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Based on observation and interview, it was determined that the facility failed to ensure the fire resistive rated doors in communicating openings of the fire rated common wall, positively latched in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 1:41 pm, revealed the double doors located in the common wall shared with the Holy Family Pavilion, failed to close and positively latch. The doors were located in the Cath lab area.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the doors failed to positively latch.

Based on observation and interview, it was determined the facility failed to ensure the fire resistive rated doors in communicating openings of the fire rated common wall, positively latched in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 1:41 pm, revealed on the second floor, the double doors located in the common wall shared with the St. Joseph's building failed to close and positively latch. The doors were located in the Cath lab area.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the doors failed to positively latch.

Based on observation and interview, it was determined the facility failed to ensure the gap between the face of corridor doors and the door frame does not exceed 1/2 inch; and the facility failed to ensure the corridor doors positively latch into the door frame and remained closed in the frame in three of seventeen smoke compartments.

Findings include:

1. Observations on December 23, 2014, between 10:15 am and 11:15 am, revealed at the following locations the gap between the corridor door face edge and the door frame was greater than 1/2 inch:

a. 10:15 am, sixth floor room 613, even with a gasket installed along the frame.
b. 11:13 am, fourth floor room 449.
c. 11:15 am, fourth floor room 450.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the condition of the gap around the corridor doors.


2. Observations on December 23, 2014, between 11:10 am and 1:20 pm, revealed the following corridor doors failed to positively latch into the door frame when tested:

a. 11:10 am, fourth floor, patient room 444.
b. 11:12 am, fourth floor, patient room 447.
c. 11:20 am, fourth floor, patient room 453.
d. 1:20 pm, second floor, janitors closet located by outreach manager office.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the corridor doors failed to latch into the frame.

Based on observation and interview, it was determined that the facility failed to ensure that corridor doors are free of impediments to closing, in one of nine smoke compartments.

Findings include:

Observation on December 23, 2014, at 10:20 am, revealed on the third floor, the door to patient room #376 was blocked from closing by a linen cart and portable toilet.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the corridor was blocked.

Based on observation and interview, it was determined the facility failed to ensure the doors in the smoke barrier walls properly close in order to impede the transfer of smoke in two of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 11:00 am, revealed on the third floor the smoke barrier doors located by exit stairway three, failed to release and close properly when manually tested.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the doors failed to release and close properly.

Based on observation and interview, it was determined the facility failed to ensure the doors to hazardous areas were self-closing and remain closed within the door frame in one of seventeen smoke compartments within the facility.

Findings include:

Observation on December 23, 2014, at 1:15 pm, revealed the second floor Clinical Chemistry room was used to store numerous cardboard boxes and papers. The room had a door leading into the Micro Biology lab. There were no self closing devices on the connector door or the corridor door to the Micro Biology lab. Both rooms were greater than 50 square feet in area.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the doors to the storage area did not have self closing devices.

Based on observation and interview, it was determined the facility failed to ensure doors protecting exit egress components, such as exit stairways, positively latched into the door frame in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 10:45 am, revealed on the sixth floor the entrance door into exit stairway three, failed to positively latch when tested.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the exit stairway door failed to positively latch.

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of exit stairways, and failed to ensure doors protecting exit egress components, such as exit stairways, positively latched into the door frame in two of two exit stairways within this component.

Findings include:

1. Observation on December 23, 2014, at 11:00 am, revealed on the second floor the entrance door into exit stairway number seven, located in the cafeteria, failed to positively latch when tested.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the exit stairway door failed to positively latch.


2. Observation on December 23, 2014, at 1:40 pm, revealed on the first floor, there was a hole in the drywall behind the door inside stairway number six.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the hole in the drywall inside exit stairway six.

Based on observation and interview, it was determined that the facility failed to ensure that items are not being stored in exit stairways, in one of two exit stairways.

Findings include:

Observation on December 23, 2014, at 10:20 am, revealed the exit stairway which discharges onto the ground level near the Emergency Department was being used to store two wheelchairs, a broom and a dust pan.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the items being stored in the stairway.

Based on observation and interview, it was determined the facility failed to ensure that exits are readily accessible and access to exits are not blocked in one instance within the facility.

Findings include:

Observation on December 23, 2014, at 2:10 pm, revealed inside the ground floor vestibule to exit stairway one there were several discarded cardboard boxes placed in front of the stairway entrance door. Also, there was yellow construction tape placed across the doors indicating a hazard beyond the doors, however the stairway contained no hazard and was available to be used as an exit.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the condition of the exit stairway vestibule.

Based on observation and interview, it was determined the facility failed to maintain the illumination of the exit stairway in two of six exit stairways within this component.

Findings include:

1. Observations on December 23, 2014, between 12:45 pm and 1:00 pm, revealed at the following locations the lights were not illuminated in the exit stairways:

a. 12:45 pm, third floor, in exit stairway five, landing between second d and third floor.
b. 1:00 pm, second floor landing, in exit stairway four.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the exit stairway lights were not illuminated.

Based on observation and interview, it was determined that the facility failed to maintain emergency battery back-up lighting to ensure a minimum of ninety (90) minutes of reserve illumination in one of one emergency genertator room.

