HospitalInspections.org

Based on observations, the facility failed to maintain the required 2 hour separation between the hospital and the garages.

The findings included:

1. Observation on 11/29/16 at 10:25 AM, revealed the following 90 minute fire doors bottom latches would not latch to the floor.
a. the 4 south exit doors to garage #2.
b. the 4 south entrance doors to the doctors area.
c. the D3 exit doors to garage #3.
d. the 3 south exit doors to garage #2.


2. Observation on 11/29/16 at 11:08 AM, revealed the following 90 minute fire doors bottom latches would not latch to the floor.
a. the 3rd floor fire doors by stairway D321did not have the floor hardware for the bottom pins to latch.
b. the 90 minute fire doors in front of the D3 elevators would not close.

National Fire Protection Association
NFPA 101, 19.1.3 ( 2012 Ed.), NFPA 101, 6.1.14.4.2 (2012 Ed.) and NFPA 101, 8.3.3.1 (2012 Ed.)

The Vice President of Hospital services, Director of Security, and engineering staff was present when the deficiencies were identified. The deficiencies were acknowledged by the interim CEO at the exit conference on 11-29-16.

Based on observations, the facility failed to maintain the corridor width.

The findings included:

Observation on 11/26/16 at 3:03 AM, revealed the Neonatal ICU entrance corridor was obstructed by 3 chairs, reducing the available egress width below four feet. NFPA 101, 19.2.3.4 (2012 Ed.) and NFPA 101, 19.2.3.5 (2012 Ed.)

The Vice President of Hospital services, Director of Security, and engineering staff was present when the deficiencies were identified. The deficiencies were acknowledged by the interim CEO at the exit conference on 11-29-16.

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Based on observations, the facility failed to maintain the vertical openings.

The findings included:

1. Observation on 11/29/16 at 10:38 AM, revealed the 4th floor D2 stairway had mixed fire stop around the 2 inch sprinkler line penetrating the wall. NFPA 101, 19.3.11-19.3.1.6, and NFPA 101, 8.3.5

2. Observation on 11/28/16 at 10:58 AM, revealed a 2 inch steel sprinkler pipe above the wall light in the 8th floor C8101 stairway had mixed fire stop at the concrete block wall.NFPA 101, 19.3.11-19.3.1.6, and NFPA 101, 8.3.5

3. Observation on 11/26/16 at 10:08 AM, revealed the 9H stairwell 2 hour fire wall located next to room A936 had a sprinkler pipe not properly sealed at the wall. Interview with Maintenance staff member #1 at 10:40 AM, revealed he sealed the sprinkler pipe but did not use the proper firestop system. NFPA 101, 19.3.11-19.3.1.6, NFPA 101, 8.3.5 and NFPA 101, 8.3.5.1

4. Observation on 11/26/16 at 10:18 AM, revealed stairwell 1 located next to room A936 had a sprinkler pipe not properly sealed at the 2 hour fire wall. NFPA 101, 19.3.11-19.3.1.6, and NFPA 101, 8.3.5

5. Observation on 11/26/16 at 1:46 PM, revealed the 2 hour ventilation chase shaft located across room A330 had a conduit not sealed at the wall. NFPA 101, 19.3.11-19.3.1.6, and NFPA 101, 8.3.5

6. Observation on 11/26/16 at 2:05 PM, revealed 5 membrane penetrations in the B-3 visitors elevators ' 2 hour fire wall. NFPA 101, 19.3.11-19.3.1.6, and NFPA 101, 8.3.5

7. Observation on 11/26/16 at 2:40 PM, revealed the stairwell located next to room C3132 fire wall located next to room A936 had penetrations on the top of the wall and 2 conduits not properly sealed at the wall. NFPA 101, 19.3.11-19.3.1.6, and NFPA 101, 8.3.5

8. Observation on 11/26/16 at 3:13 PM, revealed the stairwell located next to room D3262 had an electrical junction box not sealed at the fire wall. NFPA 101, 19.3.11-19.3.1.6, and NFPA 101, 8.3.5

The Vice President of Hospital services, Director of Security, and engineering staff was present when the deficiencies were identified. The deficiencies were acknowledged by the interim CEO at the exit conference on 11-29-16.

