HospitalInspections.org

Based on observation and interview, the facility failed to maintain the communicating opening in the two hour fire-resistant common wall in two areas on two of five floors.

Findings include:

1. Observation on August 29, 2011, at 10:29 AM revealed the 6th floor fire wall doors near room E6401 do not close and latch into the frame.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the door would not close and latch on the specific date and time stated above.

2. Observation on August 29, 2011, at 1:33 PM revealed the 3rd floor fire wall doors do not close and latch into the frame.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the door would not close and latch on the specific date and time stated above.

Based on observation and interview, the facility failed to meet the requirements for the common wall to a nonconforming building per code requirements in two locations on two of six floors.

Findings include:

1. Observation on 08/30/11 13:30 pm revealed that the 2 hour door on the 3rd floor, Swank section and the Theatre was being propped open by a rubber cable mat.
2. Observation on 08/30/11 14:10 am revealed that the 2 hour door on the 4th floor, between the patient care building and Swank bldg did not close and positively latch.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the fire rated doors existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to maintain the building construction type in one instance on one of ten floors.

Findings Include:

Observation on 8/29/11 at 11:10 am revealed the following:

There was fireproofing missing on the ceiling beam in the main medical gas storage room.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed there was exposed structural steel.

Based on observation and interview, the facility failed to meet the requirements for building construction type per code requirements on one of six floors.

Findings include:

Observation on 08/30/11 at 8:15 a.m. revealed that there are structural beams in the elevator penthouse that are not protected.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the exposed steel existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance on one of nine floors.

Findings Include:

Observation on 8/31/11 at 9:59am revealed the following:

The conference room door GS2123 lacked positive latching hardware.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed the corridor door did not latch on the specific date and time stated above.

Based on observation and interview, the facility failed to maintain stairways, elevator shafts, light and ventilation shafts, and chutes, and to ensure other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour in one area within the entire facility.

Findings include:

Observation on August 29, 2011, at 1:39 PM revealed that there was a 2-inch unsealed penetration on the 1st floor shaft, S1C1, near the Information Desk and elevators above a donation box.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the shaft penetration on the specific date and time stated above.

Based on observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of smoke barrier walls in four of six floors.

Findings include:

Observation on August 29, 2011, at the following times and locations revealed the following unsealed smoke barrier penetrations:

a. 8:31 AM, 6th floor sleap lab control room W650 and office W668 have numerous unsealed smoke wall penetrations.
b. 8:55 AM, 5th floor above corridor doors near physicians lounge has unsealed penetration around wires and MC cable.
c. 9:53 AM, 4th floor smoke wall between door to room P460 and exit sign has unsealed penetration inside a conduit.
d. 9:57 AM, 4th floor smoke wall inside room P460 is not sealed to deck.
e. 10:17 AM, 4th floor smoke wall in alcove across from room P440 has unsealed penetration around an MC cable.
f. 10:59 AM, 2th floor smoke wall above Walnut Wing corridor doors near conference room has an unsealed penetration.
g. 11:07 AM, 2th floor smoke wall doors between therapy office, W268, and janitor's closet, have a gap greater than 1/8 in while in closed position.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above smoke wall deficiencies on the specific date and times stated above.

1. Observation on August 30, 2011, at 11:07 AM revealed the 2nd floor smokewall doors between the Therapy Office W268 and the janitor's closet have a gap greater than 1/8 inch while in the closed position.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above smoke wall doors deficiency on the specific date and time stated above.

Based on observation and interview, the facility failed to meet the requirements for smoke barrier walls per code requirements on nine of ten floors.

Findings include:

1. Observation on 08/29/11 at 10:30 am revealed that there is a penetration in the smoke wall above the ceiling near smoke doors P926X.
2. Observation on 08/29/11 at 10:50 am revealed that there is a penetration in the smoke wall above the ceiling near smoke doors P826X.
3. Observation on 08/29/11 at 11:15 am revealed that there is a penetration (blue wires) in the smoke wall above the ceiling near smoke doors P614X.
4. Observation on 08/29/11 at 1:00 pm revealed that there are multiple penetration in the smoke wall on the 2nd floor above the ceiling near CR2130X.
5. Observation on 08/29/11 at 1:40 pm revealed that the window (glass) in the smoke wall in the E.R. Security Office on the 2nd floor is not rated glass. It is tempered glass.
6. Observation on 08/29/11 at 1:40 pm revealed that there is a penetration in the smoke wall above the ceiling in the E.R. Security Office.
7. Observation on 08/29/11 at 14:00 pm revealed that there is a penetration (medical vacuum line) in the smoke wall partition above the ceiling near M7056.
8. Observation on 08/29/11 at 14:30 pm revealed that there is a penetration in the smoke wall above the smoke doors B688X.
9. Observation on 08/29/11 at 14:37 pm revealed that there is are penetrations in the smoke wall above the ceiling in patient room M6559 in the corner above the metal lockers.
10. Observation on 08/29/11 at 14:45 pm revealed that there is a penetration in the smoke wall above the smoke doors M6568.
11. Observation on 08/29/11 at 14:55 pm revealed that the smoke wall is incomplete in room M6518 next to the ductwork.
12. Observation on 08/29/11 at 15:15 pm revealed that there is a penetration in the smoke wall between the ductwork in mechanical room # CP5130.
13. Observation on 8/29/11 at 15:20 pm revealed the rated separation with the parking garage on the 3rd floor had non-rated door glass.
14. Observation on 08/29/11 at 15:30 pm revealed that there are penetrations in the smoke wall above the ceiling near 4th floor director's office.
15. Observation on 08/29/11 at 15:45 pm revealed that there is a penetration in the smoke wall above the rated door on the 4th floor by the M4 elevator and vending machine leading into the Anesthesia corridor.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the rated smoke partitions existed on the specific dates and times stated above.

Based on observation and interview, the facility failed to meet the requirements for smoke barrier doors per code requirements in two instances on two of ten floors.

Findings include:

1. Observation on 08/29/11 @ 11:35 a.m revealed that smoke barrier doors next to CP3050XX had a gap exceeding an 1/8 inch and would not resist the passage of smoke.

2. Observation on 08/29/11 @ 1:50 p.m revealed that the 1 1/2 hour doors near CP 1009 discharge lobby did not close and positively latch.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the smoke barrier doors existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to provide the proper fire resistance ratings of one hazardous area on one of three floors.

Findings include:

Observation on August 29, 2011, at 9:53 AM revealed the Soiled Utility Room does not have an operational closure on the door.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the door lacked a closure on the specific date and time stated above.

Based on observation and interview, the facility failed to maintain the one hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system or ensure doors are self-closing in three areas on two of five floors.

Findings include:

Observation on August 29, 2011, at the following times and locations revealed the following rated room issues:

a. 10:49 AM, 6th floor clean storage room, E6428, does not have a door closure.
b. 1:57 PM, 3rd floor file room, E3364, does not have a door closure.
c. 2:35 PM, 3rd floor Reception Office, E3304, has a glass window and does not have a door closure. The room has approximately 84 feet of files stored on shelves.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the rated room deficiencies on the specific date and times stated above.

Based on observation and interview, it was determined the facility failed to maintain hazardous area rooms in one instance on one of ten floors.

Findings Include:

Observation on 08/29/11 revealed the following:

a) At 11:25 am the door to the Cardiac Diagnostic file room was being propped open by a carpet and the electrical cord for a copy machine was being run through the door jam rendering the door incapable of closing and positively latching.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the hazardous rooms existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to maintain hazardous area rooms in one instances on one of nine floors.

Findings Include:

Observation on 08/31/11 revealed the following:

At 08:40 am room GS8803 does not meet the requirements for a storage room because the door lacks a self-closing device.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the hazardous rooms existed on the specific date and time stated above.

Based on observation and interview, it was determined the facility failed to maintain hazardous area rooms in one instances on one of six floors.

Findings Include:

Observation on 08/30/11 revealed the following:

At 14:10 pm room 5486A does not meet the requirements for a storage room because the door lacks a self-closing device.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the hazardous rooms existed on the specific dates and times stated above.

Based upon observation the capacity of exits are not in accordance with 7.3 as per regulations in one area on one of six floors.

Findings include:

Observation on 8/29/11 @ 11:45 am revealed the 6th floor PC mechanical room was a manned location with only 1 exit / escape route. This area also lacks proper exit signage.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed the exiting issue on the specific date and time stated above.

Based on observation and interview, the facility failed to ensure that the width of aisles or corridors was clear and unobstructed on one of five floors of the facility.

