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Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Midtown Surgery Center 2nd floor Midtown Medical Building - fire door between medical office buildings did not self close and latch

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Midtown Surgery Center 8th floor electrical equipment room - fire proofing is missing on web of steel beam

2. Midtown Surgery Center , all floors- The facility has rated shafts that are not complete at the mechanical rooms.


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Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 7th floor North - room is open to corridor; located across from nourishment room

2. Main Building 7th floor F wing - dictation room beside glass block wall is open to corridor

3. Main Building 1st floor Ultra Sound Exam room #1 - space beside exam room is open to corridor

4. Main Buildig 1st floor Ultras Sound wing - office space is open to corridor near stairwell 9

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Midtown Surgery Center7th floor mechanical room does not self close and latch

2. Midtown Surgery Center 7th floor Dirty utility room hardware does not self close and latch

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main building ground floor outpatient soiled utility room -The Soiled utility room closet does not have a complete laundry chase installed as a plate above the chase is not secured properly.

2. Main building ground floor outpatient waiting room nurses station -The laundry chase top plate is not installed leaving the laundry chase incomplete.

3. Main building 5th floor elevator lobby, The door to the vertical chase was not-self-closing and latching during the survey.

4. Main building, 1st Floor, Kitchen. There is a duct penetrating the ceiling in the catering office/room that is not properly sealed.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 6th floor from 6A to mechanical room -Door in fire wall was undercut much larger than ¾ inches.

2. Main building, 3rd Floor, Stairwell 40. The stairwell door was found to be wedge open with cardboard to prevent it from closing

3. Main building 1st floor, Stairwell 40. The stairwell door located on floor exit discharge door would not close latch and seal.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 2nd floor -Unsealed Penetration in the smoke wall above the ceiling at anesthesia office

2. Main Building 6th floor near room 651 -Door in smoke wall did not close latch and seal to prevent the passage of smoke.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 7th floor E wing smoke barrier doors did not open in opposite directions near adult behavior entrance

2. Main Building 2nd floor PICU wing, cross corridor doors did not close smoke tight at Metro view Tower.


3. Main building 2nd floor Family Center cross corridor on left side did not close with activation of fire alarm.

4. Main building, 3rd Floor, 3A, the cross corridor door at the dietary elevator area did not close upon activation of the fire alarm system. (Door 3a-23)

5. Main building, 3rd floor, Harris Hospice. The facility has cross corridor smoke doors at H31, and H32 that had a gap grater than 1/8th of an inch when closed.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Metroview, Sleep Center, 3rd floor, the soiled linen closet located in the unit is not one hour construction or sprinkled.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 6th floor stairwell 6 & 7 in ER overflow, stairwell 1, 4, & 2 in endoscopy -Delayed egress with electric strike plate, no longer in use, should be rendered no longer capable of reengaging with the turn of a key. Corrected during survey

2. Main Building 2nd floor -Exit access blocked by vapor barriers of OR ' s new construction. Exit must not exceed 100 feet to stairwell. Corrected during survey.

3. Main Building 2nd floor near children ' s elevator -Special locking could be reengaged/relocked with fire alarm system in alarm mode.

4. Main Building 2nd floor entrance to children ' s wing from hospital - Special locking did not release with fire alarm or smoke head activation

5. Main Building 7th floor D wing - magnetic lock near 7D elevator must have a manual override not more than 3 feet from the door

6 Main Building 7th floor F wing - access control egress door at ICN Entrance is a magnetic lock and has a push pad without additional features as required for access controlled egress doors in the Life Safety Code.

7. Main Building 7th floor F wing - no emergency release in ICN nurses station for special locking arrangements.

8. Main Building 7th floor North wing - egress corridor exceeds twenty feet from a point where two exits can be reached. The corridor is located near cross corridor doors between service corridor and Women's Center.

