HospitalInspections.org

Based on observation and interview, the facility failed to maintain a two hour barrier between itself and a medical office building. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

On 02/24/16 at 9:03 AM observation above the drop down ceiling of the three hour fire barrier separating the facility from a medical office building in the radiology file room and near grid position N10 revealed a half inch conduit with an annular space across from the door.

On 02/24/16 at 9:03 AM in an interview, Staff Q confirmed the finding.

On 02/24/16 at 9:12 AM observation above the drop down ceiling of the three hour barrier between the facility and a medical office building as seen in the corridor above the door to the laboratory, second tile from the west wall, near grid N9, revealed a one inch conduit with an annular space.

On 02/24/16 at 9:12 AM in an interview, Staff Q confirmed the finding.

Based on observation and record review, the facility failed to meet the requirement for building construction and type as required at 19.1.6. This had the potential to affect any patient receiving treatment at the facility.


Findings include:

On 02/26/16 at 8:00 AM a review of the facility ' s fire safety documentation was completed. The review revealed an architectural drawing that revealed part of the building was three stories high, rated to be Type II(111), and part of the building was unsprinklered.

Review of a letter from the architect, dated 02/26/16, confirmed the building rating.

Observation of the first floor on 02/25/16 confirmed parts of the building on the first floor were unsprinklered.

Based on observation and interview the facility failed to ensure the walls of its corridors were smoke tight as rated. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.

1. On 02/22/16 at 12:17 PM observation above the drop down ceiling of the smoke tight barrier two tiles near the door to the staff breakroom revealed two one inch open conduits holding white, yellow, and blue wiring.

On 02/22/16 at 12:17 PM in an interview, Staff Q confirmed the finding.

2. On 02/22/16 at 1:56 PM observation above the drop down ceiling of the smoke tight barrier over room 314 revealed two open one inch conduits just to the right of the call light and holding wiring.

On 02/22/16 at 1:56 PM in an interview, Staff Q confirmed the finding.

3. On 02/22/16 at 1:52 PM observation above the drop down ceiling of the smoke tight barrier near room 316 revealed an open white tipped conduit holding two lines.

On 02/22/16 at 1:52 PM in an interview, Staff Q confirmed the finding.

4. On 02/22/16 at 2:51 PM observation above the drop down ceiling of the smoke tight barrier above the door to the clean utility room revealed a one inch open conduit holding blue and white cables.

On 02/22/16 at 2:51 PM in an interview, Staff Q confirmed the finding.

5. On 02/22/16 at 3:10 PM observation above the drop down ceiling of the smoke tight barrier over the unisex bathroom revealed an open one inch conduit holding blue and white cables that penetrated completely through the barrier.

On 02/22/16 at 3:10 PM in an interview, Staff Q confirmed the finding.

6. On 02/22/16 at 3:40 PM observation above the drop down ceiling of the smoke tight barrier as seen to the left of room 303 and over the " 303 " placard revealed a two inch by two inch square complete penetration under heating, ventilation, and cooling ductwork.

On 02/22/16 at 3:40 PM in an interview, Staff Q confirmed the finding.

7. On 02/22/16 at 3:58 PM observation above the drop down ceiling of the smoke tight barrier between room 308 and 309 revealed a complete three inch diameter circular penetration through the barrier.

On 02/22/16 at 3:58 PM in an interview, Staff Q confirmed the finding.

8. On 02/22/16 at 4:06 PM observation above the drop down ceiling of the smoke tight barrier to the right of room 310 revealed a one inch open conduit holding an orange line that completely penetration the barrier.

On 02/22/16 at 4:06 PM in an interview, Staff Q confirmed the finding.

9. On 02/22/16 at 4:08 PM observation above the drop down ceiling of the smoke tight barrier to the left of room 311 revealed an open one inch conduit holding an orange line that completely penetrated the barrier.

On 02/22/16 at 4:08 PM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

10. On 02/23/16 at 8:50 AM observation above the drop down ceiling of the smoke tight barrier above the chaplain office revealed a two inch hole above a heating, ventilation, and cooling duct completely through the barrier.

On 02/23/16 at 8:50 AM in an interview, Staff Q confirmed the finding.

11. On 02/23/16 at 8:58 AM observation above the drop down ceiling of the smoke tight barrier at room 219 revealed a polyvinyl pipe with an annular space that went completely through the barrier.

On 02/23/16 at 8:58 AM in an interview, Staff Q confirmed the finding.

12. On 02/23/16 at 9:08 AM observation above the drop down ceiling of the smoke tight barrier near room 217 revealed a one inch complete penetration on top of a heating, ventilation, and cooling duct.

On 02/23/16 at 9:08 AM in an interview, Staff Q confirmed the finding.

13. On 02/23/16 at 11:03 AM observation above the drop down ceiling of the smoke tight barrier in the critical care area between the employee lounge and the a director ' s office revealed a two inch drain pipe with an annular space that penetrated through the barrier and held two blocks of wood.

On 02/23/16 at 11:03 AM in an interview, Staff Q confirmed the finding.

14. On 02/23/16 at 1:43 PM observation above the drop down ceiling of the smoke tight barrier two tiles to the west of room 225 a six by eight inch square was observed to go completely through the barrier and hold a one and a half inch conduit itself holding three grey cables.

On 02/23/16 at 1:43 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM the tour of the first floor resumed with Staff Q.

15. On 02/25/16 at 2:03 PM observation above the drop down ceiling of the wall over room 1034 in an unsprinklered corridor revealed a three inch pipe with an annular space that went completely through.

On 02/25/16 at 2:03 PM in an interview, Staff Q confirmed the finding.

16. On 02/25/16 at 2:24 PM observation above the drop down ceiling of the smoke tight barrier over x-ray A revealed an annular space around a sprinkler line.

On 02/25/16 at 2:24 PM in an interview, Staff Q confirmed the finding.

17. On 02/25/16 at 2:46 PM observation above the drop down ceiling of the smoke tight barrier four tiles to the south of the door to the break room in radiology revealed two red lines traveling from an open conduit.

On 02/25/16 at 2:46 PM in an interview, Staff Q confirmed the finding.

18. On 02/25/16 at 2:57 PM observation above the drop down ceiling of the smoke tight barrier over the door on a southeast diagonal from exit sign 136 revealed a one inch conduit open to air holding a red cable.

On 02/25/16 at 2:57 PM in an interview, Staff Q confirmed the finding.

19. On 02/25/16 at 4:28 PM observation above the drop down ceiling of the smoke tight barrier opposite endoscopy two revealed an open conduit holding red and black cables.

On 02/25/16 at 4:28 PM in an interview, Staff Q confirmed the finding.

20. On 02/25/16 at 4:37 PM observation above the drop down ceiling of the smoke tight barrier as seen from the corridor and to the south of the double doors to OR E revealed an annular space around a chiller pipe that completely pierced the barrier.

On 02/25/16 at 4:37 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors protecting corridor opening that had self-closing and latching hardware closed and latched the doors. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

1.On 02/23/16 at 11:02 AM observation of the employee lounge corridor door revealed it had self-closing and latching hardware that did not self-close and latch the door when tested.

On 02/23/16 at 11:02 AM in an interview, Staff Q confirmed the finding.

2. On 02/25/16 at 11:56 PM the CT scan room door that opens onto a corridor was observed to have self-closing and latching hardware that when tested did not close and latch the door.

On 02/25/16 at 11:56 PM in an interview, Staff Q confirmed the finding.

3. On 02/25/16 at 12:02 PM observation of the radiology waiting room door that opens on to a corridor was observed to have self-closing and latching hardware that when tested did not close and latch the door.

On 02/25/16 at 12:02 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM the tour of the first floor resumed with Staff Q.

4. On 02/25/16 at 1:45 PM the door to the locker room located at grid position C12 revealed it was a corridor door in an unsprinklered corridor. The door was observed to have self-closing and latching hardware that did not self-close and latch the door.

On 02/25/16 at 1:45 PM in an interview, Staff Q confirmed the finding.

5. On 02/25/16 at 3:55 PM doors to the endoscopy suite revealed they opened onto a corridor and had self-closing and latching hardware that did not self-close and latch the door when tested.

On 02/25/16 at 3:55 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the stated rating surrounding each of its shafts and stairways. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.

1. On 02/22/16 at 11:55 AM observation above the drop down ceiling of the two hour rated barrier surrounding the shaft room on the east end of the floor revealed on the west side of the shaft an open one inch conduit holding yellow, blue, and grey cables.

On 02/22/16 at 11:55 AM in an interview, Staff Q confirmed the finding.

2. On 02/22/16 at 12:01 PM observation of the floor in the penthouse area housing a Motorola appliance revealed a three inch open conduit between the penthouse floor and the third floor ceiling holding green, blue, and yellow wiring.

On 02/22/16 at 12:01 PM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

3. On 02/24/16 at 3:02 PM observation above the drop down ceiling of the two hour fire barrier surrounding an elevator shaft revealed to the east of the door to the shaft was a one inch hole with two grey cables traveling through it.

On 02/24/16 at 3:02 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each path of egress was marked with readily visible exit signs. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/25/16 at 11:52 AM the path of egress by room 6 was observed to have an exit sign obscured by drop down lighting.

On 02/25/16 at 11:52 AM in an interview, Staff Q confirmed the finding.

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Based on observation and interview, the facility failed maintain the stated rating of smoke barriers. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.


1.On 02/22/16 at 3:20 PM observation above the drop down ceiling of the one hour smoke barrier over the double doors perpendicular to room 321 and two tiles from the south revealed an open one inch conduit holding a yellow line.

On 02/22/16 at 3:20 PM in an interview, Staff Q confirmed the finding.

2. On 02/22/16 at 4:00 PM observation above the drop down ceiling of the double doors in the one hour smoke barrier and perpendicular to room 310 as seen from the west and three tiles from the north, revealed an open two inch conduit holding turquois and other colored lines.

On 02/22/16 at 4:00 PM in an interview, Staff Q confirmed the finding.

3. On 02/22/16 at 4:12 PM observation above the drop down ceiling of the one hour fire barrier over the door leading to the equipment storage room revealed two open conduits with one completely open and the other holding a beige line.

On 02/22/16 at 4:12 PM in an interview, Staff Q confirmed the finding.

4. On 02/22/16 at 4:15 PM observation above the drop down ceiling of the one hour fire barrier surrounding the same equipment room revealed to the right of the door as seen from the hall a sprinkler line with an annular space next to a one inch corrugated conduit holding two yellow lines.

On 02/22/16 at 4:15 PM in an interview, Staff Q confirmed the finding.

5. On 02/22/16 at 4:19 PM observation above the drop down ceiling of the one hour fire barrier surrounding the same equipment room as seen above the door from inside the room revealed to the right of the door a one inch corrugated conduit open to air and holding a yellow line.

On 02/22/16 at 4:19 PM in an interview, Staff Q confirmed the finding.