Based on observations, the facility failed to maintain the hazardous areas.

The findings included:

1. Observation on 11/28/16 at 9:45 AM, revealed the following penetrations in the 9th floor BXX9X9C electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. 2 unapproved drywall patches.
b. 2 - 1 1/2 inch metal sleeves, and a sleeve with a bundle of yellow low voltage cable had mixed fire stop over the door.
c. 2 - 1 inch conduits above panel 9HA, and 2 - 1 inch conduits above panel 9LZA had mixed fire stop at the wall.
d. a 2 ½ inch metal conduit had mixed fire stop at the wall by the Siemens panel.
e. 3 - 3 inch metal sleeves from ceiling to floor and 2 - 4inch sleeves from ceiling to floor were not sealed per approved methods.
f. 1 - 5 inch, 2 - 3 ½ inch, and 1 - 3 inch metal floor sleeves were not sealed per approved methods.
2. Observation on 11/28/16 at 10: 10 AM, revealed the following penetrations on the 9th floor BXX9X9B electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. 2 unapproved drywall patches above the 9LB panel.
b. a metal floor sleeve with red and black cable was not sealed per approved methods.

3. Observation on 11/28/16 at 10:30 AM, revealed the following penetrations in the 9th floor CXX9BEN electrical room constructed of concrete block walls and concrete floors and ceilings.
a. 7 unapproved drywall patches on all 4 walls.
b. low voltage cables and a conduit in the same annular space above the door.
c. a 1 inch conduit had mixed fire stop above the door.
d. a 2 inch metal sleeve had mixed fire stop above the door.
e. 4 metal sleeves above the door had mixed fire stop.
f. a 1 inch conduit from the phone rack to the ceiling was not sealed per an approved method.
g. 8 of 10 - 1 ½ inch conduits from the floor to the ceiling were not sealed per an approved method at the ceiling.
h. a 2 inch sleeve at the back wall ceiling was not sealed per an approved fire stop method.
i. a 2 inch black fiber optic cable in the ceiling was not sleeved or sealed.
j. the back wall was not sealed to the deck per an approved fire stop method.
k. a ½ inch metal conduit from panel PL had mixed fire stop in wall.
l. 5 - 4 inch metal conduits from floor to ceiling had mixed fire stop at the floor.
m. a 2 inch floor sleeve at the back wall had mixed fire stop.
n. a 3 inch floor sleeve at the back wall had mixed fire stop.
o. 4 - fiber optic cables at the back wall were not sleeved.
p. 2 - 2 inch fiber optic cables at the back wall were not sleeved.
q. a 3 inch floor sleeve to the right of the door had mixed fire stop.

4. Observation on 11/28/16 at 11:00 AM, revealed the following penetrations in the 8th floor AXX8X8B telecom room constructed of concrete block walls and concrete floor and ceiling.
a. a 2 ½ inch metal sleeve with orange and gray cables and a 5 inch sleeve with gray and black cables were not sealed per approved methods.

5. Observation on 11/28/16 at 11:18 AM, revealed the following penetrations in the 8th floor AXX8X8A electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. 2 - 1 inch conduits above panel 8LSLA were not sealed in wall.
b. the back wall fire insulated I beam had mixed fire stop.

6. Observation on 11/28/16 at 11:33 AM, revealed the following penetrations in the 8th floor BXX8X electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. A 4 inch metal sleeve, 8 - 1½ inch metal conduits, 2 - 2 inch metal sleeves, 1 - 3 inch metal sleeve, and 3 - 2 inch white conduits were sealed with mixed fire stop at the wall and 1 of the white conduits was not sealed at the opening.
b. 2 low voltage cables over the door were not sleeved.
c. A 2 inch metal sleeve in the floor was not sealed.
d. 11 white 1 inch conduits above panel 8LYA, and 9 white 1 inch conduits above panel 8LA had mixed fire stop.

