HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of common walls between components in four locations, on two of four floors in this component.

Findings include:

1. Observation on June 4, 2015, at 10:30 AM revealed the common wall, separating the Old Building Component 01 and the New Building Component 12, had an unsealed penetration inside a 4-inch conduit, over Door #M302A, on the 3rd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:30 AM confirmed the unsealed penetration.

2. Observation on June 4, 2015, at 10:35 AM revealed the common wall, separating the Old Building Component 01 and the New Building Component 12, had an unsealed penetration around a green wire, in Room #M303, on the 3rd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:35 AM confirmed the unsealed penetration.

3. Observation on June 4, 2015, at 11:00 AM revealed the common wall, separating the Old Building Component 01 and the New Building Component 12, had an unsealed penetration around a red wire, in Room #M301, on the 3rd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:00 AM confirmed the unsealed penetration.

4. Observation on June 4, 2015, at 11:25 AM revealed the common wall, separating the Old Building Component 01 and the New Building Component 12, had an unsealed penetration around a green wire, in Room #M202, on the 2nd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:25 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain the 1-hour rated floor/ceiling assembly, in one area of this component.

Findings include:

1. Observation on June 4, 2015, at 10:55 AM revealed the rated access door had the closing spring disconnected and would not close automatically in the 1-hour rated floor/ceiling assembly, on the 3rd level in Vestibule #M301.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:55 AM confirmed the disconnected spring.

Based on observation and interview, it was determined the facility failed to maintain the building construction requirements for the entire building.

Findings include:

1. Observation on June 3-4, 2015, revealed this component was a two-story unprotected ordinary structure, which is fully sprinklered. This type of construction may not exceed one story.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:20 PM confirmed the construction type and building height.

Based on observation and interview, it was determined the facility failed to ensure corridor doors would properly close and resist the passage of smoke, on one of four floors in this component.

Findings include:

1. Observation on June 4, 2015, at 10:00 AM revealed the double corridor doors, to the 3rd level Closet #329, required a closure adjustment to properly close and latch in the frame.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:00 AM confirmed the needed adjustment.

2. Observation on June 4, 2015, at 11:12 AM revealed the corridor door, to the 3rd level Resident Room #386, was held open by a wastebasket.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:12 AM confirmed the impeded door.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls in three locations, on one of four floors in this component.

Findings include:

1. Observation on June 4, 2015, at 10:15 AM revealed various unsealed smoke barrier penetrations in the corridor (#257), to the Extended Acute Unit, on the 3rd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:15 AM confirmed the unsealed penetrations.

2. Observation on June 4, 2015, at 10:25 AM revealed an unsealed smoke barrier penetration over door #385, on the 3rd level, around a white water line.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:25 AM confirmed the unsealed penetration.

3. Observation on June 4, 2015, at 11:05 AM revealed an unsealed smoke barrier penetration over the corner unit, on the 3rd level, EAU Main Nurses' Station.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:05 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls in three locations, on two of three levels in this component.

Findings include:

1. Observation on June 4, 2015, between 1:45 PM and 3:00 PM revealed the following unsealed smoke barrier penetrations:

a) 1:45 PM, 3rd level, over Corridor Double Doors #3082, around data wires;
b) 2:00 PM, 3rd level, over Door #3055, around various data wires;
c) 3:00 PM, 2nd level, over Door #2129, around data and M/C cables.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:00 PM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to ensure doors to hazardous areas would properly close and latch in one location, on one of four floors of this component.

Findings include:

1. Observation on June 4, 2015, at 12:01 PM revealed the corridor door to the 2nd level Elevator Equipment Room #277, required a latch adjustment to properly close and latch in the frame.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 12:01 PM confirmed the needed latch adjustment.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas enclosures in one location, within the building.

Findings include:

1. Observation on June 4, 2015, at 3:15 PM revealed the storage of combustible items, an A/C unit, chairs, painter's drop cloth and trash, in the 1st level Elevator Equipment Room #M105.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:15 PM confirmed the combustible storage within the elevator equipment room.

Based on observation and interview, it was determined the facility failed to maintain not less than two remote exits on one of four levels of this component.