6. On 02/22/16 at 4:21 PM observation above the drop down ceiling of the one hour fire barrier between the same equipment room and an oxygen closet revealed to the west over the door to the oxygen closet two open white tipped conduits holding white wiring and to the east over the door a one and a half inch open conduit holding white lines and an open two inch conduit holding yellow lines.

On 02/22/16 at 4:21 PM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

7. On 02/23/16 at 9:45 AM observation above the drop down ceiling of the one hour smoke barrier surrounding the clean utility room as seen from the hall above room 211 revealed a two inch open conduit holding grey wiring.

On 02/23/16 at 9:45 AM in an interview, Staff Q confirmed the finding.

8. On 02/23/16 at 9:51 AM observation above the drop down ceiling of the one hour barrier surrounding the clean utility room as seen from inside revealed over the door a six inch by six inch square in the barrier.

On 02/23/16 at 9:51 AM in an interview, Staff Q confirmed the finding.

9. On 02/23/16 at 10:00 AM observation above the drop down ceiling of the one hour smoke barrier as seen from within room 211 and over the bed next to the bathroom, a three yard by one foot high opening was observed in the barrier.

On 02/23/16 at 10:00 AM in an interview, Staff Q confirmed the finding.

10. On 02/23/16 at 10:06 AM observation above the drop down ceiling of the one hour smoke barrier as seen from the critical care isolation anteroom revealed pipe with an annular space.

On 02/23/16 at 10:06 AM in an interview, Staff Q confirmed the finding.

11. On 02/23/16 at 10:13 AM observation above the drop down ceiling of the one hour smoke barrier as seen from the east side of the double doors leading to the critical care area revealed a two inch open conduit holding orange and yellow lines.

On 02/23/16 at 10:13 AM in an interview, Staff Q confirmed the finding.

12. On 02/23/16 at 10:48 AM observation inside the equipment room in the critical care area and above the drop down ceiling of the one hour fire barrier surrounding it revealed a copper line with an annular space (seen above the computer), over the door a one inch conduit with an annular space, and ninety degrees east to the door a one inch conduit with an annular space.

On 02/23/16 at 10:48 AM in an interview, Staff Q confirmed the finding.

13. On 02/23/16 at 10:55 AM observation above the drop down ceiling of the one hour smoke barrier as seen from the east side of the southern double doors leading into the critical care area revealed a one inch hole with blue and black cables traveling through it.

On 02/23/16 at 10:55 AM in an interview, Staff Q confirmed the finding.

14. On 02/23/16 at 10:58 AM observation above the drop down ceiling of the one hour smoke barrier over the south double doors leading to the critical care area, but seen from the west side of the doors and looking above the south door, revealed a one inch penetration with black, blue, and white wiring traveling through it.

On 02/23/16 at 10:58 AM in an interview, Staff Q confirmed the finding.

15. On 02/23/16 at 11:39 AM observation above the drop down ceiling of the one hour smoke barrier in critical care family waiting area as seen above the television stand revealed a one foot by one foot square penetration, and six tiles from the door, the barrier was observed not to extend all the way up to the deck.

On 02/23/16 at 11:39 AM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 2:12 PM a tour was taken of the first floor with Staff Q

16. On 02/23/16 at 2:37 PM observation from the hall and above the drop down ceiling of the one hour fire barrier surrounding the pharmacy revealed three tiles north from the door to pharmacy a one inch open conduit.

On 02/23/16 at 2:37 PM in an interview, Staff Q confirmed the finding.

17. On 02/23/16 at 2:42 PM observation above the drop down ceiling of the one hour fire barrier surrounding the pharmacy as seen from inside revealed a one inch penetration by conduits. The penetration can be seen two tiles north from the door.

On 02/23/16 at 2:42 PM in an interview, Staff Q confirmed the finding.

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

18. On 02/24/16 at 10:28 AM observation above the drop down ceiling of the one hour smoke barrier over the double doors perpendicular to the women ' s bathroom at H10 revealed over the west side of the south door a two inch open conduit holding blue and turquois wiring and a one inch open conduit holding blue wiring.

On 02/24/16 at 10:28 AM in an interview, Staff Q confirmed the finding.

19. On 02/24/16 at 10:30 AM observation above the drop down ceiling of the one hour smoke barrier revealed at the same set of double doors, on the east side of the north door, a two inch penetration with blue plastic conduits, and in the north barrier perpendicular to the doors, and four tiles east of the doors, a blue plastic conduit was observed in a two inch penetration.

On 02/24/16 at 10:30 AM in an interview, Staff Q confirmed the finding.

20. On 02/24/16 at 10:35 AM observation above the drop down ceiling of the one hour smoke barrier above the double doors leading to the cafeteria and near grid position H10 revealed on south side of the west door a two inch conduit with an annular space.

On 02/24/16 at 10:35 AM in an interview, Staff Q confirmed the finding.

21. On 02/24/16 at 11:15 AM observation above the drop down ceiling of the one hour fire barrier as seen from the corridor and between door 13 and the riser room, a half inch open white tip conduit holding white wiring and a 1.5 inch open conduit holding black wiring, and a three inch conduit holding white wiring and having an annular space in the sleeve it ran through.

On 02/24/16 at 11:15 AM in an interview, Staff R confirmed the finding.

22. On 02/24/16 at 1:43 PM observation above the drop down ceiling of the one hour fire barrier inside rise room A, revealed, going from west to east, one grey cable in a one inch penetration, a copper line traveling through a stainless steel sleeve and having an annular space between it and the sleeve, an annular space between a white pipe and a stainless steel sleeve, and a conduit with blue cable open to air.

On 02/24/16 at 1:43 PM in an interview, Staff Q confirmed the finding.

23. On 02/24/16 at 1:52 PM observation above the drop down ceiling of the one hour fire barrier as seen from the corridor and two tiles from the corner opposite exit sign 009 revealed a white tip conduit with two cables open to air.

On 02/24/16 at 1:52 PM in an interview, Staff Q confirmed the finding.

24. On 02/24/16 at 2:05 PM observation above the drop down ceiling of the two hour barrier between pathology and the birthing center, as seen from the corridor just north of exit sign 025 revealed a white tip conduit open to air holding blue cables.

On 02/24/16 at 2:05 PM in an interview, Staff Q confirmed the finding.

25. On 02/24/16 at 2:09 PM observation above the drop down ceiling of the one hour fire barrier four tiles west from the storage room near exit sign 025 revealed a conduit traveling out of a two inch by two inch square opening.

On 02/24/16 at 2:09 PM in an interview, Staff Q confirmed the finding.

26. On 02/24/16 at 2:42 PM observation above the drop down ceiling of the one hour fire barrier between the mail area and the waiting area and near exit sign 013 revealed an annular space around a plumb line.

On 02/24/16 at 2:42 PM in an interview, Staff Q confirmed the finding.

27. On 02/24/16 at 2:49 PM observation above the drop down ceiling of the two hour fire barrier located near the elevator shaft and room 1052, and just north of the door to room 1052, revealed three conduits with a collective annular space.

On 02/24/16 at 2:49 PM in an interview, Staff Q confirmed the finding.

28. On 02/24/16 at 2:56 PM observation above the drop down ceiling of the one hour fire barrier two tiles north from the marketing office revealed a half inch conduit open to air holding a cable.

On 02/24/16 at 2:56 PM in an interview, Staff Q confirmed the finding.

29. On 02/24/16 at 2:58 PM observation above the drop down ceiling of the one hour fire barrier as seen from within a waiting area located at grid position B10 and five tiles to the left of the clock revealed a two inch grey tip conduit open to air holding yellow, white, and grey cables.

On 02/24/16 at 2:58 PM in an interview, Staff Q confirmed the finding.

30. On 02/24/16 at 3:10 PM observation above the drop down ceiling of the one hour fire barrier near exit sign 003 and three tiles down from a fire extinguisher cabinet revealed one inch open penetration.

On 02/24/16 at 3:10 PM in an interview, Staff Q confirmed the finding.

31. On 02/24/16 at 3:25 PM observation above the drop down ceiling of the two hour fire barrier between the sleep rooms located in the physician lounge at grid location E9 revealed two heating, ventilation, and cooling ducts with annular spaces, one sprinkler line with an annular space, and one open conduit holding two red cables. (This was observed inside the east sleep room.)

On 02/24/16 at 3:25 PM in an interview, Staff Q confirmed the finding.

32. On 02/24/16 at 3:28 PM observation above the drop down ceiling of the two hour fire barrier in the same physician ' s lounge above the couch revealed an open conduit holding two red cables, and above the entrance to the east sleep room an open conduit holding one red cable.

On 02/24/16 at 3:28 PM in an interview, Staff Q confirmed the finding.

33. On 02/24/16 at 3:38 PM observation above the drop down ceiling of the one hour fire barrier near the second door east from exit sign 057 revealed a one inch conduit open to air holding two red cables.

On 02/24/16 at 3:38 PM in an interview, Staff Q confirmed the finding.

34. On 02/24/16 at 3:52 PM observation above the drop down ceiling of the one hour smoke barrier of the most south double doors in the birth center revealed above the north door a one inch penetration with two orange cables running through it.

On 02/24/16 at 3:52 PM in an interview, Staff Q confirmed the finding.

35. On 02/24/16 at 4:03 PM observation above the drop down ceiling the one hour fire barrier over the entrance to the cafeteria near exit sign 59 revealed it did not extend all the way to the deck above.

On 02/24/16 at 4:03 PM in an interview, Staff M confirmed the finding explaining the door had been moved north from the barrier, but the barrier had not come with it.

36. On 02/24/16 at 4:08 PM observation above the drop down ceiling of the one hour smoke barrier as seen within birthing suite three revealed five open conduits, from right to left, starting at the door: one holding a red cable, one holding two yellow cables, one holding one orange cable, one holding one blue and one red cable, and another holding one grey cable.

On 02/24/16 at 4:08 PM in an interview, Staff Q confirmed the finding.

37. On 02/24/16 at 4:45 PM observation above the drop down ceiling of the one hour smoke barrier at grid position H13 (south wall) revealed a yellow tipped conduit open to air.

On 02/24/16 at 4:45 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM a tour of the first floor was resumed with Staff Q.

38. On 02/25/16 at 1:22 PM observation above the drop down ceiling of the one hour smoke barrier as seen in the purchasing office revealed a three inch by three inch hole with a plumb line running through it.

On 02/25/16 at 1:22 PM in an interview, Staff Q confirmed the finding.

39. On 02/25/16 at 1:26 PM observation above the drop down ceiling of the one hour smoke barrier in the west wall of the office next to purchasing revealed a plumbing with an annular space.

On 02/25/16 at 1:26 PM in an interview, Staff Q confirmed the finding.

40. On 02/25/16 at 1:29 PM observation above the drop down ceiling of the one hour barrier in the west wall of the biomedical office and two tiles from the corner revealed a collective annular space around six conduits.

On 02/25/16 at 1:29 PM in an interview, Staff Q confirmed the finding.