7. Observation on 11/28/16 at 1:15 PM, revealed the following penetrations in the 8th floor CXX8BEO electrical room constructed of concrete block walls and concrete floor and ceiling:
a. a 4 inch metal sleeve from the ceiling was not sealed per an approved method.
b. a bundle of cables with a 1 inch metal conduit was sharing the same annular space and was not sleeved.
c. a 1 inch metal conduit and a 1 ½ inch metal conduit were sharing the same annular space above the door.
d. a 2 inch metal sleeve was not sealed at the opening above the door.
e. 1 unapproved drywall patch above the door.
f. a 2 ½ inch metal sleeve was not sealed per an approved method.
g. 4 2 - ½ inch metal sleeves from the ceiling at the back wall were not sealed per an approved method.
h. 2 black fiber optic cables were not sleeved through the ceiling.
i. a 1 inch metal conduit and low voltage cables were sharing the same annular space above panel EK.
j. ½ inch metal conduit above panel EK was not sealed per an approved fire stop method at the wall.
k. a 1 inch metal conduit above panel EKC was not sealed per an approved fire stop method.
l. the wall to deck seam above panels PK and EKA had mixed fire stop.
m. the 2 ½ inch metal floor sleeve at the back wall was not sealed per an approved fire stop.

8. Observation on 11/28/16 at 1:30 PM, revealed the following penetrations in the 7th floor CXX7BEP electrical room constructed of concrete block walls and concrete floor and ceiling:
a. an unapproved drywall patch in the back wall.
b. a 3 inch floor sleeve at the back wall was not sealed per an approved fire stop method.
c. a 3 inch floor sleeve at the back wall had a copper line and low voltage cables were sharing the same annular space.
d. a 3 inch metal sleeve from the ceiling had mixed fire stop.
e. a bundle of black and gray low voltage cables were not sealed per an approved fire stop method.
f. 2 -1/2 conduits above panel EJB were not sealed per an approved fire stop method.
g. 2 - 1 inch conduits above panel PJ were not sealed at the opening.
h. 3 - 4 inch conduits from floor to ceiling were not sealed at the ceiling.
i. a 1 ½ metal sleeve above the door had mixed fire stop.
j. a 3 inch metal sleeve above the door was not sealed per an approved fire stop method.
k. a 2 inch metal sleeve above the door was not sealed per an approved fire stop method.
l. 4 of 8 - 2 inch ceiling sleeves were not sealed per an approved fire stop method.


9. Observation on 11/28/16 at 1:50 PM, revealed the following penetrations in the 7th floor AXX7X7A telecom room constructed of concrete block walls and concrete floor and ceilings:
a. 7 - 4 inch metal sleeves from the ceiling were unsealed.
b. 7 - 4 inch metal floor sleeves were not sealed per an approved fire stop method.

10. Observation on 11/28/16 at 2:09 PM, revealed the following penetrations in the 7th floor AXX7X7B electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. the 2 inch sprinkler line above the door had mixed fire stop.
b. 2 - 1 inch electrical sleeves above the door had mixed fire stop.

11. Observation on 11/28/16 at 2:17 PM, revealed the following penetrations in the 7th floor electrical room by the environmental closet and nurses station. Walls are constructed of drywall and floors and ceilings are concrete.
a. the rated walls were not sealed to the floor with fire stop.
b. a ½ inch metal conduit above panel 7LB had unapproved fire stop.
c. a 2 inch metal conduit from panel 7HB was not sealed at the ceiling.
d. 14 metal conduits on the back wall were not sealed at the ceiling.
e. 2 - 1 ½ inch metal conduits from panel ELPTW through floor had mixed fire stop.
f. a 3 inch metal floor sleeve with orange and black cable was not sealed per approved method.
g. 4 of 6 - 2 ½ inch metal sleeves above the data rack were not sealed per approved method.
h. a 1 inch metal conduit from the power supply box behind the door had mixed fire stop.


