HospitalInspections.org

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

Findings include:

1. Observation on March 25, 2014, at 9:12 AM revealed an unsealed penetration inside and around a conduit, above 4th floor door T4C1 in the Patient Tower.

Interview with the Director of Plant Operations on March 25, 2014, at 9:12 AM confirmed the unsealed penetration.

2. Observation on March 25, 2014, at 9:40 AM revealed 3rd floor cross corridor doors NFD 304 entering the South component, would not close and latch completely when released.

Interview with Maintenance Man 1 on March 25, 2014, at 9:40 AM confirmed the cross corridor doors NFD 304, would not close and latch completely.

3. Observation on March 25, 2014, at 9:47 AM revealed an unsealed penetration between the top of the drywall and the I beam, above the 3rd floor double doors TFD 301, entering Component 56.

Interview with Maintenance Man 1 on March 25, 2014, at 9:47 AM confirmed the drywall was incomplete to the I-beam.

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

Findings include:

1. Observation on March 25, 2014, at 9:20 AM revealed a section of the fire-rated ceiling assembly was missing in the ground (South) Substation 2/3.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 9:20 AM confirmed the missing ceiling.

2. Observation on March 25, 2014, at 9:22 AM revealed various unsealed penetrations of the fire-rated ceiling assembly in the ground (South) Maintenance Shop S030.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 9:22 AM confirmed the unsealed penetrations.

3. Observation on March 26, 2014, at 12:30 PM revealed the building construction type, a three-story, Type III(211), did not meet the requirements of the 2000 Life Safety Code for an existing health care facility. A building of this construction type cannot exceed two stories in height.

Interview with the Vice President for Support Services on March 26, 2014, at 12:30 PM confirmed the construction type and identified that the facility has an FSES reviewed on March 26, 2014, addressing this issue.

Based on observation and interview, it was determined the facility failed to protect openings through the fire rated floor assembly in one location, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:20 PM revealed the following deficiencies in the two-hour fire rated floor/ceiling assembly in the 2nd Floor Mechanical Closet #W242:

a) unsealed penetration inside of 2-inch conduit, above the nurse call gear;
b) unsealed penetration around an orange data line, under Electrical Panel #LP 120-W2A;
c) the fire rated ceiling access door was not in the closed position.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 1:20 PM confirmed the unsealed floor and ceiling penetrations.

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating for structural steel, in one location, on one of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 2:15 PM revealed multiple areas of exposed structural steel, on various beams located above the suspended ceiling, by ground floor Room N050 and near the elevator.

Interview with the Director of Plant Operations on March 25, 2014, at 2:15 PM confirmed the unprotected steel.

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

Findings include:

1. Observation on March 24, 2014, between 1:05 PM and 2:20 PM revealed the following corridor door deficiencies:

a. 2nd floor Patient Room W269 required an adjustment to properly close and latch in its frame;
b. 2nd floor Patient Room W276 required an adjustment to properly close and latch in its frame;
c. 1st floor Patient Room W165 required an adjustment to properly close and latch in its frame;
d. 1st floor Patient Room W167 required an adjustment to properly close and latch in its frame;
e. 1st floor Patient Room W169 would not close and latch due to a computer electrical cord plugged into the patient room receptacle;
f. 1st floor Patient Room W172 required an adjustment to properly close and latch in its frame;
g. 1st floor Patient Room W154 had a gap greater than 1/2 inch between the door face and the door stop;
h. 1st floor Patient Room W159 had a gap greater than 1/2 inch between the door face and the door stop;
i. 1st floor Patient Room W155 had a gap greater than 1/2 inch between the door face and the door stop;
j. 1st floor Patient Room W153 had a gap greater than 1/2 inch between the door face and the door stop.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:20 PM confirmed the corridor door deficiencies.

Based on observation and interview, it was determined the facility failed to maintain latching hardware for corridor doors in one location, on one of four floors of this component.