Findings include:

1. Observation on June 4, 2015, at 12:30 PM revealed the facility lacked two approved exits, remote from each other, on the 4th floor.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 12:30 PM confirmed the lack of two exits.

Based on observation and interview, it was determined the facility failed to maintain fire alarm components in one location within the building.

Findings include:

1. Observation on June 4, 2015, at 10:45 AM revealed a smoke detector to control the #M306 and #M307 Corridor and Smoke Doors #M306A on the 3rd level, was mounted within twelve inches of the bulkhead.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:45 AM confirmed the smoke detector was mounted within twelve inches of the bulkhead.

Based on observation and interview, it was determined the facility failed to ensure that the sprinkler system provided complete coverage in nine locations, on two of four floors of this component.

Findings include:

1. Observation on June 3, 2015, at 3:30 PM revealed the exit egress (approximately 6' X 30' and constructed of combustible material), from the 4th level Administrative Area and the 3rd level Cafe, lacked sprinkler protection.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 3:30 PM confirmed the lack of sprinkler protection.

2. Observation on June 4, 2015, at 9:50 AM revealed the exit egress (approximately 24' X 20' and constructed of combustible material), from the 3rd level Staff Lounge #313 and the 3rd level Ed Therapy #318, lacked sprinkler protection.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 9:50 AM confirmed the lack of sprinkler protection.

3. Observation on June 4, 2015, between 9:30 AM and 3:30 PM revealed all exit egress stairtowers lacked sprinkler protection under the lowest level landing.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:30 PM confirmed the lack of sprinkler protection.

Based on observation and interview, it was determined the facility failed to ensure that the sprinkler system provided complete coverage within all stair enclosures of the building.

Findings include:

1. Observation on June 4, 2015, between 9:30 AM and 3:30 PM revealed all exit egress stairtowers lacked sprinkler protection under the lowest level landing.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:30 PM confirmed the lack of sprinkler protection.

Based on review of documentation and interview, it was determined the facility failed to maintain the automatic sprinkler system for the building.

Findings include:

1. Review of documentation on June 3, 2015, at 10:00 AM revealed the facility lacked documentation verifying the interior of the water storage tank for the sprinkler system had been inspected, in the past three years.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 10:00 AM confirmed the last inspection was in 2009.

Based on review of documentation and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting the entire building.

Findings include:

1. Review of documentation on June 3, 2015, at 10:00 AM revealed the facility lacked documentation verifying the interior of the water storage tank, for the sprinkler system, had been inspected, in the past three years.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 10:00 AM confirmed the last inspection was in 2009.

2. Observation on June 3, 2015, at 3:35 PM revealed there were two surface-mounted light fixtures, within 12 inches of the sprinkler head, which extended below the deflector of the head, in the Kitchen over the prep tables, along the outside wall.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 3:35 PM confirmed the obstructed sprinkler heads.

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers, which were provided for the protection of cooking appliances using vegetable or animal oils and fats, were maintained in one location of the facility.

Findings include:

1. Observation on June 3, 2015, at 3:20 PM revealed the type 'K' fire extinguisher, in the 3rd floor Kitchen, lacked and inspection for the past two months.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 3:20 PM confirmed the missed inspection.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and proper use of equipment and receptacle multipliers, in four locations in this component.

Findings include:

1. Observation on June 4, 2015, at 10:25 AM revealed an electrical junction box lacked a cover plate with exposed wires, in the EAU 70's Activities Room.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:25 AM confirmed the missing cover plate and exposed wires.

2. Observation on June 4, 2015, at 11:02 AM revealed the use of a receptacle multiplier below the counter, in the 3rd level EAU 70's Nurses' Station.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:02 AM confirmed the use of a receptacle multiplier.

3. Observation on June 4, 2015, at 11:30 AM revealed two ceiling surface-mounted ceramic light fixtures, without bulbs and exposed sockets, in the 2nd level Corridor by the Mail Center and Room #211, used a receptacle multiplier below the counter, in the 3rd level EAU 70's Nurses' Station.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:30 AM confirmed the exposed sockets and the use of a receptacle multiplier.

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of common walls between components in four locations, on two of four floors in this component.