Findings include:

Observation on December 23, 2014, at 11:50 am, revealed inside the Holy Family Building generator room, the emergency battery back-up light failed to illuminate when tested.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the battery back-up light failed to illuminate.

Based on observation and interview, it was determined the facility failed to to ensure that automatic sprinkler systems were maintained free of external loads placed on the sprinkler piping or pipe hangers; and failed to maintain the integrity of the suspended ceiling which could prevent activation of the sprinkler system in two of seventeen smoke compartments within this component.

Findings include:

1. Observation on December 23, 2014, at 10:00 am, revealed on the seventh floor above the ceiling at the Educator's Office there was a ceiling light wire support attached to the sprinkler pipe anchor support.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the non-system item supported by the sprinkler system support.

2. Observation on December 23, 2014, at 12:30 pm, on the third floor revealed in stairway one vestibule, there was a suspended ceiling tile with a large unsealed hole in the corner that could delay sprinkler activation.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the condition of the suspended ceiling tile.

Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishers in two of nine smoke compartments.

Findings include:

1. Observations on December 23, 2014, between 12:30 pm and 1:55 pm, revealed portable fire extinguisher that had pressure gauges which indicated an overcharged condition at the following locations:

a. 12:30, first floor, in the corridor near room 26167.b. 1:55, basement, inside the general storage room next to the print shop.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the fire extinguishers were in an overcharged condition at the above named locations

Based on observation and interview, it was determined the facility failed to ensure that medical gas storage locations maintain minimum requirements in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 10:40 am, revealed in the sixth floor clean linen room there were cardboard boxes stacked on top of nine E type oxygen cylinders. In sprinklered rooms, combustibles must not be stored within five feet of oxygen cylinders.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the storage of the oxygen cylinders.

Based on observation and interview, it was determined the facility failed to ensure that temporary wiring was not used in place of permanent wiring in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 1:40 pm, revealed in the first floor Medical Records storage room, there was a homemade quad extension cord in use powering a microwave.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the extension cord in use.

Based on observation and interview, it was determined that the facility failed to ensure that abandoned contractor lighting and wiring had been removed in one of nine smoke compartments.

Findings include:

Observation on December 23, 2014, at 10:45 am, revealed on the second floor, there was yellow temporary contractor lighting and wiring present above the ceiling in the corridor located near the PFT Interpretation Room.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the temporary contractor lighting and wiring was in place.

Based on observation and interview, it was determined that the facility failed to ensure the fire resistive rated doors in communicating openings of the fire rated common wall, positively latched in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 1:41 pm, revealed the double doors located in the common wall shared with the Holy Family Pavilion, failed to close and positively latch. The doors were located in the Cath lab area.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the doors failed to positively latch.

Based on observation and interview, it was determined the facility failed to ensure the fire resistive rated doors in communicating openings of the fire rated common wall, positively latched in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 1:41 pm, revealed on the second floor, the double doors located in the common wall shared with the St. Joseph's building failed to close and positively latch. The doors were located in the Cath lab area.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the doors failed to positively latch.

Based on observation and interview, it was determined the facility failed to ensure the gap between the face of corridor doors and the door frame does not exceed 1/2 inch; and the facility failed to ensure the corridor doors positively latch into the door frame and remained closed in the frame in three of seventeen smoke compartments.

Findings include:

1. Observations on December 23, 2014, between 10:15 am and 11:15 am, revealed at the following locations the gap between the corridor door face edge and the door frame was greater than 1/2 inch:

a. 10:15 am, sixth floor room 613, even with a gasket installed along the frame.
b. 11:13 am, fourth floor room 449.
c. 11:15 am, fourth floor room 450.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the condition of the gap around the corridor doors.


2. Observations on December 23, 2014, between 11:10 am and 1:20 pm, revealed the following corridor doors failed to positively latch into the door frame when tested:

a. 11:10 am, fourth floor, patient room 444.
b. 11:12 am, fourth floor, patient room 447.
c. 11:20 am, fourth floor, patient room 453.
d. 1:20 pm, second floor, janitors closet located by outreach manager office.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the corridor doors failed to latch into the frame.

Based on observation and interview, it was determined that the facility failed to ensure that corridor doors are free of impediments to closing, in one of nine smoke compartments.

Findings include:

Observation on December 23, 2014, at 10:20 am, revealed on the third floor, the door to patient room #376 was blocked from closing by a linen cart and portable toilet.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the corridor was blocked.

Based on observation and interview, it was determined the facility failed to ensure the doors in the smoke barrier walls properly close in order to impede the transfer of smoke in two of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 11:00 am, revealed on the third floor the smoke barrier doors located by exit stairway three, failed to release and close properly when manually tested.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the doors failed to release and close properly.

Based on observation and interview, it was determined the facility failed to ensure the doors to hazardous areas were self-closing and remain closed within the door frame in one of seventeen smoke compartments within the facility.

