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Based on observation and staff interview, the facility failed to maintain the integrity of smoke/fire barriers. This potentially allows the spread of smoke/fire to other areas of the facility, exposing residents to a smoke or fire environment. The findings are as follows.

During the facility tour on July 30, 2013 from 0800-1700 and July 31, 2013 0500-1500 penetrations were observed in the following location(s)

1. Birthing wing - by patient room 1 in the ceiling tile by reception area
2. Employee exercise room - gym closet
3. Drywall missing above fire panel on 10th floor housekeeping closet (CORRECTED)
4. 6th floor, clean bed storage 6 center - by door and under windows


These findings were acknowledged by the Maintenance Director.

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially exposed residents to a smoke/fire environment. Findings include:

During the facility tour on July 30 2013 from 0800-1700 and July 31, 2013 from 0500-1500 it was observed that the following doors did not close, latch or open properly when tested:

1. 9th floor nurses lounge door
2. 8th floor family room
3. 7th floor doctors room
4. Anesthia and MD Lounge - OR side door
5. OR Core east entry door (closure assembly not attached)

These findings were acknowledged by the facility Maintenance Director.

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially exposed residents to a smoke/fire environment. Findings include:

During the facility tour on July 30, 2013 from 0800-1700 and July 31, 2013 from 0500-1500 it was observed that the following doors did not latch properly when tested:

1. Patient room 1 door obstructed from closing due to trash can - women's child birth center
2. Patient room 3 door obstructed from closing due to trash can - women's child birth center
3. Micro biology doors did not have latching hardware
4. Eleventh Floor, Patient Tower - fire sep doors to family waiting room north door failed to latch
5. Eleventh floor, helipad door failed to latch
6. Seventh floor, Patient tower - fire sep doors by nurses station to elevator lobby south, failed to close with coordinator
7. Sixth floor, Patient tower - elevator lobby doors obstructed from closing
8. Emergency Room - fire door into waiting area not functioning with coordinator
9. Emergency room, express care reception - door wedged open (CORRECTED)
10. Receiving dock - fire doors main receiving not functioning with coordinator
11. OR West - auto doors failed to latch.
12. Cross corridor doors by OR 3 - failed to close all the way
13. Cross corridor doors by OR Control desk - failed to close all the way.

These findings were acknowledged by the facility Maintenance Staff.

Based on observations and staff interview, the facility failed to provide functional fire doors in a hazardous area. This has the potential to expose residents to a fire or smoke environment. The findings are as follows:

During the facility tour on July 30, 2013 from 0800-1700 and July 31, 2013 from 0500-1500 found doors that did not close and latch:

1. 9th floor soiled utility room
2. 9th floor activity storage
3. ER - rubbish chute door
4. Receiving dock - linen chute door
5. OR West - clean utility room 435
6. Mop room door across from OR 6
7. Cell Netix lab door by OR Control desk

These findings were acknowledged by the Maintenance Director.

Based upon observation and staff interviews the facility has failed to maintain exits so that they are readily accessible and useable at all times. This may result in residents and staff not being able to exit the building in an emergency.

During the facility tour on July 30, 2013 from 0800 to 1700 it was observed that the exit doors at NICU back hallway were equipped with delayed egress but no sign was posted for the 15 second alarm mode.

This finding was acknowledged by the maintenance staff.

Based on observation and staff interviews, the facility failed to maintain proper exit signage. This has the potential to misdirect residents or staff while exiting during an emergency.

During the facility tour on July 30, 2013 from 0800-1700 the following exit signs were observed to be deficient:

1. Exit sign by OR 12 being held in place by tape (CORRECTED)
2. Exit sign missing at stairwell located by inpatient pre op (CORRECTED)


These findings were acknowledged by the Maintenance Director.

Based on observations, the facility failed to maintain the proper operational condition of the fire alarm system. This has the potential of having a non-functional fire alarm system that would expose residents to a fire or smoke environment. The findings are as follows:

During the facility tour on July 30, 2013 from 0800-1700 the following deficiency was observed:

1. ER - the roll down door in the ER express care reception are not connected to the fire alarm system

These findings were acknowledged by the Maintenance Director.

Based on observations and staff interview during the facility tour on July 30, 2013 from 0800 to 1700 and July 31, 2013 from 0500 to 1500, the facility failed to provide a complete approved sprinkler system in accordance to NFPA 13, Section 5-1.1. This lack of sprinkler coverage has the potential to expose residents to a fire or smoke environment. The findings are as follows:

1. The following areas did not have sprinkler coverage:
a. Old autoclave room
b. Entry room into the case management lead office
c. Supply storage off nurses station - 7th floor of tower
d. Pharmacy room - emergency room area
e. Walk in freezer and cooler - main receiving dock
f. Box bailer room off trash compactor room

The facility ' s Maintenance Director acknowledged these findings.