41. On 02/25/16 at 3:02 PM observation above the drop down ceiling of the one hour barrier approximately three tiles to the north of exit sign 139 revealed an open junction box with an open conduit holding black, red, and blue cables.

On 02/25/16 at 3:02 PM in an interview, Staff Q confirmed the finding.

42. On 02/25/16 at 3:25 PM observation above the drop down ceiling of the two hour barrier as seen in the dry storage area of the kitchen and two doors down from the coolers (grid position F11 and opposite the entrance to the room) revealed three two inch holes, one containing a bundle of red wires.

On 02/25/16 at 3:25 PM in an interview, Staff Q confirmed the finding.

43. On 02/25/16 at 3:32 PM observation of a door in the physician ' s lounge revealed it was in a two hour barrier but did not self-close and latch.

On 02/25/16 at 3:32 PM in an interview, Staff Q confirmed the finding.

44. On 02/25/16 at 4:12 PM observation above the drop down ceiling of the one hour fire barrier in the north wall west of the double doors west of exit sign 109 and at grid position K13 revealed a one inch open conduit holding a red cable.

On 02/25/16 at 4:12 PM in an interview, Staff Q confirmed the finding.

45. On 02/25/16 at 4:48 PM observation above the drop down ceiling of the one hour fire barrier between the clean-up room and janitor closet (near exit sign 113) revealed a one inch conduit open to air.

On 02/25/16 at 4:48 PM in an interview, Staff Q confirmed the finding.

46. On 02/25/16 at 5:03 PM observation above the drop down ceiling of the two hour barrier on the other side of the double doors near exit sign 115 revealed over the north door a conduit with an annular space and in that annular space blue, white, and grey cables.

On 02/25/16 at 5:03 PM in an interview, Staff Q confirmed the finding.

47. On 02/25/16 at 5:13 PM the door to the women ' s locker room in surgery was observed to be in a two hour barrier but have a ¾ hour rating.

On 02/25/16 at 5:13 PM in an interview, Staff Q confirmed the finding.

48. Observations were made on tour in the therapy area, treatment room #8, on 02/25/16 at 1:33 PM of a penetration in a one hour smoke partition by a white tipped conduit with two red wires feeding through it. This finding was confirmed with Staff R at the time of the observation.
49. Observations were made in the cardiopulmonary area physician lounge on 02/25/16 at 3:10 PM of a penetration in a two hour fire partition wall of a 4 " conduit with cut away drywall open space around it. This finding was confirmed with Staff R at the time of the observation.
50. Observations were made in the same day surgery area on 02/25/16 at 3:45 PM of a white tipped ½ " conduit with a red wire penetrating a two hour fire partition in room 4, and also in the same area was a 2 " diameter copper pipe with a drywall cut out opening around it resulting in a penetration in a two hour fire partition. This finding was confirmed with Staff R at the time of the observation.

Based on observation and interview, the facility failed to ensure each door in a smoke barrier self-closed and, where so equipped, latched. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.

1. On 02/22/16 at 12:18 PM the double doors perpendicular to room 314 and in a one hour smoke barrier revealed when tested that they did not completely closed.

On 02/22/16 at 12:18 PM in an interview, Staff Q confirmed the finding.

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

2. On 02/24/16 at 10:09 AM observation of the door to the chapel revealed it was in a one hour smoke barrier but did not have a self-closer.

On 02/24/16 at 10:09 AM in an interview, Staff Q confirmed the finding.

3. On 02/24/16 10:46 AM in an interview, the door to room 1023 was observed to be in a one hour fire barrier but was not observed to self-close and latch.

On 02/24/16 at 10:46 AM in an interview, Staff Q confirmed the finding.

4. On 02/24/16 at 11:37 AM observation of the door near exit sign 008 in the two hour barrier surrounding a mechanical space revealed it was held open with a rubber strap so that it could not self-close.

On 02/24/16 at 11:37 AM in an interview, Staff Q confirmed the finding.

5. On 02/24/16 at 1:34 PM observation of the door to the Director of Materials office was observed in a one hour barrier but did not have a self-closer.

On 02/24/16 at 1:34 PM in an interview, Staff Q confirmed the finding.

6. On 02/24/16 at 2:05 PM the door to the pathology department was observed to be in a two hour fire barrier but was not observed to have a rating.

On 02/24/16 at 2:05 PM in an interview, Staff Q confirmed the finding.

7. On 02/24/16 at 2:22 PM observation of the north door out of pathology revealed it was in a one hour fire barrier, but did not have a self-closer.

On 02/24/16 at 2:22 PM in an interview, Staff Q confirmed the finding.

8. On 02/24/16 at 2:38 PM the door to room 1052 was observed to be in a one hour fire barrier but was not observed to have a self-closer.

On 02/24/16 at 2:38 PM in an interview, Staff Q confirmed the finding.

9. On 02/24/16 at 2:40 PM observation of the door in the one hour fire barrier leading out of the " mail " area and into the " waiting area " (located near grid position C9) revealed it was not on a self-closer.

On 02/24/16 at 2:40 PM in an interview, Staff Q confirmed the finding.

10. On 02/24/16 at 3:23 PM observation of the door to the east sleep room of the physician lounge located at grid position E9 and in a two hour fire barrier revealed it did not have a self-closer.

On 02/24/16 at 3:23 PM in an interview, Staff Q confirmed the finding.

11. On 02/24/16 at 3:42 PM observation of the door to the anesthesia call room revealed it was in a one hour smoke barrier but did not have a self-closer.

On 02/24/16 at 3:42 PM in an interview, Staff Q confirmed the finding.

12. On 02/24/16 at 4:11 PM the door to the birthing center break room was observed to be in a one hour smoke barrier with self-closing and latching hardware that did not close and latch the door.

On 02/24/16 at 4:11 PM in an interview, Staff Q confirmed the finding.

13. On 02/24/16 at 4:48 PM observation of the door to room A006 revealed it was in a one hour fire barrier and had self-closing and latching hardware that did not self-close and latch.

On 02/24/16 at 4:48 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM the tour of the first floor resumed with Staff Q.

14. On 02/25/16 at 4:45 PM the door to the janitor closet in the operating rooms area was observed to be in a one hour fire barrier without a self-closer.

On 02/25/16 at 4:45 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the stated rating surrounding its hazardous areas and to ensure each door to a hazardous area self-closed and where so equipped, latched. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.

1. On 02/22/16 at 2:55 PM observation above the drop down ceiling of the middle of the eastern wall of the one hour fire barrier surrounding the soiled utility room revealed a one inch open conduit holding blue and white lines.

On 02/22/16 at 2:55 PM in an interview, Staff Q confirmed the finding.

2. On 02/22/16 at 2:56 PM observation above the drop down ceiling over the south door in the one hour fire barrier surrounding the soiled utility room revealed an open one inch conduit holding orange lines.

On 02/22/16 at 2:56 PM in an interview, Staff Q confirmed the finding.

3. On 02/22/16 at 3:00 PM observation above the drop down ceiling of the north wall of the one hour barrier surrounding the same soiled utility room revealed one straight open conduit holding blue and grey cables, one holding orange and red cables, and two open conduits holding nothing. All conduits were one inch in diameter.

On 02/22/16 at 3:00 PM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

4. On 02/23/16 at 9:23 AM the one hour fire barrier surrounding the soiled utility room was observed from inside and above the drop down ceiling. The observation revealed over the door a white plumb line with an annular space, over the slop sink black wiring with an annular space, and to the right of the door and above a heating, ventilation, and cooling duct a one inch seam between dry wall sheets.

On 02/23/16 at 9:23 AM in an interview, Staff Q confirmed the finding.

5. On 02/23/16 at 10:40 AM observation above the drop down ceiling of the one hour fire barrier surrounding the soiled utility room in the critical care area revealed an open junction box with an open conduit leading to the south wall.


On 02/23/16 at 10:40 AM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 2:12 PM a tour was taken on of the first floor with Staff Q and M.

6. On 02/23/16 at 2:29 PM observation of the south wall of the two hour fire barrier surrounding the air handler room as seen seven tiles down from the storage room, revealed a one inch open conduit holding black lines.

On 02/23/16 at 2:29 PM in an interview, Staff Q confirmed the finding.

7. On 02/23/16 at 3:34 PM observation above the drop down ceiling of the one hour fire barrier in the women ' s center (but surrounding the lab on the other side) near exit sign 134 and between the maid closet and storage room revealed one inch open conduit holding two red lines.

On 02/23/16 at 3:34 PM in an interview, Staff Q confirmed the finding.

8. On 02/23/16 at 3:38 PM observation above the drop down ceiling of the same one hour fire 8. barrier surrounding the laboratory and seen from the women ' s center, west from the above finding and above an alarm strobe revealed two white tip open conduits holding white lines. Continuing west along the barrier, observation above the drop down ceiling inside the reading room revealed one penetration holding three white lines.

On 02/23/16 at 3:38 PM in an interview, Staff Q confirmed the finding.

9. On 02/23/16 at 3:47 PM observation above the drop down ceiling of the same one hour fire barrier surrounding the laboratory and seen from the women ' s center in the procedure room near exit sign 132 revealed two conduits open to air holding white wiring.

On 02/23/16 at 3:47 PM in an interview, Staff Q confirmed the finding.

10. On 02/23/16 at 3:53 PM observation above the drop down ceiling of the one hour barrier surrounding the laboratory as seen from the corridor near exit sign 135 and six tiles north from staff only door to laboratory revealed two open one inch conduits and one open conduit with grey cables.

On 02/23/16 at 3:53 PM in an interview, Staff Q confirmed the finding.

11. On 02/23/16 at 3:58 PM observation above the drop down ceiling of the one hour fire barrier over the door to the laboratory and near exit sign 135 revealed a penetration with a blue plastic conduit and grey lines running through it.

On 02/23/16 at 3:58 PM in an interview, Staff Q confirmed the finding.

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

12. On 02/24/16 at 9:03 AM observation of the radiology file room revealed the room to be full of radiology records in open shelving from the floor to eight feet above. The room is sprinklered however the doors leading into the room were not on a self-closer.

On 02/24/16 at 9:03 AM in an interview, Staff Q confirmed the finding.

13. On 02/24/16 at 9:38 AM observation above the drop down ceiling of the two hour fire barrier protecting the air handler room as seen from the women ' s health, near a desk and exit sign 129 revealed a half inch conduit open to air.

On 02/24/16 at 9:38 am in an interview, Staff Q confirmed the finding.

14. On 02/24/16 at 9:46 AM observation above the drop down ceiling of the two hour fire barrier protecting the air handler room as seen in women ' s health and above the door to room 130 revealed a one and a half inch open conduit holding yellow, blue, and turquois lines, one one inch conduit holding a black line and having an annular space, and a half inch open conduit holding one red line (three tiles south of the door).

On 02/24/16 at 9:46 AM in an interview, Staff Q confirmed the finding.

15. On 02/24/16 at 9:56 AM observation above the drop down ceiling of the two hour barrier protecting the air handler room as seen from the gift shop revealed three open copper conduits, four conduits forming a collective annular space, and, over the cabinet next to the closet, a one and a half inch open conduit holding grey lines.