Findings include:

Observation on December 23, 2014, at 1:15 pm, revealed the second floor Clinical Chemistry room was used to store numerous cardboard boxes and papers. The room had a door leading into the Micro Biology lab. There were no self closing devices on the connector door or the corridor door to the Micro Biology lab. Both rooms were greater than 50 square feet in area.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the doors to the storage area did not have self closing devices.

Based on observation and interview, it was determined the facility failed to ensure doors protecting exit egress components, such as exit stairways, positively latched into the door frame in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 10:45 am, revealed on the sixth floor the entrance door into exit stairway three, failed to positively latch when tested.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the exit stairway door failed to positively latch.

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of exit stairways, and failed to ensure doors protecting exit egress components, such as exit stairways, positively latched into the door frame in two of two exit stairways within this component.

Findings include:

1. Observation on December 23, 2014, at 11:00 am, revealed on the second floor the entrance door into exit stairway number seven, located in the cafeteria, failed to positively latch when tested.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the exit stairway door failed to positively latch.


2. Observation on December 23, 2014, at 1:40 pm, revealed on the first floor, there was a hole in the drywall behind the door inside stairway number six.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the hole in the drywall inside exit stairway six.

Based on observation and interview, it was determined that the facility failed to ensure that items are not being stored in exit stairways, in one of two exit stairways.

Findings include:

Observation on December 23, 2014, at 10:20 am, revealed the exit stairway which discharges onto the ground level near the Emergency Department was being used to store two wheelchairs, a broom and a dust pan.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the items being stored in the stairway.

Based on observation and interview, it was determined the facility failed to ensure that exits are readily accessible and access to exits are not blocked in one instance within the facility.

Findings include:

Observation on December 23, 2014, at 2:10 pm, revealed inside the ground floor vestibule to exit stairway one there were several discarded cardboard boxes placed in front of the stairway entrance door. Also, there was yellow construction tape placed across the doors indicating a hazard beyond the doors, however the stairway contained no hazard and was available to be used as an exit.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the condition of the exit stairway vestibule.

Based on observation and interview, it was determined the facility failed to maintain the illumination of the exit stairway in two of six exit stairways within this component.

Findings include:

1. Observations on December 23, 2014, between 12:45 pm and 1:00 pm, revealed at the following locations the lights were not illuminated in the exit stairways:

a. 12:45 pm, third floor, in exit stairway five, landing between second d and third floor.
b. 1:00 pm, second floor landing, in exit stairway four.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the exit stairway lights were not illuminated.

Based on observation and interview, it was determined that the facility failed to maintain emergency battery back-up lighting to ensure a minimum of ninety (90) minutes of reserve illumination in one of one emergency genertator room.

Findings include:

Observation on December 23, 2014, at 11:50 am, revealed inside the Holy Family Building generator room, the emergency battery back-up light failed to illuminate when tested.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the battery back-up light failed to illuminate.

Based on observation and interview, it was determined the facility failed to to ensure that automatic sprinkler systems were maintained free of external loads placed on the sprinkler piping or pipe hangers; and failed to maintain the integrity of the suspended ceiling which could prevent activation of the sprinkler system in two of seventeen smoke compartments within this component.

Findings include:

1. Observation on December 23, 2014, at 10:00 am, revealed on the seventh floor above the ceiling at the Educator's Office there was a ceiling light wire support attached to the sprinkler pipe anchor support.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the non-system item supported by the sprinkler system support.

2. Observation on December 23, 2014, at 12:30 pm, on the third floor revealed in stairway one vestibule, there was a suspended ceiling tile with a large unsealed hole in the corner that could delay sprinkler activation.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the condition of the suspended ceiling tile.

Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishers in two of nine smoke compartments.

Findings include:

1. Observations on December 23, 2014, between 12:30 pm and 1:55 pm, revealed portable fire extinguisher that had pressure gauges which indicated an overcharged condition at the following locations:

a. 12:30, first floor, in the corridor near room 26167.b. 1:55, basement, inside the general storage room next to the print shop.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the fire extinguishers were in an overcharged condition at the above named locations

Based on observation and interview, it was determined the facility failed to ensure that medical gas storage locations maintain minimum requirements in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 10:40 am, revealed in the sixth floor clean linen room there were cardboard boxes stacked on top of nine E type oxygen cylinders. In sprinklered rooms, combustibles must not be stored within five feet of oxygen cylinders.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the storage of the oxygen cylinders.

Based on observation and interview, it was determined the facility failed to ensure that temporary wiring was not used in place of permanent wiring in one of seventeen smoke compartments within this component.

Findings include:

Observation on December 23, 2014, at 1:40 pm, revealed in the first floor Medical Records storage room, there was a homemade quad extension cord in use powering a microwave.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the extension cord in use.

Based on observation and interview, it was determined that the facility failed to ensure that abandoned contractor lighting and wiring had been removed in one of nine smoke compartments.

Findings include:

Observation on December 23, 2014, at 10:45 am, revealed on the second floor, there was yellow temporary contractor lighting and wiring present above the ceiling in the corridor located near the PFT Interpretation Room.

Interview with the Director of Facilities on December 23, 2014, at 2:35 pm, confirmed the temporary contractor lighting and wiring was in place.