HospitalInspections.org

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Room 2310 , Penetrations in firewall were not sealed in order to maintain required fire rating of wall.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1.STICU Room # 11629 - Inactive leaf with no self closing device and self- latching. Exit access doors must provide latching with a single hand motion.(Approx 29 rooms/ and 2 add'l floors)

2. Family waiting room - STICU : Master switch will not release exit access door near 11681 Conf Room. Door did release as required with sensor and push pad.

3. Dutch doors to Pharmacy Office 10682 had no self closing and self-latching device on inactive leaf. Door must be arranged to provide latching with a single hand motion.

4. Corridor doors to patient rooms # 9130 and 7133 would not latch/nor smoke tight.

5. Patient Room 6020 - Corridor door inactive leaf is not self-closing and self-latching - (12 rooms on 6th floor).

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Smoke barrier @ entrance to STICU has access door above ceiling- door is not self closing/latching (Beside Family waiting room - 11th floor)

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Cross corridor smoke doors @ Rm # 10621 and 3rd floor Smoke doors outside of Nuclear Cardiology do not close smoke tight when tested.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Corridor door to Ortho storage room near Rm 11310/11312 - Inactive leaf of 3/4 hour fire door with-out self closing device and latching hardware. (Med Center Air Training Room)

2. No self closing device on doors to Elev Machine room - Med Center Air - Mechanical Room and 7th Floor - West wing Nursery storage Rm 7600.81.

3. Clean storage across from Rm 10115 - Transom @ top of door has framing that is not listed fire door frame

4. Corridor door to Mech Room across from RM 10939B has excessive gap at top of door.

5. Room 10307 - Storage area utilizes side-wall sprinkler heads and some areas have no coverage.

6. 10 L - Storage Area/Access area (beside Gold Elevator) is not sprinklered and one hour required corridor wall has gypsum board on one side of studs with studs exposed from inside the room.

7. 2nd Floor Trash Chute Termination Room - abandoned access door thru wall was not secured to maintain required fire rating of the wall.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. The third floor delayed egress locking device on corridor doors required more than 15 lbs of pressure to initiate the un-locking process (next to the linen and trash chutes from L to P ). The door released as required under normal operating conditions and released with activation of the Fire Alarm System as required.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Stairway #18, Level 2 - No signage to indicate continuance of egress to exit discharge.

2. Stairway #18 - Exit discharge contains less than 6 ft 8 inches of headroom from top of stair tread to landing above. The height between the finished floor and ceiling of stair landing is less than seven feet and six inches as required under the 1982 Life Safety Code; NFPA 101 edition. This area of the facility was constructed in year 1991 according to hospital data; and serves multiple patient floors.

3. Stair # 24, Fire Door will not latch, Beside room 1660.

4. 6th Floor , 6-L/S, Door to Stairwell 6th floor to 5th floor did not close/latch/seal as required.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. The corridors at staff area on 9th floor (and floors below) are only five feet wide. Exit signs directing general public, staff and patients to these corridors require these corridors to be eight feet wide for Healthcare Occupancy.

Note: If truly staff only areas, and not intended for customary access by patients, then five feet corridors are permitted.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. 1st floor @ room 1001 - Exit Discharge lighting had only one single bulb fixture. Emergency lighting connected to the Life Safety Branch of the essential electrical system must be provided from the exit discharge to the publicway.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. No emergency lighting in small corridor @ Rm # 9422 - Epilepsy Monitoring Unit.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Corridor area @ Stairwell #4 - Exit directional sign did not indicate correct travel path to exit stairwell.

2. 4th Floor Radiology Reading Rooms exit egress corridor - no exit directional sign

3. Stairwell 17, Level 1, T-wing, Exit sign directs people back into building, Chevron directional indicator missing.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Corridor smoke detector installed more than 15 feet from end wall of corridor - Near 9 A wing and L wing intersection.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. ESRD - Staff breakroom - 10th floor - No sprinkler coverage for shower stall area.

2. Stairway # 20 - Lower landing at exit passageway has no sprinkler coverage.

3. J-Wing , 5th Floor - There was no sprinkler coverage nor heat/smoke detection in the area at construction entrance.

4. 7th Floor - I.S. Closet @ rm 7719 had no sprinkler coverage.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. The Pre-Action Dry Sprinkler system (Covering ORs) - Valve @ air pressure alarm not supervised.

2. 7-D, Stairwell # 5 - Tamper alarm was secured with "J" hooks.

3. Loading dock area - Dry sprinkler system - pressure operated flow switch valve not supervised.

4. Blythe Pkg Deck - Sprinkler System - Back flow preventers tamper switches (2 of 3 tested) did not send alarm.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. CMC- Main - Penthouse - A-wing: Chair and 2X4 wood members found in AHU plenum - make -up air unit.

2. 2-B Mech Room, Smoke duct detector # N7L3057 in AHU # 13, Detection tube turned 180 degrees wrong direction.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Kitchen/ Dietary - New deep fryer added with no Ansul fire suppression nozzle installed to cover the new equipment.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

Portable Space Heater -High Temp Type- in Nurse Manager's office -across from ESRD Continuum Care

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. 10 floor - C-wing - Dumbwaiter fire rated door (Near elevator) has a hole in the door leaf.

2. Vertical Chase across from room 9948 - access door is not required 2 hr fire rated.

3. Trash Hold Room # 1662 - door to trash chute terminal room was found to be 3/4 hr rated door instead of required 1.5 hr rating.

4. Vertical chute fire access door 6000.3 is not self closing and latching.

5. A-Wing Mech Room - Door to vertical chute did not close/latch/seal as required.

6. 7th Floor - Dumbwaiter chute door in NICU large storage room does not self close and latch as required.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. 2nd Floor, across from room 2E-86, Corridor doors to storage rooms opened into corridor. They were not equipped with self closing hardware nor would swing 180 degrees in order not to impede egress.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Room 10402 - Unsecured O 2 tank (freestanding on floor).

2. Unsecured O 2 tanks at old loading dock, also H tanks - O 2 gang chained and not individually secured as required. (Gang chain found loose and not supporting tanks as necessary to prevent damage to valves).

Based on observation and staff records on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Relative humidity levels were found to be less than 35% in OR# 1 and OR #2. This data was provided by hospital reports.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Generator Annunciator did not show loss of normal power to ATS with audible/visual signaling device. Test switch did not activate audible signaling device @ Security Station & Plant operations.

Based on observation on Tuesday 3/1/2011, 9 AM onward thru Friday 3/4/2011, 3:30 PM:

1. Unitary Light required @ Generator Set control panel area - Lower Blythe Parking Deck.

2. Unit heater to Fire Pump Room is connected to Normal power source (Blythe Pkg Deck).

3. Electrical Snap Switch was broken @ M-wing exit passageway - beside pull station N6L1M01.

4. Electrical Panel Board circuit directory is not labeled to indicate devices served - panelboard serving exit passageway beside pull station N6L1M01.