Findings include:

Observation on August 29, 2011, at 11:11 AM, revealed a blood pressure machine stored in the 6th floor corridor near room E6414. The BP machine was charging for over 30 minutes.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the storage in the corridor on the specific date and time stated above.

Based on observation and interview, the facility failed to ensure that emergency lighting was properly tested and maintained in one location within the entire facility.

Findings include:

Observation on August 29, 2011, at 9:51 AM revealed there was an inoperative battery back-up light in the Equipment Room.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the battery back-up light was inoperative on the specific date and time stated above.

Based on observation and interview, it was determined the facility failed to maintain sprinkler protection in two instances on two of ten floors.

Findings Include:

Observation on 8/30/11 revealed the following:

a) Office M206b on the second floor lacks sprinkler protection.
b) C22 suite on the basement level lacks sprinkler protection.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions existed with the sprinkler protection on the specific dates and times stated above.

Based on observation and interview, the facility failed to provide adequate sprinkler coverage for six areas on three of five floors.

Findings include:

Observation on August 29, 2011, at the following times and locations revealed the following sprinkler issues:

a. 10:47 AM, 6th floor room E6432 lacked sprinkler coverage in air conditioning closet .
b. 11:09 AM, 6th floor room E6407 lacked sprinkler coverage in two metal closets.
c. 11:13 AM, 6th floor room E6400, janitor closet, had a sprinkler head within 4 inches of the wall.
d. 11:51 AM, 5th floor room E514 lacked sprinkler coverage in a closet.
e. 2:13 PM, 3rd floor room E3319, Exam Room 6, lacked sprinkler coverage in two closets.
f. 2:17 PM, 3rd floor room E3321, Exam Room 6, lacked sprinkler coverage in two closets.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above sprinkler issues on the specific date and times stated above.

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per code requirements in three instances on two of nine floors.

Observation on 08/31/11 revealed the following:

1. At 10:00 am in room # 8867 there were several sprinkler heads that were within 6 feet of other sprinkler heads in this room causing an obstruction to the discharge pattern of the sprinkler heads.
2. At 10:30 am in the Employee Fitness area room # GS 315 room A there were heavy moving blankets being used as blackout curtains clamped and hanging from the sprinkler pipes.
3. At 10:30 am in the Employee Fitness area room # GS 315 room A there were rolls of padded foam stuffed between the sprinkler lines and the ceiling being stored.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions concerning sprinklers existed on the specific dates and times stated above.

Based on documentation review and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in reliable operating condition throughout the facility.

Findings include:

1. Observation on August 31, 2011, between 8:00 AM and 11:00 AM revealed the vendor sprinkler reports dated 11/9-12/10, 2/15/11, 5/19-23/11, and 8/9-12/11 indicated the sprinkler head in Mechanical Room CP 2106 had no liquid in the bulb and needed to be replaced.

2. Observation on August 31, 2011, between 8:00 AM and 11:00 AM revealed the vendor sprinkler reports dated 5/19-23/11, and 8/12-17/11 indicated the sprinkler head on the 4th floor hallway near room M4023 is above the ceiling tile and needs to be lowered.

3. Observation on August 31, 2011, between 8:00 AM and 11:00 AM revealed the vendor sprinkler reports dated 5/19-23/11 indicated the sprinkler heads in the M4 stair 6 were not installed properly.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these sprinkler issues existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in reliable operating condition in numerous locations on three of five floors.

Findings include:

Observation on August 29, 2011, at the following times and locations revealed the following sprinkler issues:

a. 10:57 AM, 6th floor alcove, near the nurses station and room E 6417, is missing an escutcheon.
b. 11:55 AM, 5th floor room E509 restroom is missing an escutcheon.
c. 2:05 PM, 3rd floor room E3305 physician's office, is missing an escutcheon.
d. 2:09 PM, 3rd floor room E3315a nurse manager office, is missing an escutcheon.
e. 2:15 PM, 3rd floor room E3319b, janitor's closet, is missing an escutcheon.
f. 2:21 PM, 3rd floor room E3325 has storage less than 18 inches from the sprinkler head.
g. 2:25 PM, 3rd floor room E3329 Chairman, Department of Medicine, closet, is missing an escutcheon.
h. 2:31 PM, 3rd floor room E3314 physician's office, is missing an escutcheon.
i. 2:55 PM, 2nd floor room E2216, Exam Room 11, is missing an escutcheon.
j. 3:07 PM, 2nd floor room E2247, Special Procedures Room, is missing an escutcheon.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above sprinkler deficiencies on the specific date and times stated above.