On 02/24/16 at 9:56 AM in an interview, Staff Q confirmed the finding.

16. On 02/24/16 at 11:10 AM observation of the two hour fire barrier surrounding the power plant and seen above the drop down ceiling opposite door 13 revealed a blue plastic one inch conduit with an annular space.

On 02/24/16 at 11:10 AM in an interview, Staff R confirmed the finding.

17. On 02/24/16 at 11:20 AM observation above the drop down ceiling of the two hour barrier surrounding the power plant as seen in the corridor and near exit sign 008 revealed four copper lines that formed a collective annular space.

On 02/24/16 at 11:20 AM in an interview, Staff Q confirmed the finding.

18. On 02/24/16 at 11:47 AM observation of the two hour barrier between the mechanical space and the kitchen/dining area, as seen from inside the mechanical space, revealed near grid position F12 medical gas lines with a collective annular space, a three inch sleeve open to air with blue, black, and white cables running through it, and a white tip conduit open to air holding one grey cable.

On 02/24/16 at 11:47 AM in an interview, Staff Q confirmed the finding.

19. On 02/24/16 at 11:52 AM observation of the two hour barrier protecting the mechanical space, as seen from inside the mechanical space, revealed a red cable through a penetration through the east wall seen within the switch room at grid position F13. The door to the switch room was observed to be in a two hour barrier but the self-closing and latching hardware did not self-close and latch door when tested.

On 02/24/16 at 11:52 AM in an interview, Staff Q confirmed the finding.

20. On 02/24/16 at 11:56 AM observation of the two hour barrier in the mechanical space at location F14 revealed, over a desk, a two inch conduit open to air holding a black cable.

On 02/24/16 at 11:56 AM in an interview, Staff Q confirmed the finding.

21. On 02/24/16 at 2:25 PM observation above the drop down ceiling of the one hour fire barrier surrounding the pathology department as seen from inside the department, two tiles west from the door to " mail " room, revealed a one inch conduit with green cables open to air.

On 02/24/16 at 2:25 PM in an interview, Staff Q confirmed the finding.

22. On 02/24/16 at 2:32 PM observation above the drop down ceiling of the one hour smoke barrier protecting the storage room located at grid position D10 revealed at the entrance above the south door blue and yellow cables traveling from an open conduit.

On 02/24/16 at 2:32 PM in an interview, Staff Q confirmed the finding.

23. On 02/24/16 at 2:36 PM observation above the drop down ceiling of the one hour fire barrier between the pathology department and a storage space located at grid position D10 revealed a white plumb line with and annular space. This was seen inside the storage space.

On 02/24/16 at 2:36 PM in an interview, Staff Q confirmed the finding.

24. On 02/24/16 at 4:52 PM observation above the drop down ceiling of the one hour fire barrier as seen inside the soiled utility room of same day surgery and three tiles south of the door revealed an open conduit holding two grey wires and above the slop sink an open conduit holding two red cables.

On 02/24/16 at 4:52 PM in an interview, Staff Q confirmed the finding.

25. On 02/24/16 at 5:02 PM observation above the drop down ceiling of the one hour barrier surrounding the clean laundry room in same day surgery as seen outside and at the west wall revealed a three inch open conduit holding black and grey cables.

On 02/24/16 at 5:02 PM in an interview, Staff Q confirmed the finding.

26. On 02/24/16 at 5:14 PM observation above the drop down ceiling of the one hour barrier surrounding the clean laundry room in same day surgery as seen outside and south of the door revealed a corrugated conduit traveling through an open one inch square and a three inch conduit holding a bundle of white wires.

On 02/24/16 at 5:14 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM the tour of the first floor resumed with Staff Q.

27. On 02/25/16 at 1:38 PM observation of the double doors in the one hour fire barrier in the hazardous area next to the morgue revealed they did not coordinate and therefore did not always close and shut completely.

On 02/25/16 at 1:38 PM in an interview, Staff Q confirmed the finding.

28. On 02/25/16 at 2:30 PM observation above the drop down ceiling of the one hour barrier surrounding the soiled utility room in radiology revealed, as observed within, in the north barrier, a two inch open conduit and two open conduits with red cables traveling out from them.

On 02/25/16 at 2:30 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each of its exit stairways were enclosed with a fire resistive rating of at least one hour. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

1.On 02/23/16 at 8:42 AM observation of the door to exit stair 2, enclosed in a one hour rated fire barrier, revealed it was unrated.

On 02/23/16 at 8:42 AM in an interview, Staff Q confirmed the finding.

2. On 02/23/16 at 11:17 AM observation above the drop down ceiling of the one hour barrier to stairwell 2 revealed it did not extend all the way to the deck above.

On 02/23/16 at 11:17 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the width of the corridor in its geriatric psychiatric unit to at least four feet.This had the potential to affect any patient receiving treatment at the facility.


Findings include:

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

On 02/23/16 at 1:52 PM observation of the southeast corridor within a unit holding mentally ill geriatric patients and leading to a patient gathering room and quiet room revealed near exit sign 222 a fixed glass partition was in the corridor shrinking the width of the corridor at that point to three feet, seven inches.

On 02/23/16 at 1:52 PM in an interview, Staff Q and M confirmed the finding.

Based on record review and staff interview the facility failed to ensure fire drills were conducted in accordance with facility policy/ procedure. This deficient practice had the potential to affect any patient receiving services at the facility.

Findings include:
Review of the Fire Drill Evaluation Form revealed the Sleep Lab had a different form than the Fire Drill Evaluation Form that was part of the hospital policy/ procedure (11.04.02). Comparison of the forms revealed the hospital policy/ procedure form was more comprehensive, requiring more evaluation and steps than the Sleep Lab form, therefore the drills completed at the Sleep Lab had not followed the facility procedure. Interview with Staff M on 02/25/16 at 9:30 AM confirmed that the Sleep Lab form was not consistent with the facility policy / procedure for fire drills.

Based on record review and interview, the facility failed to ensure its fire drills were held at unexpected times under varying conditions. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/26/16 at 8:00 AM a review of the facility ' s fire safety documentation was completed. The review revealed the fire drills for 2015 for the third shift all occurred within 15 minutes of 6:32 AM., and for the second shift all drill occurred within an hour of 8:00 PM.

On 02/26/16 at 8:40 AM staff Q and M confirmed the finding explaining drill were held at times that are least likely to be disruptive.

Based on observation, record review, and interview, the facility failed to maintain its fire alarm system in accordance with NFPA 72, 1999 edition. This had the potential to affect any patient receiving treatment at the facility.

Findings include

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

On 02/23/16 at 8:50 AM a fire strobe was observed outside the chaplain office.

On 02/23/16 at 9:08 AM a fire bell was observed outside room 215.

On 02/23/16 at 10:06 AM a fire bell was observed outside room 211.

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

On 02/24/16 at 9:12 AM a fire strobe was observed in laboratory room 016, outside at the door, and in a nearby bathroom.

On 02/26/16 at 8:00 AM a review of the facility ' s fire safety documentation was completed. The review revealed the fire alarm system was inspected on 09/29/15.

The review did not reveal a list of the building ' s fire bells and strobes with their location to validate each and every appurtenance in inventory, including those observed on tour, was tested and passed, and to validate the accuracy of the inventory with what is seen in the building.

On 02/29/16 at 11:30 AM in an interview, Staff Q confirmed the finding.

Based on record review and staff interview the facility failed to ensure the time lapse for the fire notification signal was documented to determine compliance with NFPA 72, 1999 edition, 7-2. This had the potential to affect any patient receiving treatment at the facility.
Findings include:
Review of fire drill documentation for the Sleep Center located in Building B on 02/24/16 revealed the time lapse from the time the signal was initiated until it was received by the monitoring company was not documented. Interview with Staff M on 02/24/16 1:26 PM confirmed this observation.

Based on interview, observation, and record review, the facility failed to maintain its sprinkler system in accordance with NFPA 13 and 25, 1999 editions. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/23/16 at 2:12 PM a tour was taken of the first floor with Staff Q and M.

1.On 02/23/16 at 2:43 PM observation of shelving within the pharmacy, 180 degrees from the entrance door, revealed paraphernalia place on top bring the gap from the sprinkler heads to less than 18 inches.

On 02/23/16 at 2:43 PM in an interview, Staff M confirmed the observation.

2. On 02/24/16 at 11:33 AM a tour of the bathrooms in the geriatric psychiatric unit revealed they had a type of sprinkler head of which the facility did not have spare heads for.

On 02/24/16 at 11:33 AM in an interview, Staff R confirmed the observation.

3. On 02/26/16 at 8:00 AM a review of the facility fire safety documentation was completed. The review revealed the sprinkler system was inspected four times in 2015. The sprinkler report for 03/17/15 revealed the gauges for the pump suction, pump discharge, and system pressure had static per square inch pressure readings but did not indicate they were okay.

A review of the sprinkler report for 06/16/15 revealed the same gauges had per square inch pressure readings that were marked as okay.

Contradicting this, a review of the sprinkler report for 09/15/15 revealed the same gauges had per square inch pressure readings but did not indicate they were okay.

On 02/26/16 at 8:40 AM in an interview, Staff Q confirmed the findings.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4.This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/26/16 at 8:00 AM a review of the facility ' s fire safety documentation was completed. The review revealed not all dampers had been tested in the last six years.

On 02/26/16 at 8:40 AM in an interview, Staff M confirmed the dampers had not been tested in the last six years.

Based on observations and staff interview the facility failed to meet NFPA 9.7.5 related to maintenance of the sprinkler system. This had the potential to affect any patient receiving treatment at the facility.

Findings include:
Review of quarterly Sprinkler Inspection Certificate reports revealed the facility failed to maintain consistent documentation for gauges related to air and water pressure. Review of the quarterly report for MOB-B, M3-025 dated 03/17/15 for gauges #09807699 (city water pressure) and #0980770 (air pressure) revealed data was recorded but the boxes labeled " OK " had not been checked. Review of the gauge report dated 06/16/15 revealed the boxes labeled " OK " were marked. Review of the gauge report dated 09/15/15 revealed the boxes labeled " OK " were not marked. Review of the gauge report dated 12/15/15 revealed the boxes labeled " OK " were not marked. Interview with Staff M on 02/25/16 at 9:22 AM confirmed the documentation was inconsistent related to the inspection of the gauges.

Based on observation and interview, the facility failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. This had the potential to affect any patient receiving treatment at the facility.


Findings include:

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

On 02/24/16 at 1:53 PM observation of the break room in the " electric room " revealed a power strip plugged into an extension cord. Plugged into the power strip was a microwave, toaster oven, and coffee maker.

On 02/24/16 at 1:53 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain a two hour barrier between itself and a medical office building. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

On 02/24/16 at 9:03 AM observation above the drop down ceiling of the three hour fire barrier separating the facility from a medical office building in the radiology file room and near grid position N10 revealed a half inch conduit with an annular space across from the door.