12. Observation on 11/28/16 at 2:28 PM, revealed the following penetrations in the 7th floor BXX7E electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. the 2 - 1 ½ inch conduits from the right side of panel 7LYA had mixed fire stop at the wall.
b. 1 - 2 inch conduit to the right of panel 7LYA and 1 - 1inch conduit to the left of the panel had mixed fire stop at the wall.
c. a 1 ½ inch conduit above panel 7L2A was not sealed.
d. 12 - 2 inch metal conduits penetrating concrete ceiling were not sealed per an approved method.
e. a 2 inch floor sleeve at the back wall was not sealed per an approved method.
f. 2 of 3 - 3 inch metal floor sleeves were not sealed per an approved method.
g. 4 of 6 - 2 ½ inch curved metal sleeves were not sealed per an approved method.
h. 2 - 2 inch metal sleeves above the door had mixed fire stop.

13. Observation on 11/28/16 at 2:44 PM, the 6th floor AXX6XA electrical room back 2 corners of the wall had a 3 inch high x 6 inch wide gap between the concrete deck and drywall.

14. Observation on 11/28/16 at 2:54 PM, revealed the following penetrations in the 6th floor BXX6X6F electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. a 2 inch metal sleeve with a blue collar was not sealed per an approved method.
b. a 3 ½ inch metal sleeve above the responder control box was not sealed per an approved method.
c. a 5 inch floor sleeve was not sealed per an approved fire stop.
d. 2 - 3 inch floor sleeves were not sealed per an approved fire stop.
e. 6 - 2 ½ inch metal sleeves over the light were not sealed at the openings per an approved fire stop method.
f. 11 conduits from the ceiling at the back wall were not sealed per an approved method.
g. a 3 inch white conduit from the ceiling to the floor behind the fiber optic control box was not sealed per an approved method.

15. Observation on 11/28/16 at 3:05 PM, revealed the following penetrations in the 6th floor BXX6X6E electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. a 1 inch metal conduit above the door had mixed fire stop.
b. 4 of 6 - 2 ½ inch metal curved sleeves by the left wall were not sealed per an approved method.

16. Observation on 11/28/16 at 3:15 PM, revealed the following penetrations in the 6th floor BXX6BEQ electrical room constructed of concrete block walls and concrete floor and ceiling:
a. an unapproved dry wall patch above panel EH.
b. 7 - 1 inch conduits above the panel EH were not sealed per an approved fire stop method.
c. a 2 inch copper line above panel EH was not sealed.
d. a 3 inch floor sleeve at the back wall was not sealed per an approved fire stop method.
e. 2 - 2 ½ inch conduits from floor to ceiling were not sealed per an approved fire stop method.
f. a 2 inch copper line was not sealed per an approved fire stop method.

17. Observation on 11/29/16 at 8:28 AM, revealed the following penetrations in the 4th floor AXX4X4B electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. an unapproved drywall patch above panel 4CRLA.
b. the wall above panels 4LSHA and 4LSLA lacked 4 inches meeting the deck.
c. a 2 inch sprinkler line, 2 - 1 inch metal conduits, and 2 metallic flexible conduits were not sealed per an approved fire stop method above the door.

18. Observation on 11/29/16 at 8:37 AM, revealed the following penetrations in the 4th floor AXX4X4c telecom room constructed of concrete block walls and concrete floor and ceiling:
a. 14 - 4 inch metal floor and ceiling sleeves were not sealed per an approved method.
b. an air vent was penetrated on 1 side.
c. the insulated I beam was not sealed per an approved fire stop method.

19. Observation on 11/29/16 at 8:55 AM, revealed the following penetrations in the 4th floor BXX4X4G electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. 3 - 1 inch white conduits above panel 4LA1 in the corner of wall had mixed fire stop.
b. 3 - 1 inch white conduits above panel 4HA were not sealed in the drywall.
c. a 1 inch metal conduit above panel 4LZA was not sealed the drywall.
d. 2 - 3 ½ inch floor sleeves and 3 - 2 inch sleeves had mixed fire stop in the floor.
e. the wall above panels 4LA1 and 4LA2 lacked 4 inches meeting the deck.
f. a 4 inch metal sleeve had mixed fire stop above the door in the drywall.
g. a 2 inch and 2 ½ inch metal sleeve were not sealed per an approved fire stop method above the door in the drywall.
h. 4 - 2 inch curved metal conduits were not sealed per an approved fire stop method.

