HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain one two-hour fire rated common wall affecting one of three floors in this component.

Findings include:

1. Observation on April 20, 2015, at 10:04 AM, revealed the double set of doors, number 0001, serving the ground floor two-hour fire rated common wall, did not provide positive latching when closed.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the double set of common wall doors did not latch when tested.

Item not completed as of 6/29/2015, revisit.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors in this component.

Findings include:

2. Observation on April 20, 2015, at 9:44 a.m. revealed a load-bearing wall at the basement level to be constructed of unprotected, wooden two by fours (lacked required one-hour integrity.)

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the load-bearing wall at the basement level was constructed of wooden two by fours and lacked one-hour integrity.

3. Observation on April 21, 2015, between 8:20 a.m. and 9:02 a.m. revealed the following:

a. 8:20 a.m., unprotected structural steel was noted within the 3023 chase.
b. 8:22 a.m., recessed lighting fixtures within the 3020 restroom lacked bonnet protection.
c. 8:25 a.m., ceiling diffusers within the 3020 restroom lacked fire dampers.
d. 8:50 a.m., recessed lighting fixtures within the 3023 restroom lacked bonnet protection.
e. 9:02 a.m., recessed lighting fixtures lacked bonnet protection within room 3022.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the unprotected structural steel, recessed lighting fixtures lacking bonnet protection, and ceiling diffusers lacking fire dampers.

Items numbered 2, 3a, 3b, 3c, 3d, and 3e not completed as of 06/29/2015, revisit.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in multiple locations, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, between 9:00 AM and 1:55 PM revealed the third floor, "second section" corridor doors could not latch when closed.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the doors could not latch.

Item not completed as of 06/29/2015, revisit.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one half hour fire resistance rating in one instance affecting two of seventeen smoke compartments within the component.

Findings include:

1. Observation on April 21, 2015, at 8:00 AM revealed the 1st floor smoke barrier wall was not fully sheathed on both sides of the horizontal area, located above the cross corridor doors #1034.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the incomplete wall.

Item not completed as of 06/29/2015, revisit.

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation door, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 11:12 a.m. revealed the 1022 smoke barrier separation door would not release upon activation of the fire alarm system.

Exit interview with the facility administrator, maintenance one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the smoke barrier separation door would not release upon activation of the building fire alarm system.


Item 1 not completed as of 06/29/2015, revisit.

Based on observation and interview the facility failed to maintain exit stair towers in two instances within the component.

Findings include:

1. Observation on April 20, 2015, at 1:40 PM revealed the 1st floor stair tower #1114 had an IT closet located under the lower landing.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the IT closet within a stair tower.

2. Observation on April 21, 2015, at 8:10 AM revealed the Basement level stair tower door #1028 had storage at the bottom of the stairs.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the storage in the stair tower.

Item 1 and item 2 not completed as of 06/29/2015, revisit.

Based on observation and interview, it was determined the facility failed to install and maintain automatic sprinkler protection in one location, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 9:55 a.m. revealed the basement-level, 0007 Electrical Room lacked automatic sprinkler protection.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the 0007 Electrical Room lacked automatic sprinkler protection.


Item 1 not completed as of 06/29/2015, revisit.

Based on observation and interview, it was determined the facility failed to install and maintain automatic sprinkler protection in one location, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 10:16 AM revealed the 3rd floor wet area had perforated suspended ceilings with no sprinkler coverage above.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the non-sprinklered area.

2. Observation on April 21, 2015, at 9:30 AM revealed the basement level Electrical rooms did not have sprinkler coverage.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the non-sprinklered area.

Item number 1 and item number 2 not completed as of 06/29/2015, revisit.