Based on observations, the facility failed to maintain the proper operational condition of the sprinkler system. This has the potential of having a non-functional sprinkler system that would expose residents to a fire or smoke environment. The findings are as follows:

During the facility tour on July 30, 2013 from 0800-1700 and July 31, 2013 from 0500-1500 the following deficiencies were found:

1. Escutcheon rings missing in the following locations
a. patient room 2026
b. physical therapy corridor
c. medical records corridor restroom
d. employee exercise room woman's restroom
e. 11th floor nourishment room
f. 11th floor hallway by nourishment room
g. ER hallway by reception area
h. 6 center divider curtain room
i. 6 center clean bed storage
j. cardiac short stay office 4 south
k. housekeeping closet across from OR 5

2. High pile storage obstruction the sprinkler head flow
a. 9th floor - clean pillow closet across from room 923
b. 8th floor - toy closet

These findings were acknowledged by the Maintenance Director.

Based on observation and record review, the facility failed to assure fire extinguishers are properly maintained. This potentially delays a quick response to contain a fire from spreading, exposing residents to fire in the environment.

During the facility tour on July 31, 2013 from 0500-1500 observed a fire extinguisher in the following location out of service:

1. Plant - elevator equipment room (CORRECTED)

During the facility tour on July 31, 2013 from 0500-1500 observed a fire extinguisher in the following locations obstructed:

1. Receiving dock (CORRECTED)
2. North Wing 2nd floor - PFE #214 blocked by refrigerator
3. Surgery Core (CORRECTED)

The Maintenance Director acknowledged the findings.

Based on record review and staff interview, the facility failed to assure that emergency power was available during primary power outage in accordance with NFPA 99, 3-4.4.2 requiring documentation of testing, maintenance and repairs of the generator. This potentially affected all residents to loss of illumination of exit egress, fire and smoke alarms during a power outage. Findings include:

During the facility tour on July 30, 2013 from 0800-1700 the following deficiency was observed:

On the electrical panels from the emergency back up generator the circuits are not clearly identified as to what systems are supplied i.e. life safety branch.

This deficiency was acknowledged by the maintenance staff.

Based on observations, the facility failed to maintain proper electrical conditions per NFPA 70, National Electrical Code. This has the potential to expose staff and patients to a fire
environment. The findings are as follows:

During the facility tour on July 30, 2013 from 0800-1700 and July 31, 2013 from 0500-1500, the following deficiencies were found:

1. NICU physicians room - extension cord powering microwave
2. Birthing wing - med room exposed electrical wiring
3. Room 2023 - electrical conduit exposed in ceiling
4. Mother/baby staff lounge - extension cord powering microwave/toaster
5. Basement IT storage room - exposed j box
6. Physical therapy - exposed wiring behind clock
7. Physical therapy office - daisy chain multi plug adapter
8. Hyperbaric Wound care patient access rep desk - hanging power strip
9. Employee exercise room - exposed wiring by entrance
10. Tumor registry - unapproved electrical outlet extension cord
11. Record processing analysis - daisy chain multi plug adapter
12. MARC area in Pharmacy office - extension cord powering fan
13. NARC area in Pharmacy - 2 refrigerators plugged into multi plug adapter
14. Micro biology - refrigerator plugged in multi plug adapter
15. Case Management Admin Asst - daisy chain multi plug adapters
16. CDM Coordinator - brown extension cord powering radio
17. Case Management office - daisy chain multi plug adapters by copy machine
18. Case Management Asst desk - daisy chain multi plug adapters
19. Electrical closet by Fire sep doors 11th floor - open j box on ceiling by patient room 1101
20. 8th floor - Data closet - cover missing on panel (CORRECTED)
21. ER - extension cord in use in break room
22. ER - nurses station missing cover plate on box by copy machine
23. Receiving dock - combustibles stored in electrical vault across from mech room S-31
24. Garbage chute room - j box missing cover
25. North wing 4th floor - daisy chain multi plug adapters
a. office - 301-521 (CORRECTED)
b. office - 301-526
c. office - 301-522
d. office - 301-472
e. office - 301-525
26. North wing 3rd floor - daisy chain multi plug adapters
a. copy room 301-933 (CORRECTED)
b. office - 301-232
c. office - 301-963 (CORRECTED)
27. North wing 2nd floor - daisy chain multi plug adapters
a. office - 302-321 (CORRECTED)
b. office - 302-313
c. office - 302-306
d. office - 302-309
e. office - 302-315
28. North wing 2nd floor - extension cord plugged into multi plug adapter
a. office - 302-321 (CORRECTED)
b. office - 302-312 (CORRECTED)
c. office - 302-308 (CORRECTED)
29. Histology lab - extension cord powering tissue tek machine
30. OR Coordinator office - multi to multi plug adapter (CORRECTED)

These findings were acknowledged by the Maintenance Director

Based on observation and staff interview, the facility failed to maintain the proper distance for hand based alcohol hand gel from an electrical source. This potentially allows the spread of smoke and fire to other areas of the facility, exposing residents to a hazardous environment. The findings are as follows.

During the facility tour on July 30 2013 from 0800-1700 and July 31 2013 from 0500-1500 improper mounting of alcohol based hand rub was observed in the following location(s)

1. Baby room 6
2. Baby room 7
3. OR 8

These findings were acknowledged by the Maintenance Director.