20. Observation on 11/29/16 at 9:16 AM, revealed the following penetrations in the 4th floor BXX4X4F electrical room constructed of concrete block walls and concrete floor and ceiling:
a. an unapproved drywall patch on concrete block wall above electrical panel 4LB1.
b. a bundle of low voltage cables were not sleeved through the ceiling.
c. a 2 inch metal floor sleeve had mixed fire stop.
d. a 2 inch and 3 inch white metal conduit was not sealed at the ceiling.
e. a ½ inch and a 1 ½ inch white metal conduit were not sealed at the ceiling.
f. an unapproved drywall patch above the door in the concrete block wall.
21. Observation on 11/29/16 at 9:33 AM, revealed the following penetrations in the 5th floor CXX5BER electrical room constructed of concrete block walls and concrete floor and ceiling.
a. a bundle of low voltage cables were not sleeved in the floor.
b. a black cable that had been cut into was not sealed in the concrete block wall.
c. 5 ceiling penetrations with low voltage cables were not sleeved.
d. a ½ inch metal conduit had mixed fire stop in the concrete block wall above panel EG.
e. 2 - 1 inch metal conduits above panel PG had mixed fire stop in the concrete block wall.
g. low voltage cables and 2 - 1 inch metal conduits above the door were sharing the same annular space.
h. 2 low voltage cable bundles were not sleeved from the ceiling.
i. 7 - 1inch metal conduits from the ceiling were not sealed with approved fire stop.

22. Observation on 11/29/16 at 9:16 AM, revealed the following penetrations in the 4th floor DC-X4-BFL electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. 6 - 2 inch metal sleeves had mixed fire stop above the door.
b. 11 - 1 inch metal sleeves had mixed fire stop above the door.
c. the drywall ceiling had been damaged and separated at the seams.
d. 2 - 1 inch metal conduits above panel W4L had mixed fire stop.
e. 4 - 3 inch metal floor sleeves were not sealed per an approved fire stop method.

23. Observation on 11/29/16 at 10:50 AM, revealed the following penetrations in the 3rd floor clean linen room. Walls and ceiling were constructed of drywall.
a. a 2 inch sleeve in the ceiling had mixed fire stop.
b. an unapproved drywall patch with a bundle of low voltage cables.
c. an unapproved aluminum patch in the ceiling.
d. a 5 inch metal sleeve in the drywall was not sealed per an approved fire stop method.
e. a 2 inch white conduit was not sealed at the ceiling.
f. a 2 inch and 1 ½ inch metal sleeves wall were not sealed per an approved fire stop method.
g. a bundle of low voltage cables were not sleeved in the wall.
h. a 1 inch metal conduit above the black power box was not sealed in the wall.

24. Observation on 11/29/16 at 1:15 PM, revealed the following penetrations in the 3rd floor BXX3X31 electrical room. Walls are constructed of drywall and floors and ceilings are concrete.
a. 4 - 1 inch metal conduits penetrating the floor were not sealed per an approved fire stop method.
b. a 2 inch metal floor sleeve was not sealed per an approved fire stop method.

25. Observation on 11/26/16 at 12:10 PM, revealed the B7 electrical room located across the nurses station had one conduit not sealed at the fire barrier corridor wall.

26. Observation on 11/26/16 at 12:11 PM, revealed the B7 electrical room had one conduit not sealed at the fire barrier wall above circuit breaker panel 7lZA.

27. Observation on 11/26/16 at 1:51 PM, revealed a 1 inch conduit not sealed at the fire barrier located on the corridor side of equipment storage room A3.

28. Observation on 11/26/16 at 2:50 PM, revealed room C3118 was being used as a storage room. Further observations revealed the room was not constructed as a storage room and there was not a ¾ hour fire door installed with a self-closer.

29. Observation on 11/28/16 at 11:54 AM, revealed multiple metal conduits with mixed fire stop in the A pod Bxx8xD room.

National Fire Protection Association NFPA 101, 19.3.2.1 and NFPA 101, 8.3.5 (2012 Ed.)