Based on observation and interview, the facility failed to ensure that Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities, NFPA 99 4.3.1.1.2, 19.3.2.4, in one area within the entire facility.

Findings include:

Observation on August 29, 2011, at 9:49 AM revealed one oxygen H-cylinder was not secured in the Equipment Room.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the the oxygen cylinder was not secured on the specific date and time stated above.

Based on observation and interview, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2 for three areas on two of 5 floors.

Findings include:

Observation on August 29, 2011, revealed the following issues at the following times and locations:

a. 10:35 AM, two open electrical boxes on the 6th floor in room E6406h.
b. 11:07 AM, a coffee pot and microwave plugged into a surge protector and a toaster plugged into another surge protector on the 6th floor, CDMP room E6407.
c. 2:33 PM, a refrigerator plugged into a surge protector on the 3rd floor room E3308, Physicians Office.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above electrical deficiencies on the specific date and times stated above.

Based on observation and interview, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2 for one area on one of six floors.

Findings include:

Observation on August 29, 2011, at 9:31 AM revealed two exposed electrical junction boxes in the 4th floor lobby near the Swank elevators.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above electrical deficiency on the specific date and time stated above.

Based on observation and interview, the facility failed to meet the requirements for electrical wiring per code requirements in several instances on one of nine floors.

Findings include:

1. Observation on 8/31/11 @ 10:45 am revealed several (4) extension cords being used in the employee fitness area room# GS313B.
2. Observation on 8/31/11 @ 10:45 am revealed an extension cord plugged into a surge protector in the employee fitness area room# GS313B.
3. Observation on 8/31/11 @ 10:50 am revealed an extension cord in use for a stereo in employee fitness area room GS303.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed the electrical issues existed on the specific dates and times stated above.

Based on observation and interview, the facility failed to maintain the communicating opening in the two hour fire-resistant common wall in two areas on two of five floors.

Findings include:

1. Observation on August 29, 2011, at 10:29 AM revealed the 6th floor fire wall doors near room E6401 do not close and latch into the frame.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the door would not close and latch on the specific date and time stated above.

2. Observation on August 29, 2011, at 1:33 PM revealed the 3rd floor fire wall doors do not close and latch into the frame.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the door would not close and latch on the specific date and time stated above.

Based on observation and interview, the facility failed to meet the requirements for the common wall to a nonconforming building per code requirements in two locations on two of six floors.

Findings include:

1. Observation on 08/30/11 13:30 pm revealed that the 2 hour door on the 3rd floor, Swank section and the Theatre was being propped open by a rubber cable mat.
2. Observation on 08/30/11 14:10 am revealed that the 2 hour door on the 4th floor, between the patient care building and Swank bldg did not close and positively latch.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the fire rated doors existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to maintain the building construction type in one instance on one of ten floors.

Findings Include:

Observation on 8/29/11 at 11:10 am revealed the following:

There was fireproofing missing on the ceiling beam in the main medical gas storage room.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed there was exposed structural steel.

Based on observation and interview, the facility failed to meet the requirements for building construction type per code requirements on one of six floors.

Findings include:

Observation on 08/30/11 at 8:15 a.m. revealed that there are structural beams in the elevator penthouse that are not protected.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the exposed steel existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance on one of nine floors.

Findings Include:

Observation on 8/31/11 at 9:59am revealed the following:

The conference room door GS2123 lacked positive latching hardware.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed the corridor door did not latch on the specific date and time stated above.

Based on observation and interview, the facility failed to maintain stairways, elevator shafts, light and ventilation shafts, and chutes, and to ensure other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour in one area within the entire facility.

Findings include:

Observation on August 29, 2011, at 1:39 PM revealed that there was a 2-inch unsealed penetration on the 1st floor shaft, S1C1, near the Information Desk and elevators above a donation box.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the shaft penetration on the specific date and time stated above.

Based on observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of smoke barrier walls in four of six floors.