Findings include:

1. Observation on June 4, 2015, at 10:30 AM revealed the common wall, separating the Old Building Component 01 and the New Building Component 12, had an unsealed penetration inside a 4-inch conduit, over Door #M302A, on the 3rd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:30 AM confirmed the unsealed penetration.

2. Observation on June 4, 2015, at 10:35 AM revealed the common wall, separating the Old Building Component 01 and the New Building Component 12, had an unsealed penetration around a green wire, in Room #M303, on the 3rd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:35 AM confirmed the unsealed penetration.

3. Observation on June 4, 2015, at 11:00 AM revealed the common wall, separating the Old Building Component 01 and the New Building Component 12, had an unsealed penetration around a red wire, in Room #M301, on the 3rd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:00 AM confirmed the unsealed penetration.

4. Observation on June 4, 2015, at 11:25 AM revealed the common wall, separating the Old Building Component 01 and the New Building Component 12, had an unsealed penetration around a green wire, in Room #M202, on the 2nd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:25 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain the 1-hour rated floor/ceiling assembly, in one area of this component.

Findings include:

1. Observation on June 4, 2015, at 10:55 AM revealed the rated access door had the closing spring disconnected and would not close automatically in the 1-hour rated floor/ceiling assembly, on the 3rd level in Vestibule #M301.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:55 AM confirmed the disconnected spring.

Based on observation and interview, it was determined the facility failed to maintain the building construction requirements for the entire building.

Findings include:

1. Observation on June 3-4, 2015, revealed this component was a two-story unprotected ordinary structure, which is fully sprinklered. This type of construction may not exceed one story.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:20 PM confirmed the construction type and building height.

Based on observation and interview, it was determined the facility failed to ensure corridor doors would properly close and resist the passage of smoke, on one of four floors in this component.

Findings include:

1. Observation on June 4, 2015, at 10:00 AM revealed the double corridor doors, to the 3rd level Closet #329, required a closure adjustment to properly close and latch in the frame.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:00 AM confirmed the needed adjustment.

2. Observation on June 4, 2015, at 11:12 AM revealed the corridor door, to the 3rd level Resident Room #386, was held open by a wastebasket.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:12 AM confirmed the impeded door.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls in three locations, on one of four floors in this component.

Findings include:

1. Observation on June 4, 2015, at 10:15 AM revealed various unsealed smoke barrier penetrations in the corridor (#257), to the Extended Acute Unit, on the 3rd level.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:15 AM confirmed the unsealed penetrations.

2. Observation on June 4, 2015, at 10:25 AM revealed an unsealed smoke barrier penetration over door #385, on the 3rd level, around a white water line.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:25 AM confirmed the unsealed penetration.

3. Observation on June 4, 2015, at 11:05 AM revealed an unsealed smoke barrier penetration over the corner unit, on the 3rd level, EAU Main Nurses' Station.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:05 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls in three locations, on two of three levels in this component.

Findings include:

1. Observation on June 4, 2015, between 1:45 PM and 3:00 PM revealed the following unsealed smoke barrier penetrations:

a) 1:45 PM, 3rd level, over Corridor Double Doors #3082, around data wires;
b) 2:00 PM, 3rd level, over Door #3055, around various data wires;
c) 3:00 PM, 2nd level, over Door #2129, around data and M/C cables.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:00 PM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to ensure doors to hazardous areas would properly close and latch in one location, on one of four floors of this component.

Findings include:

1. Observation on June 4, 2015, at 12:01 PM revealed the corridor door to the 2nd level Elevator Equipment Room #277, required a latch adjustment to properly close and latch in the frame.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 12:01 PM confirmed the needed latch adjustment.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas enclosures in one location, within the building.

Findings include:

1. Observation on June 4, 2015, at 3:15 PM revealed the storage of combustible items, an A/C unit, chairs, painter's drop cloth and trash, in the 1st level Elevator Equipment Room #M105.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:15 PM confirmed the combustible storage within the elevator equipment room.

Based on observation and interview, it was determined the facility failed to maintain not less than two remote exits on one of four levels of this component.

Findings include:

1. Observation on June 4, 2015, at 12:30 PM revealed the facility lacked two approved exits, remote from each other, on the 4th floor.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 12:30 PM confirmed the lack of two exits.