The Vice President of Hospital services, Director of Security, and engineering staff was present when the deficiencies were identified. The deficiencies were acknowledged by the interim CEO at the exit conference on 11-29-16.



A survey was also conducted at the Emergency Department/Sports Plus Humboldt on 11/30/16. The findings are listed below.

Based on observations, the facility failed to maintain the Hazardous areas.

The findings included:

1. Observation on 11/30/16 at 8:37 AM, revealed the outside mechanical room had the following penetrations and/or unapproved fire stopping.
a. 1 - 1/2 inch flex conduit
b. 1 low voltage cable
c. Blow out patches along back wall.

2. Observation on 11/30/16 at 8:43 AM, revealed the fire alarm panel room had the following penetrations and/or unapproved fire stopping.
a. 1 - 2 1/2 inch metal conduit with wires
b. 1 - 1 1/2 inch metal conduit with mixed fire stop
c. 1 - 1 inch metal conduit with painted fire caulk.
d. Blow out patches along the left and back walls at the decking.

3. Observations on 11/30/16 at 8:50 AM, revealed the environmental closet had the following penetrations and/or unapproved fire stopping.
a. 1 - 10 inch insulated pipe with mixed fire caulk.
b. 1- 1 inch PVC pipe
c. 1- 2 inch PVC pipe
d. Blowout patches along wall at the deck.

4. Observations on 11/30/16 at 8:56 AM, revealed the soiled utility room had the following penetrations and/or unapproved fire stopping.
a. 12x12 large opening in the dry wall.
b. Dry wall seams not properly sealed.
c. Blowout patches along the wall at the deck.
d. 5X3 blowout patch below the HVAC duct.
e. Hole around junction box.
f. 1- 1 inch metal conduit
g. 1- 1 1/2 inch metal conduit
h. 2 - 1/2 metal conduit with mixed fire caulk.

5. Observations on 11/30/16 at 930 AM, revealed the sports plus mechanical room had the following penetrations and/or unapproved fire stopping.
a. 3 - 1 inch metal conduits with mixed fire stop.
b. 7 - 1 inch metal conduits not properly sealed.

6. Observations on 11/30/16 at 9:20 AM, revealed the entrance hall barrier wall above the cross corridor doors had the following penetrations and/or unapproved fire stopping.
a. Damaged E-Z sleeve
b. Drywall seams not properly sealed.
National Fire Protection Association NFPA 101, 19.3.2.1 and NFPA 101, 8.3.5 (2012 Ed.)

The maintenance manager was present when the deficiencies were identified.

Based on observations, the facility failed to maintain the fire alarm system.

The findings included:

1. Observation on 11/28/16 at 3:03 PM, revealed the fire alarm pull station located at the Neonatal ICU entrance corridor was obstructed by 3 chairs.
National Fire Protection Association NFPA 101, 19.3.4.1, NFPA 101, 9.6.1, NFPA 101, 9.6.1.3, and NFPA 72, 17.14.5

2. Observation on 11/28/16 at 10:25 AM, revealed smoke detectors within three (3) feet of HVAC air flow in the following locations:
a. Corridor by A 830 8th floor by the cross corridor fire doors.
b. Family waiting NorthWest 6th floor next to room 22.
NFPA 101,19.3.4.1 (2012 Ed), NFPA 101, 9.6.1 (2012 Ed), NFPA 101,9.6.1.3 (2012 Ed), and NFPA 72, 17.7.4.1 (2010 Ed).

The Vice President of Hospital services, Director of Security, and engineering staff was present when the deficiencies were identified. The deficiencies were acknowledged by the interim CEO at the exit conference on 11-29-16.

Based on record review, the facility failed to maintain the sprinkler system.

The finding included:

1. Record review on 11/29/16 at 10:00 AM, revealed the sprinkler report dated 9/27/16 states the facility has some fast response sprinklers that are over 20 years old that have not been replaced or sample tested. National Fire Protection Association (NFPA 25, 5.3.1.1.1.3 2011 Ed.)