On 02/24/16 at 9:03 AM in an interview, Staff Q confirmed the finding.

On 02/24/16 at 9:12 AM observation above the drop down ceiling of the three hour barrier between the facility and a medical office building as seen in the corridor above the door to the laboratory, second tile from the west wall, near grid N9, revealed a one inch conduit with an annular space.

On 02/24/16 at 9:12 AM in an interview, Staff Q confirmed the finding.

Based on observation and record review, the facility failed to meet the requirement for building construction and type as required at 19.1.6. This had the potential to affect any patient receiving treatment at the facility.


Findings include:

On 02/26/16 at 8:00 AM a review of the facility ' s fire safety documentation was completed. The review revealed an architectural drawing that revealed part of the building was three stories high, rated to be Type II(111), and part of the building was unsprinklered.

Review of a letter from the architect, dated 02/26/16, confirmed the building rating.

Observation of the first floor on 02/25/16 confirmed parts of the building on the first floor were unsprinklered.

Based on observation and interview the facility failed to ensure the walls of its corridors were smoke tight as rated. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.

1. On 02/22/16 at 12:17 PM observation above the drop down ceiling of the smoke tight barrier two tiles near the door to the staff breakroom revealed two one inch open conduits holding white, yellow, and blue wiring.

On 02/22/16 at 12:17 PM in an interview, Staff Q confirmed the finding.

2. On 02/22/16 at 1:56 PM observation above the drop down ceiling of the smoke tight barrier over room 314 revealed two open one inch conduits just to the right of the call light and holding wiring.

On 02/22/16 at 1:56 PM in an interview, Staff Q confirmed the finding.

3. On 02/22/16 at 1:52 PM observation above the drop down ceiling of the smoke tight barrier near room 316 revealed an open white tipped conduit holding two lines.

On 02/22/16 at 1:52 PM in an interview, Staff Q confirmed the finding.

4. On 02/22/16 at 2:51 PM observation above the drop down ceiling of the smoke tight barrier above the door to the clean utility room revealed a one inch open conduit holding blue and white cables.

On 02/22/16 at 2:51 PM in an interview, Staff Q confirmed the finding.

5. On 02/22/16 at 3:10 PM observation above the drop down ceiling of the smoke tight barrier over the unisex bathroom revealed an open one inch conduit holding blue and white cables that penetrated completely through the barrier.

On 02/22/16 at 3:10 PM in an interview, Staff Q confirmed the finding.

6. On 02/22/16 at 3:40 PM observation above the drop down ceiling of the smoke tight barrier as seen to the left of room 303 and over the " 303 " placard revealed a two inch by two inch square complete penetration under heating, ventilation, and cooling ductwork.

On 02/22/16 at 3:40 PM in an interview, Staff Q confirmed the finding.

7. On 02/22/16 at 3:58 PM observation above the drop down ceiling of the smoke tight barrier between room 308 and 309 revealed a complete three inch diameter circular penetration through the barrier.

On 02/22/16 at 3:58 PM in an interview, Staff Q confirmed the finding.

8. On 02/22/16 at 4:06 PM observation above the drop down ceiling of the smoke tight barrier to the right of room 310 revealed a one inch open conduit holding an orange line that completely penetration the barrier.

On 02/22/16 at 4:06 PM in an interview, Staff Q confirmed the finding.

9. On 02/22/16 at 4:08 PM observation above the drop down ceiling of the smoke tight barrier to the left of room 311 revealed an open one inch conduit holding an orange line that completely penetrated the barrier.

On 02/22/16 at 4:08 PM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

10. On 02/23/16 at 8:50 AM observation above the drop down ceiling of the smoke tight barrier above the chaplain office revealed a two inch hole above a heating, ventilation, and cooling duct completely through the barrier.

On 02/23/16 at 8:50 AM in an interview, Staff Q confirmed the finding.

11. On 02/23/16 at 8:58 AM observation above the drop down ceiling of the smoke tight barrier at room 219 revealed a polyvinyl pipe with an annular space that went completely through the barrier.

On 02/23/16 at 8:58 AM in an interview, Staff Q confirmed the finding.

12. On 02/23/16 at 9:08 AM observation above the drop down ceiling of the smoke tight barrier near room 217 revealed a one inch complete penetration on top of a heating, ventilation, and cooling duct.

On 02/23/16 at 9:08 AM in an interview, Staff Q confirmed the finding.

13. On 02/23/16 at 11:03 AM observation above the drop down ceiling of the smoke tight barrier in the critical care area between the employee lounge and the a director ' s office revealed a two inch drain pipe with an annular space that penetrated through the barrier and held two blocks of wood.

On 02/23/16 at 11:03 AM in an interview, Staff Q confirmed the finding.

14. On 02/23/16 at 1:43 PM observation above the drop down ceiling of the smoke tight barrier two tiles to the west of room 225 a six by eight inch square was observed to go completely through the barrier and hold a one and a half inch conduit itself holding three grey cables.

On 02/23/16 at 1:43 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM the tour of the first floor resumed with Staff Q.

15. On 02/25/16 at 2:03 PM observation above the drop down ceiling of the wall over room 1034 in an unsprinklered corridor revealed a three inch pipe with an annular space that went completely through.

On 02/25/16 at 2:03 PM in an interview, Staff Q confirmed the finding.

16. On 02/25/16 at 2:24 PM observation above the drop down ceiling of the smoke tight barrier over x-ray A revealed an annular space around a sprinkler line.

On 02/25/16 at 2:24 PM in an interview, Staff Q confirmed the finding.

17. On 02/25/16 at 2:46 PM observation above the drop down ceiling of the smoke tight barrier four tiles to the south of the door to the break room in radiology revealed two red lines traveling from an open conduit.

On 02/25/16 at 2:46 PM in an interview, Staff Q confirmed the finding.

18. On 02/25/16 at 2:57 PM observation above the drop down ceiling of the smoke tight barrier over the door on a southeast diagonal from exit sign 136 revealed a one inch conduit open to air holding a red cable.

On 02/25/16 at 2:57 PM in an interview, Staff Q confirmed the finding.

19. On 02/25/16 at 4:28 PM observation above the drop down ceiling of the smoke tight barrier opposite endoscopy two revealed an open conduit holding red and black cables.

On 02/25/16 at 4:28 PM in an interview, Staff Q confirmed the finding.

20. On 02/25/16 at 4:37 PM observation above the drop down ceiling of the smoke tight barrier as seen from the corridor and to the south of the double doors to OR E revealed an annular space around a chiller pipe that completely pierced the barrier.

On 02/25/16 at 4:37 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors protecting corridor opening that had self-closing and latching hardware closed and latched the doors. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

1.On 02/23/16 at 11:02 AM observation of the employee lounge corridor door revealed it had self-closing and latching hardware that did not self-close and latch the door when tested.

On 02/23/16 at 11:02 AM in an interview, Staff Q confirmed the finding.

2. On 02/25/16 at 11:56 PM the CT scan room door that opens onto a corridor was observed to have self-closing and latching hardware that when tested did not close and latch the door.

On 02/25/16 at 11:56 PM in an interview, Staff Q confirmed the finding.

3. On 02/25/16 at 12:02 PM observation of the radiology waiting room door that opens on to a corridor was observed to have self-closing and latching hardware that when tested did not close and latch the door.

On 02/25/16 at 12:02 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM the tour of the first floor resumed with Staff Q.

4. On 02/25/16 at 1:45 PM the door to the locker room located at grid position C12 revealed it was a corridor door in an unsprinklered corridor. The door was observed to have self-closing and latching hardware that did not self-close and latch the door.

On 02/25/16 at 1:45 PM in an interview, Staff Q confirmed the finding.

5. On 02/25/16 at 3:55 PM doors to the endoscopy suite revealed they opened onto a corridor and had self-closing and latching hardware that did not self-close and latch the door when tested.

On 02/25/16 at 3:55 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the stated rating surrounding each of its shafts and stairways. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.

1. On 02/22/16 at 11:55 AM observation above the drop down ceiling of the two hour rated barrier surrounding the shaft room on the east end of the floor revealed on the west side of the shaft an open one inch conduit holding yellow, blue, and grey cables.

On 02/22/16 at 11:55 AM in an interview, Staff Q confirmed the finding.

2. On 02/22/16 at 12:01 PM observation of the floor in the penthouse area housing a Motorola appliance revealed a three inch open conduit between the penthouse floor and the third floor ceiling holding green, blue, and yellow wiring.

On 02/22/16 at 12:01 PM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

3. On 02/24/16 at 3:02 PM observation above the drop down ceiling of the two hour fire barrier surrounding an elevator shaft revealed to the east of the door to the shaft was a one inch hole with two grey cables traveling through it.

On 02/24/16 at 3:02 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each path of egress was marked with readily visible exit signs. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/25/16 at 11:52 AM the path of egress by room 6 was observed to have an exit sign obscured by drop down lighting.

On 02/25/16 at 11:52 AM in an interview, Staff Q confirmed the finding.

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Based on observation and interview, the facility failed maintain the stated rating of smoke barriers. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.


1.On 02/22/16 at 3:20 PM observation above the drop down ceiling of the one hour smoke barrier over the double doors perpendicular to room 321 and two tiles from the south revealed an open one inch conduit holding a yellow line.

On 02/22/16 at 3:20 PM in an interview, Staff Q confirmed the finding.

2. On 02/22/16 at 4:00 PM observation above the drop down ceiling of the double doors in the one hour smoke barrier and perpendicular to room 310 as seen from the west and three tiles from the north, revealed an open two inch conduit holding turquois and other colored lines.

On 02/22/16 at 4:00 PM in an interview, Staff Q confirmed the finding.

3. On 02/22/16 at 4:12 PM observation above the drop down ceiling of the one hour fire barrier over the door leading to the equipment storage room revealed two open conduits with one completely open and the other holding a beige line.

On 02/22/16 at 4:12 PM in an interview, Staff Q confirmed the finding.

4. On 02/22/16 at 4:15 PM observation above the drop down ceiling of the one hour fire barrier surrounding the same equipment room revealed to the right of the door as seen from the hall a sprinkler line with an annular space next to a one inch corrugated conduit holding two yellow lines.

On 02/22/16 at 4:15 PM in an interview, Staff Q confirmed the finding.

5. On 02/22/16 at 4:19 PM observation above the drop down ceiling of the one hour fire barrier surrounding the same equipment room as seen above the door from inside the room revealed to the right of the door a one inch corrugated conduit open to air and holding a yellow line.

On 02/22/16 at 4:19 PM in an interview, Staff Q confirmed the finding.

6. On 02/22/16 at 4:21 PM observation above the drop down ceiling of the one hour fire barrier between the same equipment room and an oxygen closet revealed to the west over the door to the oxygen closet two open white tipped conduits holding white wiring and to the east over the door a one and a half inch open conduit holding white lines and an open two inch conduit holding yellow lines.