9. Main Building 1st floor Emergency Department - delayed egress doors not operating properly at the back of the Pediatric unit

10. Main Building 1st floor Emergency Department - access control egress door push control must be within 5 feet to operate near the Pediatric unit

11. Main Building 1st floor Emergency Department - horizontal entrance doors do not break away properly in the direction of egress

12. 1st floor CT wing - access control egress door push control must be within 5 feet of access control doors. Located near the CT Entrance

13. Main Building 1st floor Radiology unit - dead end corridor is more than 20 feet from point were exits may be reached. Located near MRI.


Note: Special locking arrangements are permitted only in facilities equipped throughout with a complete sprinkler or detection system. The facility on the date of this survey was not equipped with the required systems.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 8th floor D wing - unprotected vertical opening in stairwell 6

2. Main Building 7th floor D wing - unprotected vertical opening in stairwell 6

3. Main Building 1st floor Stairwell 3 - swing bar between landing and stairs to lower level obstructs stairway landing. The swing bar was not self-closing at time of survey.

4. Main Building, 2nd floor, stairwell 15, (PICU) The facility has storage in closet in stairwell.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 2nd floor -Door to OR storage required more than a single range of motion to exit the room.

2. Main Building 8th floor D wing - guardrail must be a minimum of 42 inches high and prevent the passage of a 6 inch spear; located near the exit access serving the elevator equipment room.

3. Main Building 7th floor D wing - locks located higher than 48 inches on rooms D793, D787, Medical director office

4. Main Building 1st floor Radiology wing - locks located higher than 48 inches in Interventional Radiology hallway

5. Main Building 1st floor Diagnostic Radiology - excessive hardware on door requires more than one motion of the hand to exit at Diagnostic 1

6. Main Building 1st floor Diagnostic Radiology - door is less than 41 1/2 inches clear opening at Diagnostic 2

7. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Cancer data Services closet to fire exit.

8. Main building 5th floor E wing. The facility is utilizing more than one motion of the hand for egress at the CURY unit.

9. Main building 5th floor E wing. There is no emergency release switch located in the vicinity of the special locking doors, nor a master switch to release the doors at the nurses station.

10. Main building 5th floor E wing C unit, The facility is utilizing more than one motion of the hand for egress from this unit at both doors in the unit.

11. Main Building 5th floor E wing Cath Lab. The facility dows not have a door release switch at the nurse station for the special locking doors serving that location.

12. Main building 2nd floor Hemby unit. The facility is utilizing more than one motion of the hand for egress from all office doors at this location.

13. Main building 2nd floor Pathology unit. The facility is utilizing more than one motion of the hand for egress from the vent hood room.

14. Main Building 4th floor C wing -The facility is utilizing more than one motion of the hand for egress at the staff lounge across from room C443.

15. Main Building 4th floor B wing - The facility is utilizing more than one motion of the hand for egress at room B430.

16. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Cancer data Services closet to fire exit.

17. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Cancer data Services near the corridor fire doors.

18. Main Building, ground floor, C wing - The facility is utilizing more than one motion of the hand for egress at occupational therapy room.

19. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Hydrotherapy room.


20. Main building,1st Floor, Kitchen; The means of egress outside the exit door next to cooler #1 and to the upper lever loading dock was blocked and not maintained clear and unobstructed.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 2nd floor - Illumination of means of egress/ exit discharge lighting in the " old dock " egress from materials management to the public way was not on the life safety branch of the emergency electrical system.

2. Main Building Illumination of means of egress/ exit discharge lighting around the perimeter of the building was on a timer and could not be verified to come on with the emergency power system during daylight hours.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Main Building 1st floor Radiology unit - exit discharge has a single bulb light fixture for illumination of means of egress near Neuro Angio Invterventional 1

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

125 Baldwin 200 suite exit from elevator to main lobby -The facility did not have exit directional sign leading from the elevator lobby area to the main lobby exit.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Midtown Surgery Center7th floor Surgery unit - fire alarm annunciator panel is not provided in ambulatory surgery center to monitor fire alarm system.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Midtown Surgery Center 7th floor mechanical room did not have a smoke detector in return air plenum.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 7th floor C wing smoke detector more than 15 feet from smoke barrier near E elevator

2. Main Building 7th floor E wing smoke detector more than 15 feet froms moke barrier near room E914

3. Main Building 1st floor G wing smoke detector covered by duct tape at entrance to G stairwell 1

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Midtown Surgery Center Midtown Medical Office building is not fully sprinklered

2. Midtown Surgery Center 8th floor storage closet by stairs - is not sprinklered

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building, Ground Floor, Outside near the emergency entrance -The tamper alarm 113 did not give an audible and visual alert at an area where it was likely to be heard.