2. Record review on 11/29/16 at 10:00 AM, revealed the sprinkler report dated 9/27/16 states the facility has some dry sprinklers that are over 10 years old that have not been replaced or sample tested. Additional records that were reviewed revealed the facility had sample tested 4 dry sprinklers on July 29, 2015. The test results revealed that 1 of 4 sampled sprinklers failed to meet the requirements. The results of the sampled sprinklers would require all sprinklers within the sampled area to be replaced. The facility failed to provide documentation that the sprinklers had been replaced. National Fire Protection Association NFPA 25, 5.3.1.1.1.6 (2011 Ed.), NFPA 25, 5.3.1.2 (2011 Ed.), NFPA 25, 5.3.1.3 (2011 Ed.)

The Plant Operations Manager was present when these deficiencies were identified.




A survey was also conducted at the Emergency Department/Sports Plus Humboldt on 11/30/16. The findings are listed below.
Based on observations, the facility failed to maintain the sprinkler system.

The findings included:

1. Observation on 11/30/16 at 9:20 AM, revealed the following sprinklers were loaded with a foreign material.

a. ER #3 2 of 4

b. ER #7 1 of 1

c. ER #5 1 of 1

d ER # 6 1 of 1

e. Breakroom 1 of 2

f. Breakroom bathroom 1 of 1

g. Clean supply room 1 of 2

h. Triage room 1 of 1

National Fire Protection Association NFPA 25, 5.2.1.1.1 (2011 Ed)

The Maintenance Manger was present when the deficiencies were identified.

Based on observations, the facility failed to maintain the fire/smoke barriers.

The findings included:

1. Observations on 11/26/16 from 10:15 AM-11:27 AM, revealed the following 9th floor rated barrier walls had unsealed or improperly sealed penetrations:

a. The barrier located above the fire doors near room A-930, had the end of a 3 inch conduit with low voltage wires not properly sealed.
b. The barrier located above the fire doors between wings A9 and B9, had one penetration in the gypsum wall.
c. The barrier located above the fire doors near room 988, had a 1 inch low voltage conduit not properly sealed at the gypsum wall.
d. The barrier located above the fire doors near the B9 staff bathroom, had the end of a 1 inch conduit with low voltage wires not properly sealed.
e. The barrier located above the fire doors near the B9 clinical manager ' s office, had the end a 1/2 inch conduit with low voltage wires not properly sealed.
f. The barrier located above the fire doors between wings B9 and C9, had the end of a 1 inch conduit with low voltage wires not properly sealed.
g. The barrier located above the fire doors near room C9120 had a 1 inch metal conduit with low voltage wires not properly sealed at the gypsum wall and at the conduit ' s end.
h. The top of the barrier located above the fire doors near room C9122 had penetrations and was not properly sealed to the ceiling deck.

2. Observations on 11/26//16 at 11:40 PM, revealed the barrier located above the fire doors near room 7119, had a 1 inch low voltage conduit not properly sealed at the gypsum wall.

3. Observations on 11/26/16 from 1:45 PM-3:45 PM, revealed the following 3rd floor rated barrier walls had unsealed or improperly sealed penetrations:

a. The barrier located above the fire doors near room A331, had a 3 inch low voltage conduit not properly sealed at the gypsum wall.
b. The barrier located above the fire door near electrical room AXX3X3F, had the ends (2 of 4) 4 inch conduit with low voltage wires not properly sealed.
c. The barrier located above the fire doors near room B387, had one penetration in the wall.
d. The barrier located above the fire doors near room B376, had a 2 inch low voltage conduit not properly sealed at the gypsum wall behind the bracket support.
e. The barrier located above the fire doors near room C3101, had a 1 inch low voltage conduit not properly sealed at the gypsum wall and an easy pass system improperly installed.
f. The barrier located above the fire doors near room C3117, had the ends of a 1/2 inch, 1 inch, and 2 inch conduits not properly sealed.
g. The barrier located above the fire doors near the backside of the Neonatal, had the ends of a 1/2 inch low voltage conduit not properly sealed.
h. The barrier located above the Pediatrics fire doors, had a 1 inch and 2 inch low voltage conduit not properly sealed at the gypsum wall.
I. The barrier located above the fire doors near room B3012, had a sprinkler not properly sealed at the wall.