Findings include:

Observation on August 29, 2011, at the following times and locations revealed the following unsealed smoke barrier penetrations:

a. 8:31 AM, 6th floor sleap lab control room W650 and office W668 have numerous unsealed smoke wall penetrations.
b. 8:55 AM, 5th floor above corridor doors near physicians lounge has unsealed penetration around wires and MC cable.
c. 9:53 AM, 4th floor smoke wall between door to room P460 and exit sign has unsealed penetration inside a conduit.
d. 9:57 AM, 4th floor smoke wall inside room P460 is not sealed to deck.
e. 10:17 AM, 4th floor smoke wall in alcove across from room P440 has unsealed penetration around an MC cable.
f. 10:59 AM, 2th floor smoke wall above Walnut Wing corridor doors near conference room has an unsealed penetration.
g. 11:07 AM, 2th floor smoke wall doors between therapy office, W268, and janitor's closet, have a gap greater than 1/8 in while in closed position.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above smoke wall deficiencies on the specific date and times stated above.

1. Observation on August 30, 2011, at 11:07 AM revealed the 2nd floor smokewall doors between the Therapy Office W268 and the janitor's closet have a gap greater than 1/8 inch while in the closed position.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above smoke wall doors deficiency on the specific date and time stated above.

Based on observation and interview, the facility failed to meet the requirements for smoke barrier walls per code requirements on nine of ten floors.

Findings include:

1. Observation on 08/29/11 at 10:30 am revealed that there is a penetration in the smoke wall above the ceiling near smoke doors P926X.
2. Observation on 08/29/11 at 10:50 am revealed that there is a penetration in the smoke wall above the ceiling near smoke doors P826X.
3. Observation on 08/29/11 at 11:15 am revealed that there is a penetration (blue wires) in the smoke wall above the ceiling near smoke doors P614X.
4. Observation on 08/29/11 at 1:00 pm revealed that there are multiple penetration in the smoke wall on the 2nd floor above the ceiling near CR2130X.
5. Observation on 08/29/11 at 1:40 pm revealed that the window (glass) in the smoke wall in the E.R. Security Office on the 2nd floor is not rated glass. It is tempered glass.
6. Observation on 08/29/11 at 1:40 pm revealed that there is a penetration in the smoke wall above the ceiling in the E.R. Security Office.
7. Observation on 08/29/11 at 14:00 pm revealed that there is a penetration (medical vacuum line) in the smoke wall partition above the ceiling near M7056.
8. Observation on 08/29/11 at 14:30 pm revealed that there is a penetration in the smoke wall above the smoke doors B688X.
9. Observation on 08/29/11 at 14:37 pm revealed that there is are penetrations in the smoke wall above the ceiling in patient room M6559 in the corner above the metal lockers.
10. Observation on 08/29/11 at 14:45 pm revealed that there is a penetration in the smoke wall above the smoke doors M6568.
11. Observation on 08/29/11 at 14:55 pm revealed that the smoke wall is incomplete in room M6518 next to the ductwork.
12. Observation on 08/29/11 at 15:15 pm revealed that there is a penetration in the smoke wall between the ductwork in mechanical room # CP5130.
13. Observation on 8/29/11 at 15:20 pm revealed the rated separation with the parking garage on the 3rd floor had non-rated door glass.
14. Observation on 08/29/11 at 15:30 pm revealed that there are penetrations in the smoke wall above the ceiling near 4th floor director's office.
15. Observation on 08/29/11 at 15:45 pm revealed that there is a penetration in the smoke wall above the rated door on the 4th floor by the M4 elevator and vending machine leading into the Anesthesia corridor.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the rated smoke partitions existed on the specific dates and times stated above.

Based on observation and interview, the facility failed to meet the requirements for smoke barrier doors per code requirements in two instances on two of ten floors.

Findings include:

1. Observation on 08/29/11 @ 11:35 a.m revealed that smoke barrier doors next to CP3050XX had a gap exceeding an 1/8 inch and would not resist the passage of smoke.

2. Observation on 08/29/11 @ 1:50 p.m revealed that the 1 1/2 hour doors near CP 1009 discharge lobby did not close and positively latch.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the smoke barrier doors existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to provide the proper fire resistance ratings of one hazardous area on one of three floors.

Findings include:

Observation on August 29, 2011, at 9:53 AM revealed the Soiled Utility Room does not have an operational closure on the door.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the door lacked a closure on the specific date and time stated above.