On 02/22/16 at 4:21 PM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

7. On 02/23/16 at 9:45 AM observation above the drop down ceiling of the one hour smoke barrier surrounding the clean utility room as seen from the hall above room 211 revealed a two inch open conduit holding grey wiring.

On 02/23/16 at 9:45 AM in an interview, Staff Q confirmed the finding.

8. On 02/23/16 at 9:51 AM observation above the drop down ceiling of the one hour barrier surrounding the clean utility room as seen from inside revealed over the door a six inch by six inch square in the barrier.

On 02/23/16 at 9:51 AM in an interview, Staff Q confirmed the finding.

9. On 02/23/16 at 10:00 AM observation above the drop down ceiling of the one hour smoke barrier as seen from within room 211 and over the bed next to the bathroom, a three yard by one foot high opening was observed in the barrier.

On 02/23/16 at 10:00 AM in an interview, Staff Q confirmed the finding.

10. On 02/23/16 at 10:06 AM observation above the drop down ceiling of the one hour smoke barrier as seen from the critical care isolation anteroom revealed pipe with an annular space.

On 02/23/16 at 10:06 AM in an interview, Staff Q confirmed the finding.

11. On 02/23/16 at 10:13 AM observation above the drop down ceiling of the one hour smoke barrier as seen from the east side of the double doors leading to the critical care area revealed a two inch open conduit holding orange and yellow lines.

On 02/23/16 at 10:13 AM in an interview, Staff Q confirmed the finding.

12. On 02/23/16 at 10:48 AM observation inside the equipment room in the critical care area and above the drop down ceiling of the one hour fire barrier surrounding it revealed a copper line with an annular space (seen above the computer), over the door a one inch conduit with an annular space, and ninety degrees east to the door a one inch conduit with an annular space.

On 02/23/16 at 10:48 AM in an interview, Staff Q confirmed the finding.

13. On 02/23/16 at 10:55 AM observation above the drop down ceiling of the one hour smoke barrier as seen from the east side of the southern double doors leading into the critical care area revealed a one inch hole with blue and black cables traveling through it.

On 02/23/16 at 10:55 AM in an interview, Staff Q confirmed the finding.

14. On 02/23/16 at 10:58 AM observation above the drop down ceiling of the one hour smoke barrier over the south double doors leading to the critical care area, but seen from the west side of the doors and looking above the south door, revealed a one inch penetration with black, blue, and white wiring traveling through it.

On 02/23/16 at 10:58 AM in an interview, Staff Q confirmed the finding.

15. On 02/23/16 at 11:39 AM observation above the drop down ceiling of the one hour smoke barrier in critical care family waiting area as seen above the television stand revealed a one foot by one foot square penetration, and six tiles from the door, the barrier was observed not to extend all the way up to the deck.

On 02/23/16 at 11:39 AM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 2:12 PM a tour was taken of the first floor with Staff Q

16. On 02/23/16 at 2:37 PM observation from the hall and above the drop down ceiling of the one hour fire barrier surrounding the pharmacy revealed three tiles north from the door to pharmacy a one inch open conduit.

On 02/23/16 at 2:37 PM in an interview, Staff Q confirmed the finding.

17. On 02/23/16 at 2:42 PM observation above the drop down ceiling of the one hour fire barrier surrounding the pharmacy as seen from inside revealed a one inch penetration by conduits. The penetration can be seen two tiles north from the door.

On 02/23/16 at 2:42 PM in an interview, Staff Q confirmed the finding.

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

18. On 02/24/16 at 10:28 AM observation above the drop down ceiling of the one hour smoke barrier over the double doors perpendicular to the women ' s bathroom at H10 revealed over the west side of the south door a two inch open conduit holding blue and turquois wiring and a one inch open conduit holding blue wiring.

On 02/24/16 at 10:28 AM in an interview, Staff Q confirmed the finding.

19. On 02/24/16 at 10:30 AM observation above the drop down ceiling of the one hour smoke barrier revealed at the same set of double doors, on the east side of the north door, a two inch penetration with blue plastic conduits, and in the north barrier perpendicular to the doors, and four tiles east of the doors, a blue plastic conduit was observed in a two inch penetration.

On 02/24/16 at 10:30 AM in an interview, Staff Q confirmed the finding.

20. On 02/24/16 at 10:35 AM observation above the drop down ceiling of the one hour smoke barrier above the double doors leading to the cafeteria and near grid position H10 revealed on south side of the west door a two inch conduit with an annular space.

On 02/24/16 at 10:35 AM in an interview, Staff Q confirmed the finding.

21. On 02/24/16 at 11:15 AM observation above the drop down ceiling of the one hour fire barrier as seen from the corridor and between door 13 and the riser room, a half inch open white tip conduit holding white wiring and a 1.5 inch open conduit holding black wiring, and a three inch conduit holding white wiring and having an annular space in the sleeve it ran through.

On 02/24/16 at 11:15 AM in an interview, Staff R confirmed the finding.

22. On 02/24/16 at 1:43 PM observation above the drop down ceiling of the one hour fire barrier inside rise room A, revealed, going from west to east, one grey cable in a one inch penetration, a copper line traveling through a stainless steel sleeve and having an annular space between it and the sleeve, an annular space between a white pipe and a stainless steel sleeve, and a conduit with blue cable open to air.

On 02/24/16 at 1:43 PM in an interview, Staff Q confirmed the finding.

23. On 02/24/16 at 1:52 PM observation above the drop down ceiling of the one hour fire barrier as seen from the corridor and two tiles from the corner opposite exit sign 009 revealed a white tip conduit with two cables open to air.

On 02/24/16 at 1:52 PM in an interview, Staff Q confirmed the finding.

24. On 02/24/16 at 2:05 PM observation above the drop down ceiling of the two hour barrier between pathology and the birthing center, as seen from the corridor just north of exit sign 025 revealed a white tip conduit open to air holding blue cables.

On 02/24/16 at 2:05 PM in an interview, Staff Q confirmed the finding.

25. On 02/24/16 at 2:09 PM observation above the drop down ceiling of the one hour fire barrier four tiles west from the storage room near exit sign 025 revealed a conduit traveling out of a two inch by two inch square opening.

On 02/24/16 at 2:09 PM in an interview, Staff Q confirmed the finding.

26. On 02/24/16 at 2:42 PM observation above the drop down ceiling of the one hour fire barrier between the mail area and the waiting area and near exit sign 013 revealed an annular space around a plumb line.

On 02/24/16 at 2:42 PM in an interview, Staff Q confirmed the finding.

27. On 02/24/16 at 2:49 PM observation above the drop down ceiling of the two hour fire barrier located near the elevator shaft and room 1052, and just north of the door to room 1052, revealed three conduits with a collective annular space.

On 02/24/16 at 2:49 PM in an interview, Staff Q confirmed the finding.

28. On 02/24/16 at 2:56 PM observation above the drop down ceiling of the one hour fire barrier two tiles north from the marketing office revealed a half inch conduit open to air holding a cable.

On 02/24/16 at 2:56 PM in an interview, Staff Q confirmed the finding.

29. On 02/24/16 at 2:58 PM observation above the drop down ceiling of the one hour fire barrier as seen from within a waiting area located at grid position B10 and five tiles to the left of the clock revealed a two inch grey tip conduit open to air holding yellow, white, and grey cables.

On 02/24/16 at 2:58 PM in an interview, Staff Q confirmed the finding.

30. On 02/24/16 at 3:10 PM observation above the drop down ceiling of the one hour fire barrier near exit sign 003 and three tiles down from a fire extinguisher cabinet revealed one inch open penetration.

On 02/24/16 at 3:10 PM in an interview, Staff Q confirmed the finding.

31. On 02/24/16 at 3:25 PM observation above the drop down ceiling of the two hour fire barrier between the sleep rooms located in the physician lounge at grid location E9 revealed two heating, ventilation, and cooling ducts with annular spaces, one sprinkler line with an annular space, and one open conduit holding two red cables. (This was observed inside the east sleep room.)

On 02/24/16 at 3:25 PM in an interview, Staff Q confirmed the finding.

32. On 02/24/16 at 3:28 PM observation above the drop down ceiling of the two hour fire barrier in the same physician ' s lounge above the couch revealed an open conduit holding two red cables, and above the entrance to the east sleep room an open conduit holding one red cable.

On 02/24/16 at 3:28 PM in an interview, Staff Q confirmed the finding.

33. On 02/24/16 at 3:38 PM observation above the drop down ceiling of the one hour fire barrier near the second door east from exit sign 057 revealed a one inch conduit open to air holding two red cables.

On 02/24/16 at 3:38 PM in an interview, Staff Q confirmed the finding.

34. On 02/24/16 at 3:52 PM observation above the drop down ceiling of the one hour smoke barrier of the most south double doors in the birth center revealed above the north door a one inch penetration with two orange cables running through it.

On 02/24/16 at 3:52 PM in an interview, Staff Q confirmed the finding.

35. On 02/24/16 at 4:03 PM observation above the drop down ceiling the one hour fire barrier over the entrance to the cafeteria near exit sign 59 revealed it did not extend all the way to the deck above.

On 02/24/16 at 4:03 PM in an interview, Staff M confirmed the finding explaining the door had been moved north from the barrier, but the barrier had not come with it.

36. On 02/24/16 at 4:08 PM observation above the drop down ceiling of the one hour smoke barrier as seen within birthing suite three revealed five open conduits, from right to left, starting at the door: one holding a red cable, one holding two yellow cables, one holding one orange cable, one holding one blue and one red cable, and another holding one grey cable.

On 02/24/16 at 4:08 PM in an interview, Staff Q confirmed the finding.

37. On 02/24/16 at 4:45 PM observation above the drop down ceiling of the one hour smoke barrier at grid position H13 (south wall) revealed a yellow tipped conduit open to air.

On 02/24/16 at 4:45 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM a tour of the first floor was resumed with Staff Q.

38. On 02/25/16 at 1:22 PM observation above the drop down ceiling of the one hour smoke barrier as seen in the purchasing office revealed a three inch by three inch hole with a plumb line running through it.

On 02/25/16 at 1:22 PM in an interview, Staff Q confirmed the finding.

39. On 02/25/16 at 1:26 PM observation above the drop down ceiling of the one hour smoke barrier in the west wall of the office next to purchasing revealed a plumbing with an annular space.

On 02/25/16 at 1:26 PM in an interview, Staff Q confirmed the finding.

40. On 02/25/16 at 1:29 PM observation above the drop down ceiling of the one hour barrier in the west wall of the biomedical office and two tiles from the corner revealed a collective annular space around six conduits.

On 02/25/16 at 1:29 PM in an interview, Staff Q confirmed the finding.

41. On 02/25/16 at 3:02 PM observation above the drop down ceiling of the one hour barrier approximately three tiles to the north of exit sign 139 revealed an open junction box with an open conduit holding black, red, and blue cables.

On 02/25/16 at 3:02 PM in an interview, Staff Q confirmed the finding.