Based on observation and interview, it was determined the facility failed to maintain fire alarm components in one location within the building.

Findings include:

1. Observation on June 4, 2015, at 10:45 AM revealed a smoke detector to control the #M306 and #M307 Corridor and Smoke Doors #M306A on the 3rd level, was mounted within twelve inches of the bulkhead.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:45 AM confirmed the smoke detector was mounted within twelve inches of the bulkhead.

Based on observation and interview, it was determined the facility failed to ensure that the sprinkler system provided complete coverage in nine locations, on two of four floors of this component.

Findings include:

1. Observation on June 3, 2015, at 3:30 PM revealed the exit egress (approximately 6' X 30' and constructed of combustible material), from the 4th level Administrative Area and the 3rd level Cafe, lacked sprinkler protection.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 3:30 PM confirmed the lack of sprinkler protection.

2. Observation on June 4, 2015, at 9:50 AM revealed the exit egress (approximately 24' X 20' and constructed of combustible material), from the 3rd level Staff Lounge #313 and the 3rd level Ed Therapy #318, lacked sprinkler protection.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 9:50 AM confirmed the lack of sprinkler protection.

3. Observation on June 4, 2015, between 9:30 AM and 3:30 PM revealed all exit egress stairtowers lacked sprinkler protection under the lowest level landing.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:30 PM confirmed the lack of sprinkler protection.

Based on observation and interview, it was determined the facility failed to ensure that the sprinkler system provided complete coverage within all stair enclosures of the building.

Findings include:

1. Observation on June 4, 2015, between 9:30 AM and 3:30 PM revealed all exit egress stairtowers lacked sprinkler protection under the lowest level landing.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 3:30 PM confirmed the lack of sprinkler protection.

Based on review of documentation and interview, it was determined the facility failed to maintain the automatic sprinkler system for the building.

Findings include:

1. Review of documentation on June 3, 2015, at 10:00 AM revealed the facility lacked documentation verifying the interior of the water storage tank for the sprinkler system had been inspected, in the past three years.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 10:00 AM confirmed the last inspection was in 2009.

Based on review of documentation and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting the entire building.

Findings include:

1. Review of documentation on June 3, 2015, at 10:00 AM revealed the facility lacked documentation verifying the interior of the water storage tank, for the sprinkler system, had been inspected, in the past three years.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 10:00 AM confirmed the last inspection was in 2009.

2. Observation on June 3, 2015, at 3:35 PM revealed there were two surface-mounted light fixtures, within 12 inches of the sprinkler head, which extended below the deflector of the head, in the Kitchen over the prep tables, along the outside wall.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 3:35 PM confirmed the obstructed sprinkler heads.

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers, which were provided for the protection of cooking appliances using vegetable or animal oils and fats, were maintained in one location of the facility.

Findings include:

1. Observation on June 3, 2015, at 3:20 PM revealed the type 'K' fire extinguisher, in the 3rd floor Kitchen, lacked and inspection for the past two months.

Interview with the Director of Facilities and the Director of Safety on June 3, 2015, at 3:20 PM confirmed the missed inspection.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and proper use of equipment and receptacle multipliers, in four locations in this component.

Findings include:

1. Observation on June 4, 2015, at 10:25 AM revealed an electrical junction box lacked a cover plate with exposed wires, in the EAU 70's Activities Room.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 10:25 AM confirmed the missing cover plate and exposed wires.

2. Observation on June 4, 2015, at 11:02 AM revealed the use of a receptacle multiplier below the counter, in the 3rd level EAU 70's Nurses' Station.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:02 AM confirmed the use of a receptacle multiplier.

3. Observation on June 4, 2015, at 11:30 AM revealed two ceiling surface-mounted ceramic light fixtures, without bulbs and exposed sockets, in the 2nd level Corridor by the Mail Center and Room #211, used a receptacle multiplier below the counter, in the 3rd level EAU 70's Nurses' Station.

Interview with the Director of Facilities and the Director of Safety on June 4, 2015, at 11:30 AM confirmed the exposed sockets and the use of a receptacle multiplier.