2. Main building, Ground floor parking garage maintenance room -The facility does not have its pressure operated flow switch on the dry pipe sprinkler system supervised.

3. Main Building, Ground Floor, at Fourth Street -The facility does not have its post indicator valve on the Fourth Street location

4. Main building ground floor Fourth Street -There is an unapproved tamper alarm at the sprinkler at the fourth street location.

5. Main building ground floor stairwell # 8 -There is an unapproved tamper alarm at the sprinkler at stairwells 3 and 8.

6. Main building, Ground floor Emergency Department Sprinkler room -The facility does not have its pressure operated flow switch on the dry pipe sprinkler system supervised.

7. Main building, Sub-Basement, Gift shop storage area, there is an unapproved tamper alarms at the sprinkler valves at this location.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Midtown Surgery Center7th floor mechanical room unpright sprinkler is closer than 4 inches to the beam and appears to have fire proofing on it.

2. Midtown Surgery Center 2nd floor Endocronolgy unit - medical records rack within 18 inches of sprinkler

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 7th floor E wing - fire damper in electrical room is not installed in accordance with manufacturer's installation instructions. Duct penetrating floor assembly is not equipped with breakaway connections.

2. Main Building Behavioral Health Unit - there is no emergency shutdown switch for air handler serving the unit.

3. Main building 5th floor C wing short hall staff could not located shut down button for HVAC system.

4. Main Building 5th floor Cat lab and Nick U. staff could not located shut down button for HVAC system.

5. Main building, 1st Floor, Radiological Oncology, facility could not locate the HVAC emergency shutdown switch that serves the area.

6. Main building, 3rd floor, outpatient infusion, facility could not locate the HVAC emergency shutdown switch that serves the area.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Main building, 1st Floor, Kitchen, the hood and exhaust make-up air supply for the unit located by the baking ovens did not appear to be operational.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Midtown Surgery Center 4th floor - a high temperature, exposed element portable space heater was observed in a staff office

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 7th floor North wing slef latching device needed on laundry chute in soiled utility # 5

2. Main Building 6th floor -Two hour enclosure for the interstitial space at the transfer grill did not have smoke detectors on both sides for automatic closure of grills upon activation.

3. Main Building 6th floor -Two hour enclosure for the interstitial space (with the pneumatic chute) did not use both fire/smoke dampers in the transfer grill for air handling unit 24. Only fire dampers were installed.

4. Main Building the two hour enclosure for pneumatic soiled linen chute as it passes from 6th to 7th floor in the interstitial space of the 6th floor was not provided.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 8th floor D wing -obstruction of the means of exit egress in greenhouse

2. Main Building 7th floor C wing -storage in 8C short hallway

3. Main Building 7th floor C wing -wall mounted clerical pads near 764 and 767 not functioning properly

4. Main Building 7th floor C wing -blind spot mirror mounted on corridor wall protrudes inside 6ft 8in head clearance near stairwell 8

5. Main Building 7th floor E wing - access door to room E922 obstructs corridor

6. Main Building 7th floor North wing - crash carts disrupt flow of corridor outside O2 room and rooms 866 and 860

7. Main Building 1st floor Interventional Radiology - hallway lights in corridor protrude inside 6ft 8in head clearance

8. Main Building 1st floor Radiology Wing - water fountain in hallway near Nuclear Medicine area

9. Main Building 1st floor Radiology Wing -breakaway doors at entrance to MRI protrude further than 7inches from the wall

10. Main Building 6th floor near room A624 - Wall mounted charting table located near room A624 did not return to the upright position when placed down for use.

