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Based on observation, it was determined the facility failed to maintain the common wall, including all components, for a fire resistance rating of at least two hours four of ten floors.

Findings include:

Observation on August 25, 2010, between 8:35 am and 1:05 pm, revealed there were penetrations in the common/fire rated wall at the following locations:

a. 8:35 am, ground floor, there was a penetration above the fire doors by receiving, above the left hand leaf of the double doors.
b. 8:37 am, ground floor, there was an unsealed conduit on the right hand wall of the fire doors by receiving.
c. 9:40 am, second floor, there was a penetration of a white data cable going into the common wall to the right of the electrical closet, toward the double doors.
d. 11:10 am, eighth floor above the fire rated doors at the atrium above the ceiling there were two unsealed penetrations for data wiring.
e. 1:05 pm, on the seventh floor above the fire rated doors for the atrium near stairtower 4, above the ceiling there were six unsealed penetrations for data wiring electrical wiring and conduit.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there were penetrations in the common/fire walls.

Based on observation and interview, the facility failed to maintain proper building construction type by failing to maintain the fire protection of the structural steel beams on one of ten floors.

Findings include:

Observation made on August 25, 2010, between 9:25 am and 9:33 am, revealed the following locations that were found to lack fire proofing material on the structural steel beams.

a. 9:25 am, on the tenth floor in the mechanical room near the intake on the east side exterior wall, at the top of the steel structural column near the wall brace weld point the fire proofing material was missing.
b. 9:30 am, on the tenth floor in the mechanical room northwest corner, six areas of the structural steel beams and columns were missing fire proofing material.
c. 9:33 am, on the tenth floor in the mechanical room near air-handler #3 and #5 at the base of the structural column, the fire proofing material was missing and also at the horizontal beams tie-in point at the top of the column.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed the above areas on the tenth floor that the structural steel beams and columns were missing fire proofing material.

Based on observation and interview, it was determined the facility failed to ensure the corridor doors were substantial, 1 ? inch solid-bonded core wood, capable of resisting the passage of smoke with no impediment to closing on one of ten floors, NFPA 101, 2000 edition, 19.3.6.3.

Findings include:

Observation on August 25, 2010, at 11:35 am, revealed the door of the pool room was blocked from closing by a chair wedged between the door and the frame.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed the door was impeded from closing.

Based on observation and interview, it was determined the facility failed to maintain the floor/ceiling and shaft assemblies on one of ten floors.

Findings include:

1. Observation on August 25, 2010, at 9:05 am, revealed a partially sealed vertical conduit with orange hose going through the deck in the first floor data closet.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there was a penetration.


2. Observation on August 25, 2010, at 9:07 am, revealed three unsealed conduits in the first floor electrical closet that led to the second floor.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there were unsealed conduits.

Based upon observation and interview, it was determined the facility failed to keep the hazardous area separated from other spaces by smoke resisting partitions in conjunction with the sprinkler system on one of ten floors.

Findings include:

1. Observation on August 25, 2010, at 8:45 am, revealed the door to the General Storage room on the first floor was held open with a bungee cord and a hanger.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed the door was held open with unauthorized means.


2. Observation on August 25, 2010, at 9:00 am, revealed a hole in the corridor wall into the electrical equipment room on the first floor.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there was a penetration.

Based upon observation and interview, the facility failed to maintain the exit egress component stairtower to have a fire resistive rating of at least two hour on one of ten floors.

Findings include:

Observation made on August 25, 2010, at 1:07 pm, revealed that inside the seventh floor stairtower 4 there was an unsealed penetration through the stairtower wall into the atrium landing area for electrical conduit.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed the unsealed penetration in the 4 stairtower wall.

Based on observation and interview, it was determined that the facility failed to maintain protection of the fire command center within this building.

Findings include:

Observation on August 25, 2010, at 9:30 am, revealed a penetration into the fire command center from the corridor on the ground floor.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there was a penetration.

Based on observation and interview, it was determined that the facility failed to maintain the sprinkler system in working order on six of ten floors.

Findings include:

1. Observation on August 25, 2010, between 8:55 am and 2:15 pm, revealed there were missing sprinkler escutcheons in the following locations:

a. 8:55 am, first floor, inside the mechanical closet in the security locker room.
b. 9:25 am, first floor, women's restroom.
c. 2:15 am, fifth floor, clean utility room.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there were sprinkler escutcheons missing.