42. On 02/25/16 at 3:25 PM observation above the drop down ceiling of the two hour barrier as seen in the dry storage area of the kitchen and two doors down from the coolers (grid position F11 and opposite the entrance to the room) revealed three two inch holes, one containing a bundle of red wires.

On 02/25/16 at 3:25 PM in an interview, Staff Q confirmed the finding.

43. On 02/25/16 at 3:32 PM observation of a door in the physician ' s lounge revealed it was in a two hour barrier but did not self-close and latch.

On 02/25/16 at 3:32 PM in an interview, Staff Q confirmed the finding.

44. On 02/25/16 at 4:12 PM observation above the drop down ceiling of the one hour fire barrier in the north wall west of the double doors west of exit sign 109 and at grid position K13 revealed a one inch open conduit holding a red cable.

On 02/25/16 at 4:12 PM in an interview, Staff Q confirmed the finding.

45. On 02/25/16 at 4:48 PM observation above the drop down ceiling of the one hour fire barrier between the clean-up room and janitor closet (near exit sign 113) revealed a one inch conduit open to air.

On 02/25/16 at 4:48 PM in an interview, Staff Q confirmed the finding.

46. On 02/25/16 at 5:03 PM observation above the drop down ceiling of the two hour barrier on the other side of the double doors near exit sign 115 revealed over the north door a conduit with an annular space and in that annular space blue, white, and grey cables.

On 02/25/16 at 5:03 PM in an interview, Staff Q confirmed the finding.

47. On 02/25/16 at 5:13 PM the door to the women ' s locker room in surgery was observed to be in a two hour barrier but have a ¾ hour rating.

On 02/25/16 at 5:13 PM in an interview, Staff Q confirmed the finding.

48. Observations were made on tour in the therapy area, treatment room #8, on 02/25/16 at 1:33 PM of a penetration in a one hour smoke partition by a white tipped conduit with two red wires feeding through it. This finding was confirmed with Staff R at the time of the observation.
49. Observations were made in the cardiopulmonary area physician lounge on 02/25/16 at 3:10 PM of a penetration in a two hour fire partition wall of a 4 " conduit with cut away drywall open space around it. This finding was confirmed with Staff R at the time of the observation.
50. Observations were made in the same day surgery area on 02/25/16 at 3:45 PM of a white tipped ½ " conduit with a red wire penetrating a two hour fire partition in room 4, and also in the same area was a 2 " diameter copper pipe with a drywall cut out opening around it resulting in a penetration in a two hour fire partition. This finding was confirmed with Staff R at the time of the observation.

Based on observation and interview, the facility failed to ensure each door in a smoke barrier self-closed and, where so equipped, latched. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.

1. On 02/22/16 at 12:18 PM the double doors perpendicular to room 314 and in a one hour smoke barrier revealed when tested that they did not completely closed.

On 02/22/16 at 12:18 PM in an interview, Staff Q confirmed the finding.

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

2. On 02/24/16 at 10:09 AM observation of the door to the chapel revealed it was in a one hour smoke barrier but did not have a self-closer.

On 02/24/16 at 10:09 AM in an interview, Staff Q confirmed the finding.

3. On 02/24/16 10:46 AM in an interview, the door to room 1023 was observed to be in a one hour fire barrier but was not observed to self-close and latch.

On 02/24/16 at 10:46 AM in an interview, Staff Q confirmed the finding.

4. On 02/24/16 at 11:37 AM observation of the door near exit sign 008 in the two hour barrier surrounding a mechanical space revealed it was held open with a rubber strap so that it could not self-close.

On 02/24/16 at 11:37 AM in an interview, Staff Q confirmed the finding.

5. On 02/24/16 at 1:34 PM observation of the door to the Director of Materials office was observed in a one hour barrier but did not have a self-closer.

On 02/24/16 at 1:34 PM in an interview, Staff Q confirmed the finding.

6. On 02/24/16 at 2:05 PM the door to the pathology department was observed to be in a two hour fire barrier but was not observed to have a rating.

On 02/24/16 at 2:05 PM in an interview, Staff Q confirmed the finding.

7. On 02/24/16 at 2:22 PM observation of the north door out of pathology revealed it was in a one hour fire barrier, but did not have a self-closer.

On 02/24/16 at 2:22 PM in an interview, Staff Q confirmed the finding.

8. On 02/24/16 at 2:38 PM the door to room 1052 was observed to be in a one hour fire barrier but was not observed to have a self-closer.

On 02/24/16 at 2:38 PM in an interview, Staff Q confirmed the finding.

9. On 02/24/16 at 2:40 PM observation of the door in the one hour fire barrier leading out of the " mail " area and into the " waiting area " (located near grid position C9) revealed it was not on a self-closer.

On 02/24/16 at 2:40 PM in an interview, Staff Q confirmed the finding.

10. On 02/24/16 at 3:23 PM observation of the door to the east sleep room of the physician lounge located at grid position E9 and in a two hour fire barrier revealed it did not have a self-closer.

On 02/24/16 at 3:23 PM in an interview, Staff Q confirmed the finding.

11. On 02/24/16 at 3:42 PM observation of the door to the anesthesia call room revealed it was in a one hour smoke barrier but did not have a self-closer.

On 02/24/16 at 3:42 PM in an interview, Staff Q confirmed the finding.

12. On 02/24/16 at 4:11 PM the door to the birthing center break room was observed to be in a one hour smoke barrier with self-closing and latching hardware that did not close and latch the door.

On 02/24/16 at 4:11 PM in an interview, Staff Q confirmed the finding.

13. On 02/24/16 at 4:48 PM observation of the door to room A006 revealed it was in a one hour fire barrier and had self-closing and latching hardware that did not self-close and latch.

On 02/24/16 at 4:48 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM the tour of the first floor resumed with Staff Q.

14. On 02/25/16 at 4:45 PM the door to the janitor closet in the operating rooms area was observed to be in a one hour fire barrier without a self-closer.

On 02/25/16 at 4:45 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the stated rating surrounding its hazardous areas and to ensure each door to a hazardous area self-closed and where so equipped, latched. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/22/16 at 11:45 AM a tour was taken of the facility ' s third floor with Staff Q.

1. On 02/22/16 at 2:55 PM observation above the drop down ceiling of the middle of the eastern wall of the one hour fire barrier surrounding the soiled utility room revealed a one inch open conduit holding blue and white lines.

On 02/22/16 at 2:55 PM in an interview, Staff Q confirmed the finding.

2. On 02/22/16 at 2:56 PM observation above the drop down ceiling over the south door in the one hour fire barrier surrounding the soiled utility room revealed an open one inch conduit holding orange lines.

On 02/22/16 at 2:56 PM in an interview, Staff Q confirmed the finding.

3. On 02/22/16 at 3:00 PM observation above the drop down ceiling of the north wall of the one hour barrier surrounding the same soiled utility room revealed one straight open conduit holding blue and grey cables, one holding orange and red cables, and two open conduits holding nothing. All conduits were one inch in diameter.

On 02/22/16 at 3:00 PM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

4. On 02/23/16 at 9:23 AM the one hour fire barrier surrounding the soiled utility room was observed from inside and above the drop down ceiling. The observation revealed over the door a white plumb line with an annular space, over the slop sink black wiring with an annular space, and to the right of the door and above a heating, ventilation, and cooling duct a one inch seam between dry wall sheets.

On 02/23/16 at 9:23 AM in an interview, Staff Q confirmed the finding.

5. On 02/23/16 at 10:40 AM observation above the drop down ceiling of the one hour fire barrier surrounding the soiled utility room in the critical care area revealed an open junction box with an open conduit leading to the south wall.


On 02/23/16 at 10:40 AM in an interview, Staff Q confirmed the finding.

On 02/23/16 at 2:12 PM a tour was taken on of the first floor with Staff Q and M.

6. On 02/23/16 at 2:29 PM observation of the south wall of the two hour fire barrier surrounding the air handler room as seen seven tiles down from the storage room, revealed a one inch open conduit holding black lines.

On 02/23/16 at 2:29 PM in an interview, Staff Q confirmed the finding.

7. On 02/23/16 at 3:34 PM observation above the drop down ceiling of the one hour fire barrier in the women ' s center (but surrounding the lab on the other side) near exit sign 134 and between the maid closet and storage room revealed one inch open conduit holding two red lines.

On 02/23/16 at 3:34 PM in an interview, Staff Q confirmed the finding.

8. On 02/23/16 at 3:38 PM observation above the drop down ceiling of the same one hour fire 8. barrier surrounding the laboratory and seen from the women ' s center, west from the above finding and above an alarm strobe revealed two white tip open conduits holding white lines. Continuing west along the barrier, observation above the drop down ceiling inside the reading room revealed one penetration holding three white lines.

On 02/23/16 at 3:38 PM in an interview, Staff Q confirmed the finding.

9. On 02/23/16 at 3:47 PM observation above the drop down ceiling of the same one hour fire barrier surrounding the laboratory and seen from the women ' s center in the procedure room near exit sign 132 revealed two conduits open to air holding white wiring.

On 02/23/16 at 3:47 PM in an interview, Staff Q confirmed the finding.

10. On 02/23/16 at 3:53 PM observation above the drop down ceiling of the one hour barrier surrounding the laboratory as seen from the corridor near exit sign 135 and six tiles north from staff only door to laboratory revealed two open one inch conduits and one open conduit with grey cables.

On 02/23/16 at 3:53 PM in an interview, Staff Q confirmed the finding.

11. On 02/23/16 at 3:58 PM observation above the drop down ceiling of the one hour fire barrier over the door to the laboratory and near exit sign 135 revealed a penetration with a blue plastic conduit and grey lines running through it.

On 02/23/16 at 3:58 PM in an interview, Staff Q confirmed the finding.

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

12. On 02/24/16 at 9:03 AM observation of the radiology file room revealed the room to be full of radiology records in open shelving from the floor to eight feet above. The room is sprinklered however the doors leading into the room were not on a self-closer.

On 02/24/16 at 9:03 AM in an interview, Staff Q confirmed the finding.

13. On 02/24/16 at 9:38 AM observation above the drop down ceiling of the two hour fire barrier protecting the air handler room as seen from the women ' s health, near a desk and exit sign 129 revealed a half inch conduit open to air.

On 02/24/16 at 9:38 am in an interview, Staff Q confirmed the finding.

14. On 02/24/16 at 9:46 AM observation above the drop down ceiling of the two hour fire barrier protecting the air handler room as seen in women ' s health and above the door to room 130 revealed a one and a half inch open conduit holding yellow, blue, and turquois lines, one one inch conduit holding a black line and having an annular space, and a half inch open conduit holding one red line (three tiles south of the door).

On 02/24/16 at 9:46 AM in an interview, Staff Q confirmed the finding.

15. On 02/24/16 at 9:56 AM observation above the drop down ceiling of the two hour barrier protecting the air handler room as seen from the gift shop revealed three open copper conduits, four conduits forming a collective annular space, and, over the cabinet next to the closet, a one and a half inch open conduit holding grey lines.

On 02/24/16 at 9:56 AM in an interview, Staff Q confirmed the finding.