Based on observation and interview, the facility failed to maintain the one hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system or ensure doors are self-closing in three areas on two of five floors.

Findings include:

Observation on August 29, 2011, at the following times and locations revealed the following rated room issues:

a. 10:49 AM, 6th floor clean storage room, E6428, does not have a door closure.
b. 1:57 PM, 3rd floor file room, E3364, does not have a door closure.
c. 2:35 PM, 3rd floor Reception Office, E3304, has a glass window and does not have a door closure. The room has approximately 84 feet of files stored on shelves.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the rated room deficiencies on the specific date and times stated above.

Based on observation and interview, it was determined the facility failed to maintain hazardous area rooms in one instance on one of ten floors.

Findings Include:

Observation on 08/29/11 revealed the following:

a) At 11:25 am the door to the Cardiac Diagnostic file room was being propped open by a carpet and the electrical cord for a copy machine was being run through the door jam rendering the door incapable of closing and positively latching.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the hazardous rooms existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to maintain hazardous area rooms in one instances on one of nine floors.

Findings Include:

Observation on 08/31/11 revealed the following:

At 08:40 am room GS8803 does not meet the requirements for a storage room because the door lacks a self-closing device.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the hazardous rooms existed on the specific date and time stated above.

Based on observation and interview, it was determined the facility failed to maintain hazardous area rooms in one instances on one of six floors.

Findings Include:

Observation on 08/30/11 revealed the following:

At 14:10 pm room 5486A does not meet the requirements for a storage room because the door lacks a self-closing device.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions with the hazardous rooms existed on the specific dates and times stated above.

Based upon observation the capacity of exits are not in accordance with 7.3 as per regulations in one area on one of six floors.

Findings include:

Observation on 8/29/11 @ 11:45 am revealed the 6th floor PC mechanical room was a manned location with only 1 exit / escape route. This area also lacks proper exit signage.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed the exiting issue on the specific date and time stated above.

Based on observation and interview, the facility failed to ensure that the width of aisles or corridors was clear and unobstructed on one of five floors of the facility.

Findings include:

Observation on August 29, 2011, at 11:11 AM, revealed a blood pressure machine stored in the 6th floor corridor near room E6414. The BP machine was charging for over 30 minutes.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the storage in the corridor on the specific date and time stated above.

Based on observation and interview, the facility failed to ensure that emergency lighting was properly tested and maintained in one location within the entire facility.

Findings include:

Observation on August 29, 2011, at 9:51 AM revealed there was an inoperative battery back-up light in the Equipment Room.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the battery back-up light was inoperative on the specific date and time stated above.

Based on observation and interview, it was determined the facility failed to maintain sprinkler protection in two instances on two of ten floors.

Findings Include:

Observation on 8/30/11 revealed the following:

a) Office M206b on the second floor lacks sprinkler protection.
b) C22 suite on the basement level lacks sprinkler protection.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions existed with the sprinkler protection on the specific dates and times stated above.

Based on observation and interview, the facility failed to provide adequate sprinkler coverage for six areas on three of five floors.

Findings include:

Observation on August 29, 2011, at the following times and locations revealed the following sprinkler issues:

a. 10:47 AM, 6th floor room E6432 lacked sprinkler coverage in air conditioning closet .
b. 11:09 AM, 6th floor room E6407 lacked sprinkler coverage in two metal closets.
c. 11:13 AM, 6th floor room E6400, janitor closet, had a sprinkler head within 4 inches of the wall.
d. 11:51 AM, 5th floor room E514 lacked sprinkler coverage in a closet.
e. 2:13 PM, 3rd floor room E3319, Exam Room 6, lacked sprinkler coverage in two closets.
f. 2:17 PM, 3rd floor room E3321, Exam Room 6, lacked sprinkler coverage in two closets.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above sprinkler issues on the specific date and times stated above.

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per code requirements in three instances on two of nine floors.

Observation on 08/31/11 revealed the following:

1. At 10:00 am in room # 8867 there were several sprinkler heads that were within 6 feet of other sprinkler heads in this room causing an obstruction to the discharge pattern of the sprinkler heads.
2. At 10:30 am in the Employee Fitness area room # GS 315 room A there were heavy moving blankets being used as blackout curtains clamped and hanging from the sprinkler pipes.
3. At 10:30 am in the Employee Fitness area room # GS 315 room A there were rolls of padded foam stuffed between the sprinkler lines and the ceiling being stored.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these conditions concerning sprinklers existed on the specific dates and times stated above.