2. Observation on August 25, 2010, between 11:05 am and 2:20 pm, revealed signs of corrosion on sprinkler heads or piping in the following locations:

a. 11:05 am, fourth floor, OP suite sprinkler head.
b. 2:15 am, fifth floor, clean utility room sprinkler head.
c. 2:20 am, fifth floor, above the ceiling in the elevator lobby on a section of pipe leading to the sprinkler head where it sits just above the ceiling grid.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there were signs of corrosion.

3. Observation on August 25, 2010, between 11:15 am and 1:57 pm, revealed at the following areas there was storage within eighteen inches of the sprinkler head.

a. 11:15 am, eighth floor, administration storage room (within fourteen inches).
b. 1:56 pm, on the sixth floor inside the kitchen right side refrigerator (within ten inches).
c. 1:57 pm, on the sixth floor inside the kitchen left side rear freezer (within ten inches).

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed the storage within eighteen inches of the sprinkler heads on the sixth and eighth floors.

4. Observation on August 25, 2010, at 2:30 pm, revealed that on the sixth floor above the fire rated center doors for the atrium and above the ceiling there were two air lines that were zip-tied to the sprinkler pipe.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed the two air lines that were zip-tied to the sprinkler pipe on the sixth floor.

Based on observation and interview, it was determined that the facility failed to maintain the portable fire extinguishers in working condition one of ten floors.

Findings include:

Observation on August 25, 2010, at 9:35 am, revealed the fire extinguisher in the first floor elevator machine room was sitting on the floor.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed the fire extinguisher was not hung on the wall.

Based on observation and interview it was determined the facility failed to provide piped in medical gas components that comply with NFPA 99, Chapter 4, 1999 edition in one instance within this facility.

Findings include:

Observation on August 25, 2010, at 9:20 am, revealed that on the tenth floor the medical vacuum and medical air pipes penetrate into the elevator machine room and then into the chase, the assembly built around the medical gas piping inside the elevator machine room had six unsealed penetrations for electrical conduit into this assembly. The facility also must verify the fire rating of this assembly that encloses the medical gas system piping.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there were unsealed penetrations around the medical gas piping inside the tenth floor elevator machine room for electrical conduits.

Based upon observation and interview, it was determined the facility failed to maintain the electrical elements in working order on six out of ten floors, Department of Health message board, message dated October 30, 2009, and NFPA 70.

Findings include:

1. Observation on August 25, 2010, at 8:35 am, revealed an uncovered condulet in the corridor outside of receiving on the ground floor.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there was an uncovered condulet.

2. Observation on August 25, 2010, between 9:15 am and 11:20 am, revealed the improper use of surge protectors in the following areas:

a. 9:15 am, first floor, registration, there was a refrigerator plugged into a surge protector in the cubicle closest to the elevator lobby.
b. 9:20 am, first floor, registration, there was a coffee pot plugged into a surge protector behind the registration cubicles by the copier.
c. 11:20 am, fourth floor, there were various appliances plugged into a surge protector in the OP staff locker room.
d. 1:20 pm, on the seventh floor inside the pediatric suite soiled utility room there was a refrigerator powered by a powerstrip.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed the surge protectors were being used in an unauthorized manner.


3. Observation on August 25, 2010, at 10:15 am, revealed there was an extension cord in use in the ESD Supervisor's office.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there was an extension cord being used.


4. Observation on August 25, 2010, at 9:15 am, revealed the first floor elevator machine room was being utilized as a storage room. Refer to 1999 Edition of NFPA 70 Article 620 H, 620-71. Also refer to ASME/ANSI A17.3-1993, Safety Code for Existing Elevators and Escalators.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed there were items being stored in the elevator machine room.

5. Observation on August 25, 2010, between 11:10 am and 2:00 pm, revealed at the following areas had electrical system components unsecured leaving exposed wiring or exposed live equipment.

a. 11:10 am, on the eighth floor above the ceiling on the atrium side of the rated doors to the atrium, the electrical connector for the armored flex conduit for the wiring to the hi-hat recessed lighting fixture had pulled out of the box and left the wiring exposed.
b. 1:15 pm, on the seventh floor rated wall at the atrium in front of the data closet above the ceiling, there was exposed temporary wiring and light laying on the ceiling.
c. 2:00 pm, on the sixth floor inside the kitchen in electrical panel marked SH6B there were two missing circuit breaker blanks, and an open space at the lower part of the inner face plate (8" x 3") where the protective plate was missing.

Interview at the exit conference with the Administrator and the Director of Plant Operations, Engineering & Safety on August 25, 2010, at 3:00 pm, confirmed the locations on the eighth floor, seventh floor and the sixth floor that had electrical components not properly secured or installed.