16. On 02/24/16 at 11:10 AM observation of the two hour fire barrier surrounding the power plant and seen above the drop down ceiling opposite door 13 revealed a blue plastic one inch conduit with an annular space.

On 02/24/16 at 11:10 AM in an interview, Staff R confirmed the finding.

17. On 02/24/16 at 11:20 AM observation above the drop down ceiling of the two hour barrier surrounding the power plant as seen in the corridor and near exit sign 008 revealed four copper lines that formed a collective annular space.

On 02/24/16 at 11:20 AM in an interview, Staff Q confirmed the finding.

18. On 02/24/16 at 11:47 AM observation of the two hour barrier between the mechanical space and the kitchen/dining area, as seen from inside the mechanical space, revealed near grid position F12 medical gas lines with a collective annular space, a three inch sleeve open to air with blue, black, and white cables running through it, and a white tip conduit open to air holding one grey cable.

On 02/24/16 at 11:47 AM in an interview, Staff Q confirmed the finding.

19. On 02/24/16 at 11:52 AM observation of the two hour barrier protecting the mechanical space, as seen from inside the mechanical space, revealed a red cable through a penetration through the east wall seen within the switch room at grid position F13. The door to the switch room was observed to be in a two hour barrier but the self-closing and latching hardware did not self-close and latch door when tested.

On 02/24/16 at 11:52 AM in an interview, Staff Q confirmed the finding.

20. On 02/24/16 at 11:56 AM observation of the two hour barrier in the mechanical space at location F14 revealed, over a desk, a two inch conduit open to air holding a black cable.

On 02/24/16 at 11:56 AM in an interview, Staff Q confirmed the finding.

21. On 02/24/16 at 2:25 PM observation above the drop down ceiling of the one hour fire barrier surrounding the pathology department as seen from inside the department, two tiles west from the door to " mail " room, revealed a one inch conduit with green cables open to air.

On 02/24/16 at 2:25 PM in an interview, Staff Q confirmed the finding.

22. On 02/24/16 at 2:32 PM observation above the drop down ceiling of the one hour smoke barrier protecting the storage room located at grid position D10 revealed at the entrance above the south door blue and yellow cables traveling from an open conduit.

On 02/24/16 at 2:32 PM in an interview, Staff Q confirmed the finding.

23. On 02/24/16 at 2:36 PM observation above the drop down ceiling of the one hour fire barrier between the pathology department and a storage space located at grid position D10 revealed a white plumb line with and annular space. This was seen inside the storage space.

On 02/24/16 at 2:36 PM in an interview, Staff Q confirmed the finding.

24. On 02/24/16 at 4:52 PM observation above the drop down ceiling of the one hour fire barrier as seen inside the soiled utility room of same day surgery and three tiles south of the door revealed an open conduit holding two grey wires and above the slop sink an open conduit holding two red cables.

On 02/24/16 at 4:52 PM in an interview, Staff Q confirmed the finding.

25. On 02/24/16 at 5:02 PM observation above the drop down ceiling of the one hour barrier surrounding the clean laundry room in same day surgery as seen outside and at the west wall revealed a three inch open conduit holding black and grey cables.

On 02/24/16 at 5:02 PM in an interview, Staff Q confirmed the finding.

26. On 02/24/16 at 5:14 PM observation above the drop down ceiling of the one hour barrier surrounding the clean laundry room in same day surgery as seen outside and south of the door revealed a corrugated conduit traveling through an open one inch square and a three inch conduit holding a bundle of white wires.

On 02/24/16 at 5:14 PM in an interview, Staff Q confirmed the finding.

On 02/25/16 at 1:22 PM the tour of the first floor resumed with Staff Q.

27. On 02/25/16 at 1:38 PM observation of the double doors in the one hour fire barrier in the hazardous area next to the morgue revealed they did not coordinate and therefore did not always close and shut completely.

On 02/25/16 at 1:38 PM in an interview, Staff Q confirmed the finding.

28. On 02/25/16 at 2:30 PM observation above the drop down ceiling of the one hour barrier surrounding the soiled utility room in radiology revealed, as observed within, in the north barrier, a two inch open conduit and two open conduits with red cables traveling out from them.

On 02/25/16 at 2:30 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each of its exit stairways were enclosed with a fire resistive rating of at least one hour. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

1.On 02/23/16 at 8:42 AM observation of the door to exit stair 2, enclosed in a one hour rated fire barrier, revealed it was unrated.

On 02/23/16 at 8:42 AM in an interview, Staff Q confirmed the finding.

2. On 02/23/16 at 11:17 AM observation above the drop down ceiling of the one hour barrier to stairwell 2 revealed it did not extend all the way to the deck above.

On 02/23/16 at 11:17 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the width of the corridor in its geriatric psychiatric unit to at least four feet.This had the potential to affect any patient receiving treatment at the facility.


Findings include:

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

On 02/23/16 at 1:52 PM observation of the southeast corridor within a unit holding mentally ill geriatric patients and leading to a patient gathering room and quiet room revealed near exit sign 222 a fixed glass partition was in the corridor shrinking the width of the corridor at that point to three feet, seven inches.

On 02/23/16 at 1:52 PM in an interview, Staff Q and M confirmed the finding.

Based on record review and staff interview the facility failed to ensure fire drills were conducted in accordance with facility policy/ procedure. This deficient practice had the potential to affect any patient receiving services at the facility.

Findings include:
Review of the Fire Drill Evaluation Form revealed the Sleep Lab had a different form than the Fire Drill Evaluation Form that was part of the hospital policy/ procedure (11.04.02). Comparison of the forms revealed the hospital policy/ procedure form was more comprehensive, requiring more evaluation and steps than the Sleep Lab form, therefore the drills completed at the Sleep Lab had not followed the facility procedure. Interview with Staff M on 02/25/16 at 9:30 AM confirmed that the Sleep Lab form was not consistent with the facility policy / procedure for fire drills.

Based on record review and interview, the facility failed to ensure its fire drills were held at unexpected times under varying conditions. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/26/16 at 8:00 AM a review of the facility ' s fire safety documentation was completed. The review revealed the fire drills for 2015 for the third shift all occurred within 15 minutes of 6:32 AM., and for the second shift all drill occurred within an hour of 8:00 PM.

On 02/26/16 at 8:40 AM staff Q and M confirmed the finding explaining drill were held at times that are least likely to be disruptive.

Based on observation, record review, and interview, the facility failed to maintain its fire alarm system in accordance with NFPA 72, 1999 edition. This had the potential to affect any patient receiving treatment at the facility.

Findings include

On 02/23/16 at 8:29 AM a tour was taken of the second floor with Staff Q.

On 02/23/16 at 8:50 AM a fire strobe was observed outside the chaplain office.

On 02/23/16 at 9:08 AM a fire bell was observed outside room 215.

On 02/23/16 at 10:06 AM a fire bell was observed outside room 211.

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

On 02/24/16 at 9:12 AM a fire strobe was observed in laboratory room 016, outside at the door, and in a nearby bathroom.

On 02/26/16 at 8:00 AM a review of the facility ' s fire safety documentation was completed. The review revealed the fire alarm system was inspected on 09/29/15.

The review did not reveal a list of the building ' s fire bells and strobes with their location to validate each and every appurtenance in inventory, including those observed on tour, was tested and passed, and to validate the accuracy of the inventory with what is seen in the building.

On 02/29/16 at 11:30 AM in an interview, Staff Q confirmed the finding.

Based on record review and staff interview the facility failed to ensure the time lapse for the fire notification signal was documented to determine compliance with NFPA 72, 1999 edition, 7-2. This had the potential to affect any patient receiving treatment at the facility.
Findings include:
Review of fire drill documentation for the Sleep Center located in Building B on 02/24/16 revealed the time lapse from the time the signal was initiated until it was received by the monitoring company was not documented. Interview with Staff M on 02/24/16 1:26 PM confirmed this observation.

Based on interview, observation, and record review, the facility failed to maintain its sprinkler system in accordance with NFPA 13 and 25, 1999 editions. This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/23/16 at 2:12 PM a tour was taken of the first floor with Staff Q and M.

1.On 02/23/16 at 2:43 PM observation of shelving within the pharmacy, 180 degrees from the entrance door, revealed paraphernalia place on top bring the gap from the sprinkler heads to less than 18 inches.

On 02/23/16 at 2:43 PM in an interview, Staff M confirmed the observation.

2. On 02/24/16 at 11:33 AM a tour of the bathrooms in the geriatric psychiatric unit revealed they had a type of sprinkler head of which the facility did not have spare heads for.

On 02/24/16 at 11:33 AM in an interview, Staff R confirmed the observation.

3. On 02/26/16 at 8:00 AM a review of the facility fire safety documentation was completed. The review revealed the sprinkler system was inspected four times in 2015. The sprinkler report for 03/17/15 revealed the gauges for the pump suction, pump discharge, and system pressure had static per square inch pressure readings but did not indicate they were okay.

A review of the sprinkler report for 06/16/15 revealed the same gauges had per square inch pressure readings that were marked as okay.

Contradicting this, a review of the sprinkler report for 09/15/15 revealed the same gauges had per square inch pressure readings but did not indicate they were okay.

On 02/26/16 at 8:40 AM in an interview, Staff Q confirmed the findings.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4.This had the potential to affect any patient receiving treatment at the facility.

Findings include:

On 02/26/16 at 8:00 AM a review of the facility ' s fire safety documentation was completed. The review revealed not all dampers had been tested in the last six years.

On 02/26/16 at 8:40 AM in an interview, Staff M confirmed the dampers had not been tested in the last six years.

Based on observations and staff interview the facility failed to meet NFPA 9.7.5 related to maintenance of the sprinkler system. This had the potential to affect any patient receiving treatment at the facility.

Findings include:
Review of quarterly Sprinkler Inspection Certificate reports revealed the facility failed to maintain consistent documentation for gauges related to air and water pressure. Review of the quarterly report for MOB-B, M3-025 dated 03/17/15 for gauges #09807699 (city water pressure) and #0980770 (air pressure) revealed data was recorded but the boxes labeled " OK " had not been checked. Review of the gauge report dated 06/16/15 revealed the boxes labeled " OK " were marked. Review of the gauge report dated 09/15/15 revealed the boxes labeled " OK " were not marked. Review of the gauge report dated 12/15/15 revealed the boxes labeled " OK " were not marked. Interview with Staff M on 02/25/16 at 9:22 AM confirmed the documentation was inconsistent related to the inspection of the gauges.

Based on observation and interview, the facility failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. This had the potential to affect any patient receiving treatment at the facility.


Findings include:

On 02/24/16 at 8:52 AM a tour of the first floor resumed with Staff Q.

On 02/24/16 at 1:53 PM observation of the break room in the " electric room " revealed a power strip plugged into an extension cord. Plugged into the power strip was a microwave, toaster oven, and coffee maker.

On 02/24/16 at 1:53 PM in an interview, Staff Q confirmed the finding.