4. Observation on 11/28/16 at 10:00-11:53 AM, revealed the following 8th floor rated barrier penetrations:

a. 2 (4 inch) metal sleeves not properly fire stopped on both sides at the A8 Telecom Axx8x8c.
b. 6 inch HVAC duct not sealed above the ceiling in the barrier next to A 831.
c. Metal conduit penetrating the barrier above the BP equipment room.
d. B pod above cross corridor doors beside 875 (3 blowout patches in the barrier wall/mixed firestop in numerous metal conduits)
e. Barrier wall above ceiling by 865 (2 medical gas lines) penetrating fire damper flange with mixed firestop.

5. Observation on 11/28/16 at 1:14 PM - 3:21 PM, revealed the following 6th floor rated barrier wall penetrations:

a. HVAC duct (not sealed) penetrating the barrier wall across from A-642.
b. 1 inch metal conduit not sealed penetrating the barrier wall above the Clean Supply room
c. 4 inch metal sleeve penetrating barrier wall not properly fire stopped by Axx6x6A.
d. A6 to B6 separation barrier wall improper repair (gyp wall) and sprinkler line mixed fire stop.
e. Barrier wall A pod B6 numerous conduit penetrations mixed firestop.
f. Mixed fire stop around metal conduits in the barrier wall next to Bpod medication room.
g. 1 inch metal conduit by above exit stair door by B661.
h. Barrier wall above cross corridor doors blowout patches with mixed fire stop Pod A nurse station both sides.
i. 4 inch metal sleeve not properly fire stopped above ceiling by the electrical room Axx4x4b
j. B4 to Ba separation above cross corridor doors 1 blowout patch and three spots at the deck sealed with mixed fire stop on the B4 side.
k. 3 blow out patches above ceiling in the barrier wall by B-488.
l. 1 blowout patch and penetration (hole) by the fire damper in the barrier wall above cross corridor doors by Bxx4x4F.
m. 1 blowout patch, 3 metal conduits 1 inch above the fire doors at Apod 4b Ortho and 3 metal conduits 1 inch on the charting side of the fire doors above ceiling.
n. Fire stop missing in the barrier wall above the ICU fire doors at the deck.

6. Observation on 11/29/16 at 8:20 AM-9:15 AM, revealed the following 2nd floor rated barrier wall penetrations:
a. 1 blow out patch above the fire doors at B-pod A
b. Exit shaft wall above ceiling had 2 communication lines with mixed fire stop and 1 communication line with the firestop falling out and 1 (3/4 inch) metal conduit with mixed fire stop by the electrical room Bxx2x2L.
c. DH 187 fire doors above ceiling had a sprinkler line with mixed fire stop, 1 domestic hot water line return with mixed firestop, and a ½ metal conduit not sealed.
d. B pod by medication room above ceiling 2 blowout patches and numerous penetrations with mixed firestop
e. B pod to C pod above the fire doors had numerous penetrations with mixed fire stop.
f. Bxx2x2m above ceiling next to the (med sled) had 1 blowout patch.
g. 2nd floor B-C pod above ceiling had 1 blowout patch and two 1 inch metal conduits not sealed by the case managers office.
h. 2B -C pod elevator lobby above ceiling had 1 blowout patch and numerous penetrations with mixed fire stop.
i. Above ceiling by C2109 sprinkler line with mixed fire stop.
j. C2119 above ceiling (cross corridor fire doors) two 4 inch metal sleeves improperly fire stopped on both sides.

The Vice President of Hospital services, Director of Security, and engineering staff was present when the deficiencies were identified. The deficiencies were acknowledged by the interim CEO at the exit conference on 11-29-16.

Based on record review, the facility failed to maintain the HVAC systems.

The finding included:

Record review on 11/29/16 at 10:00 AM, revealed the fire damper inspection dated 2/19/15 stated the facility had 18 dampers with no access. NFPA 101,19.5.2.1 (2012 Ed.), NFPA 101, 9.2 (2012 Ed.), and NFPA 80, 19.3.2.4 (2010 Ed).

The Plant Operations Manager was present when the deficiencies were identified.