HospitalInspections.org

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:

1. Observation of building construction on November 2, 2016, between 8:30 AM and 1:15 PM, revealed the component exceeded the maximum allowable story height for this type of construction.

Exit interview with facility administrator and facility maintenance representative #1 on November 2, 2016, between 1:15 PM and 1:45 PM, confirmed the building construction deficiencies in the 1941 and 1953 wings.

Based on observation and interview, it was determined the facility failed to properly configure exit access affecting two of four floors in this component.

Findings include:

Observation on November 2, 2016, between 8:30 AM and 1:15 PM, revealed the following exit access deficiencies:

a. Basement-level, materials management suite had headroom measuring six feet two inches, at the lowest point within the suite.
b. Basement-level landing of the 1953 exit stair tower had headroom measuring six feet four inches, at the lowest point.

Exit interview with facility administrator and facility maintenance representative #1 on November 2, 2016, between 1:15 PM and 1:45 PM, confirmed the exit access deficiencies.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical enclosures, affecting four of four floors in this component.

Findings include:

1. Observation on November 2, 2016, between 8:30 AM and 1:15 PM, revealed the following vertical shaft enclosures, located throughout this component, were not constructed with a required two-hour fire resistance rating.

a. 1953 Wing restroom exhaust enclosures lacked the required fire resistance rating.
b. The 1941 Wing elevator enclosure lacked the required fire resistance rating.
c. The 1941 Wing communicating stair enclosure lacked the required fire resistance rating.
d. Expansion joints within the 1965, 1974 and 1994 Wings lacked the required fire resistance rating.

Exit interview with facility administrator and facility maintenance representative #1 on November 2, 2016, between 1:15 PM and 1:45 PM, confirmed the vertical enclosure deficiencies.

2. Observation on November 2, 2016, at 9:48 AM, revealed an unprotected penetration in the freight elevators shaft wall, seen to the right from inside the elevator on the third floor.

Exit interview with facility administrator and facility maintenance representative #1 on November 2, 2016, between 1:15 PM and 1:45 PM, confirmed this unprotected penetration in the freight elevator shaft.

Based on observation and interview it was determined the facility failed to maintain installed automatic sprinkler system components affecting three of four floors in this component.

Findings include:

1. Observation on November 1, 2016, at 1:30 PM, revealed a mix of both standard and quick response sprinkler heads at the second floor, Med/Surg North nurses station.

Exit interview with facility administrator and facility maintenance representative #1 on November 2, 2016, between 1:15 PM and 1:45 PM, confirmed the area by the second floor Med/Surg nurses station had a mix of quick response and standard response sprinklers.

2. Observation on November 2, 2016, between 9:10 AM and 10:40 AM, revealed the following areas lacked sprinkler protection:

a. 9:10 AM - Basement level, no sprinkler located under the lowest landing of the 1953 exit stair tower.
b. 10:40 AM - Second floor, no sprinkler protection in the emergency generator room.

Exit interview with facility administrator and facility maintenance representative #1 on November 2, 2016, between 1:15 PM and 1:45 PM, confirmed these areas lacked sprinkler protection.