Based on documentation review and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in reliable operating condition throughout the facility.

Findings include:

1. Observation on August 31, 2011, between 8:00 AM and 11:00 AM revealed the vendor sprinkler reports dated 11/9-12/10, 2/15/11, 5/19-23/11, and 8/9-12/11 indicated the sprinkler head in Mechanical Room CP 2106 had no liquid in the bulb and needed to be replaced.

2. Observation on August 31, 2011, between 8:00 AM and 11:00 AM revealed the vendor sprinkler reports dated 5/19-23/11, and 8/12-17/11 indicated the sprinkler head on the 4th floor hallway near room M4023 is above the ceiling tile and needs to be lowered.

3. Observation on August 31, 2011, between 8:00 AM and 11:00 AM revealed the vendor sprinkler reports dated 5/19-23/11 indicated the sprinkler heads in the M4 stair 6 were not installed properly.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed these sprinkler issues existed on the specific dates and times stated above.

Based on observation and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in reliable operating condition in numerous locations on three of five floors.

Findings include:

Observation on August 29, 2011, at the following times and locations revealed the following sprinkler issues:

a. 10:57 AM, 6th floor alcove, near the nurses station and room E 6417, is missing an escutcheon.
b. 11:55 AM, 5th floor room E509 restroom is missing an escutcheon.
c. 2:05 PM, 3rd floor room E3305 physician's office, is missing an escutcheon.
d. 2:09 PM, 3rd floor room E3315a nurse manager office, is missing an escutcheon.
e. 2:15 PM, 3rd floor room E3319b, janitor's closet, is missing an escutcheon.
f. 2:21 PM, 3rd floor room E3325 has storage less than 18 inches from the sprinkler head.
g. 2:25 PM, 3rd floor room E3329 Chairman, Department of Medicine, closet, is missing an escutcheon.
h. 2:31 PM, 3rd floor room E3314 physician's office, is missing an escutcheon.
i. 2:55 PM, 2nd floor room E2216, Exam Room 11, is missing an escutcheon.
j. 3:07 PM, 2nd floor room E2247, Special Procedures Room, is missing an escutcheon.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above sprinkler deficiencies on the specific date and times stated above.

Based on observation and interview, the facility failed to ensure that Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities, NFPA 99 4.3.1.1.2, 19.3.2.4, in one area within the entire facility.

Findings include:

Observation on August 29, 2011, at 9:49 AM revealed one oxygen H-cylinder was not secured in the Equipment Room.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the the oxygen cylinder was not secured on the specific date and time stated above.

Based on observation and interview, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2 for three areas on two of 5 floors.

Findings include:

Observation on August 29, 2011, revealed the following issues at the following times and locations:

a. 10:35 AM, two open electrical boxes on the 6th floor in room E6406h.
b. 11:07 AM, a coffee pot and microwave plugged into a surge protector and a toaster plugged into another surge protector on the 6th floor, CDMP room E6407.
c. 2:33 PM, a refrigerator plugged into a surge protector on the 3rd floor room E3308, Physicians Office.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above electrical deficiencies on the specific date and times stated above.

Based on observation and interview, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2 for one area on one of six floors.

Findings include:

Observation on August 29, 2011, at 9:31 AM revealed two exposed electrical junction boxes in the 4th floor lobby near the Swank elevators.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 PM confirmed the above electrical deficiency on the specific date and time stated above.

Based on observation and interview, the facility failed to meet the requirements for electrical wiring per code requirements in several instances on one of nine floors.

Findings include:

1. Observation on 8/31/11 @ 10:45 am revealed several (4) extension cords being used in the employee fitness area room# GS313B.
2. Observation on 8/31/11 @ 10:45 am revealed an extension cord plugged into a surge protector in the employee fitness area room# GS313B.
3. Observation on 8/31/11 @ 10:50 am revealed an extension cord in use for a stereo in employee fitness area room GS303.

Interview with the Hospital President, the Director of Maintenance and other facility personnel on 8/31/11 at 1:00 p.m. confirmed the electrical issues existed on the specific dates and times stated above.