section 3-4.1.1.15. Note: The facility must also ensure the responsible staff is aware of these requirements.

Interview with Safety Officer (S. O.) on October 6, 2011, at 11:00 a.m. confirmed the above item shall be maintained to meet generator requirements.

Based upon observation and interview, the facility failed to meet the requirements for electrical wiring and/or equipment on nine of thirteen floors.

Findings include:

1. Observation on October 3, 2011, at 10:47 a.m. revealed that there are appliances plugged into a six-plug extension in the nurses' lounge, room 1451.
2. Observation on October 4, 2011, at 9:05 a.m. revealed that there is romex cable being used for the television amplifier in room T813.
3. Observation on October 4, 2011, at 10:32 a.m. revealed that there is medical equipment plugged into a surge protector in room T727.
4. Observation on October 4, 2011, at 11:05 a.m. revealed that there is exposed wiring at the clock location in women's locker room OP783.
5. Observation on October 4, 2011, at 11:56 a.m. revealed that there is storage in front of the electrical panels in room F707.
6. Observation on October 4, 2011, at 1:20 p.m. revealed that there is an open junction box above the ceiling in the corridor near room E714.
7. Observation on October 4, 2011, at 11:30 a.m. revealed that electrical panels (N-1 & N-2) on 7E corridor walls were found unlocked.
8. Observation on October 4, 2011, at 10:15 a.m. revealed first floor supply E.D. 131-A has a coffee pot that need the cord replaced (insulation gone to expose wiring).
9. Observation on October 4, 2011, at 11:13 a.m. revealed second floor purchasing office (pharmacy order placement) has a surge protector plugged into another surge protector.
10. Observation on October 4, 2011, at 11:15 a.m. revealed second floor pharmacy unpacking area has a surge protector plugged into another surge protector.
11. Observation on October 4, 2011, at 11:35 a.m. revealed purchasing/materials management has a microwave and coffee pot plugged into a surge protector.
12. Observation on October 4, 2011, at 11:50 a.m. revealed "the barn" storage area door 280 has electrical panels blocked with shelving and boxes.
13. Observation on October 4, 2011, at 11:57 a.m. revealed office 275 has a microwave and refrigerator plugged into a surge protector.
14. Observation on October 4, 2011, at 1:45 p.m. revealed O. P. #1, O. P. 118 has electrical panels blocked with ladders, wheelchairs, and shelving.
15. Observation on October 4, 2011, at 2:20 p.m. revealed O. P. #2, O. P. 214 cardiac holter monitoring room has a refrigerator, microwave, and coffee pot plugged into a surge protector.
16. Observation on October 4, 2011, at 2:30 p.m. revealed O. P. #2, O. P. 206 respiratory is utilizing a hospital grade extension cord.
17. Observation on October 4, 2011, at 3:05 p.m. revealed third floor tower 304A lab office has an extension cord plugged into a surge protector.
18. Observation on October 4, 2011, at 3:15 p.m. revealed third floor tower 305 lab area has two refrigerators plugged into a surge protector.
19. Observation on October 4, 2011, at 3:20 p.m. revealed third floor tower micro-biology has a surge protector plugged into another surge protector.
20. Observation on October 4, 2011, at 3:25 p.m. revealed third floor tower lab 332 has a ladder stored in front of electrical panel.
21. Observation on October 4, 2011, at 3:32 p.m. revealed third floor tower T-371 has a laundry cart and I. V. poles stored in front of electrical panels.
22. Observation on October 4, 2011, at 3:35 p.m. revealed third floor tower support services T-385A has a surge protector plugged into another surge protector.
23. Observation on October 4, 2011, at 3:54 p.m. revealed two open junction boxes by sprinkler main in 3E, E-307.
24. Observation on October 4, 2011, at 3:57 p.m. revealed 3E, E-308 volunteer services has two coffee pots plugged into a surge protector.
25. Observation on October 4, 2011, at 4:06 p.m. revealed 3E, E-316 plumbing shop is utilizing a hospital grade extension cord.
26. Observation on October 4, 2011, at 4:15 p.m. revealed 3E, E-319 plumbing shop has a toaster plugged into a surge protector and two permanently mounted surge protectors.
27. Observation on October 6, 2011, at 9:25 a.m. revealed there is an extension cord being used on the second floor trauma building in room TC-211.

Interview with S. O. on October 6, 2011, at 11:15 a.m. confirmed the above electrical deficiencies shall be addressed.

K 147

Based upon observation and interview, the facility failed to meet the requirements for electrical wiring and/or equipment on one of five floors.

Findings include:

Observation on October 3, 2011, between 11:20 a. m. and 11:25 a. m. revealed the following electrical deficiencies:
A. Fourth floor office G 448 has a microwave oven plugged into a surge protector (11:20 a. m.).
B. Fourth floor area G 453 has a surge protector plugged into another surge protector (11:25 a. m.).

Interview with S. O. on October 3, 2011, at 11:25 a. m. confirmed the above items shall be plugged directly into a wall receptacle.

K 147

Based upon observation and interview, the facility failed to meet the requirements for electrical wiring and/or equipment on two of seven floors.

Findings include:

Observation on October 5, 2011, between 1:05 p. m. and 2:25 p. m. revealed the following electrical deficiencies:
A. Second floor E. D. bay #4 has temporary lighting above the ceiling tile (1:05 p. m.).
B. Second floor police department office has a microwave, refrigerator, and coffee pot plugged into a surge protector.
C. First floor dietary office, clerk area is utilizing an extension cord (1:45 p. m.).
D. First floor business office, cashier area has a coffee pot plugged into a surge protector (2:25 pm).

Interview with S. O. on October 5, 2011, at 2:25 p. m. confirmed the above electrical deficiencies.