11. Main building 5th floor , D wing. The facility has items obstruction the egress corridor at C.O.W.

12. Main building 5th floor , D wing B/P has items obstructing the egress corridor at the D wing B/P area.

13. Main building 2nd floor short C hall. The janitor closet door opens into the egress corridor and does not have either a self closing device installed to close the door when opened or open 180 degrees onto the egress corridor.

14. Main building fourth floor, D wing -Charting table located near rooms D448 D494, D486, D487 did not return to the upright position when placed down for use.

15. Main building, 5th Floor, intersection of 5A and 5F there is storage in the exit egress corridor located next to Stairwell 14, (Linen cart and stretcher)

16. Main building, 5th floor, intersection of 5A and 5C, plastic dust barrier protruding into the corridor blocking the means of egress. (Corrected during survey)

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Midtown Surgery Center Basement of Midtown Medical - unsupported oxygen cylinder located in fire control room without proper support

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Main building, 3rd building, HVAC unit # 12A. The smoke damper in mechanical room did not close upon activation of the fire alarm system.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Midtown Surgery Center 7th floor Surgery unit - only one master alarm panel for medical gas system is provided in the facility.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Main Building, 5th floor, 5A, clean storage room used for oxygen storage does not have any smoking signage on the door to indicate quantities of oxygen being stored.

Based on the observations and staff interviews on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Main Building 7th floor Surgery unit - generator annunciator panel is not located within ambulatory surgery center at a supervised station

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety items were observed as noncompliant, specific findings include:

1. Main Building 8th floor D wing electrical outlet is not GFI protected in the greenhouse

2. Main Building 8th floor D wing light is not on the life safety branch in the greenhouse

3. Main Building 7th floor C wing Lights in Medx (medication preparation room) was not verified to be on emergency power

4. Main Building 7th floor C wing room 769 red switch for nightlight not operational

5. Main Building 7th floor F wing exposed bulbs in storage room near elevator F

6. Main Building 7th floor North wing recepticals were loose and had dust buildup in OR2 and OR3

7. Main Building 1st floor Radiology wing electrical outlet is not GFI protected in Inpatient Recovery Holding area

8. Main Building 1st floor Nuclear Medicine wing 3 way switch near Nuclear Medicine 5 is not working properly

9. Main Building 1st floor Emergency Department entrance circuit breaker FACP on normal power

10. Main Building maintance shop in main building EPS supplying load did not funcation during normal loss of power

11. Main Building Ground floor switchboard room - The generator annuciator panel did not give an audible signal when the facility went from normal to emergency power when the emergency power system was tested.

12. Main building ground floor switchboard room -The generator annuciator panel lamp test did not give an emergency trouble visual indication of system trouble when tested during the emergency power system test.

13. Main Building 2nd floor -Confirm PACU pixus and blood bank #22 in OR on emergency power.

14. Main building 5th floor C wing. The facility has an open J box above the ceiling at double doors labeled FDO-5R-217

14. Main building 2nd floor PICU. The facility has a medical refrigerator which was not verified to be on emergency power.



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16. Main building, 1st Floor, Kitchen . The light in the cooler is missing the protective cover over the bulb.

17. Main building, 1st Floor, Kitchen. Two refrigeration units one located on the cook line under the hood and one located next to the tray make-up area were equipped with unapproved wiring. (Non manufactured approved wiring/cords and non approved quad receptacle box)


18. Main building, 1st Floor, Kitchen. The electrical panel located in the dishwashing area were blocked and not provided with the required clearance.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Main building 2nd floor short C hall. The facility is not a fully sprinklered building and is utilizing alcohol based hand rub dispensers over carpet.

Based on observations and staff interviews, on August 2nd, 2011 through August 4th, 2011 the following Life Safety item was observed as noncompliant, specific findings include:

Sleep Center, 3rd floor, throughout the facility Alcohol rub hand sanitizers were found located within 6 inches of electrical switched and/or devices and were installed above carpet in a building that was not sprinkled.