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Based upon observation and interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could affect occupants in one smoke compartment in the event of fire.

Findings Include:

On 05/06/2019, at approximately 2:30 PM, observed a linen chute on the 4th floor that did not close to a positive latch when tested.

On 5/06/2019, at approximately 2:45 PM, observed 3rd floor corridor door to the soiled utility room did not close to a positive latch when tested.

The above findings were confirmed with Facilities Representative #1 at the time of observation.

Based upon observation and interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could potentially affect the all occupants in the event of a fire.

Findings Include:

1. On 05/06/2019, at approximately 1300 the following observation was made and confirmed by interview with Facilities Representative #1, that the corridor door (S1079) to the Supply and Distribution Area blocked open.

2. On 05/06/2019 at approximately 1330, the following observation was made and confirmed by interview with Facilities Representative #1, that the double corridor doors (S1033) to the Gift Shop would not close to a positive latch, due to a security device installed on the door.

3. On 05/06/2019 at approximately 1400, the following observation was made and confirmed by interview with Facilities Representative #1, that the corridor (E3074) to the Soiled Utility Room 3300 did not close to a positive latch.

4. On 05/06/2019 at approximately 1415, the following observation was made and confirmed by interview with Facilities Representative #1, that the corridor door (W1727) to the ED Clean Utility Room 121 was blocked open.

5. On 05/06/2019 at approximately 1420, the following observation was made and confirmed by interview with Facilities Representative #1, that the double corridor fire doors (S2034) leading to the Elevator Lobby for the South Tower did not close to a positive latch. The latching devices have been removed.

Based upon observation and interview, the facility failed to ensure that occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals as required by 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, and 9.6.4. This deficient practice could affect all persons in the event of a fire.

Findings Include:

1. On 05/06/2019, at approximately, 10:00 AM, the following observation was made on the 4th floor, and confirmed by Facilities Representative #1, that the following areas on Floor 4 had no fire alarm notification device.
a. The 4500 Dining Room (S4193)
b. The Staff Lounge (E4006)
c. The Rehab Room (E4007)
d. The Staff Lounge (E4010)
e. The Manager's Office (E4037)
f. The Visitor's Lounge 4300 (E4104)
g. The Staff Lounge 4200 (E4108)

2. On 05/06/2019, at approximately, 10:30 AM, the following observation was made on the 3rd floor, and confirmed by Facilities Representative #1, that the following areas on Floor 3 had no fire alarm notification device.
a. The Staff Lounge 3200 (W3113)
b. The Nurse's Lounge 3100 (W3006)
c. The Staff Lounge 3100 (E3008)
d. The Nurse's Lounge 3300 (E3091)
e. The WOC Nurse Room (E3092)

3. On 05/06/2019, at approximately, 10:45 AM, the following observation was made on the 2nd floor, and confirmed by Facilities Representative #1, that the following areas on Floor 2 had no fire alarm notification device.
a. The Manager CRNA Office (N2081)
b. The Staff Lounge PACU (N2602)
c. The LDRP Conference Room (W2330)
d. The Women's Center Staff Lounge (W2292)
e. The CNVS Reception Waiting Area
f. The Food and Nutrition Services (S2003)

4. On 05/06/2019, at approximately, 11:00 AM, the following observation was made on the 1st floor, and confirmed by Facilities Representative #1, that the following areas on Floor 1 had no fire alarm notification device.
a. Respiratory Therapy (S1075)
b. Cancer Center Dosimetry Office (N1503)
c. Cancer Center Waiting Area (N1468)
d. MRI Staff Lounge (N1529)
e. Lab Staff Lounge (W1812)
f. Cafe Serving and Seating Area

Based upon observation and interview, the facility failed to ensure that nursing homes and hospitals were required by construction type are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 as required by 19.3.5.1 through 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, and 9.7.1.1(1). This deficient practice could affect all persons in the South Tower in the event of a fire that could damage Air Handling Units.

Findings Include:

On 05-07-2019, at approximately, 10:30 AM, the following observation was made in the South Penthouse and confirmed by Facilities Representative #1, that the area below the Swing Air Handler was unprotected.

Based upon observation and interview, the facility failed to ensure that equipment listed for use in oxygen-enriched atmospheres or oxygen delivery are labeled as required by 11.5.3.1 of NFPA 99. This deficient practice could affect all persons on the second floor.

Findings Include:

1. On 05/07/2019, at approximately 1130, the following observation was made on the 2nd floor, and confirmed by Facilities Representative #1, that the following rooms on Floor 2 storing medical gas cylinders with a combined capacity greater than 300 cubic feet of gas; that the corridor door to the rooms was not properly labeled, "Medical Gas Storage, No Smoking, No Open Flames, Open Door Slowly". .
* PACU Tank Storage Room (N2546)
* Main C-Section Hall Tank Storage (W2319)