Findings include:

1. Observation on March 25, 2014, at 10:00 AM revealed the door to 4th floor Room T484 required a latching adjustment to properly close and latch in the frame.

Interview with the Director of Plant Operations on March 25, 2014, at 10:00 AM confirmed the door did not latch.

Based on observation and interview, it was determined the facility failed to maintain latching hardware for corridor doors, in two locations, on one of five floors of this component.

Findings include:

1. Observation on March 26, 2014, at 9:27 AM revealed 1st floor door N128 required a latching adjustment to properly close and latch in the frame.

Interview with the Director of Plant Operations on March 26, 2014, at 9:27 AM confirmed the door did not latch.

2. Observation on March 26, 2014, at 9:46 AM revealed the double doors to the 1st Floor Radiology Department (N132A) required a coordinator adjustment to properly close and latch in the frame.

Interview with the Director of Plant Operations on March 26, 2014, at 9:46 AM confirmed the doors did not latch.

Based on observation and interview, it was determined the facility failed to protect openings through the floor assembly in two locations, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:50 PM revealed various unsealed penetrations through the floor/ceiling, in the ground floor Mechanical Room #W052.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:50 PM confirmed these unsealed ceiling penetrations.

2. Observation on March 24, 2014, at 3:10 PM revealed unsealed penetrations of the floor/ceiling above the storage cabinet, in the ground floor Sub Station 4 #S001.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 3:10 PM confirmed the unsealed ceiling penetrations.

Based on observation and interview, it was determined the facility failed to provide properly sized smoke compartments, on four of four floors of this component.

Findings include:

1. Observation on March 26, 2014, at 12:30 PM revealed that smoke compartments throughout the building were extended zones, exceeding 22,500 square feet.

Interview with the Vice President for Support Services on March 26, 2014, at 12:30 PM confirmed the extended smoke compartments and identified that the facility has an FSES reviewed on March 26, 2014, addressing this issue.

Based on observation and interview, it was determined the facility failed to provide properly sized smoke compartments, on three of five floors of this component.

Findings include:

1. Observation on March 26, 2014, at 9:00 AM revealed that smoke compartments 1, 3, 5, 6, and 7 were extended zones, exceeding 22,500 square feet.

Interview with the Vice President for Support Services on March 26, 2014, at 9:00 AM confirmed the extended smoke zones and identified the facility has an FSES reviewed on March 26, 2014, addressing this issue.

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

Findings include:

1. Observation on March 25, 2014, at 1:35 PM revealed the following unsealed smoke barrier penetrations in 2nd Floor Room N228:

a) around a 3" pipe on the rear wall;
b) on the right hand wall were the smoke wall meets from the adjoining room.

Interview with Maintenance Man 1 on March 25, 2014, at 1:35 PM confirmed the unsealed smoke barrier penetrations.

Based on observation and interview, it was determined the facility failed to maintain hazardous area door openings and walls in one location, on one of four floors of the component.

Findings include:

1. Observation on March 25, 2014, at 10:15 AM revealed that a 2nd floor patient treatment room (South) #S030, had been converted to a Storage Room. The room did not meet the requirements for storage.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 10:15 AM confirmed the room did not meet the requirements for a storage room.

Based on observation and interview, it was determined the facility failed to maintain hazardous area door openings in two locations, on two of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 12:50 PM revealed the corridor door to the 3rd floor Storage Closet #W301B had the closure arm disconnected.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 12:50 PM confirmed the disconnected self-closure.

2. Observation on March 24, 2014, at 2:00 PM revealed the 1st floor Tub Room had been converted to a Storage Room for dialysis supplies and did not meet the requirements for storage.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:00 PM confirmed the room did not meet the requirements for a hazardous storage area.

Based on observation and interview, it was determined the facility failed to ensure hazardous areas were protected by one-hour fire rated construction in one location, affecting one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:03 PM revealed an unsealed penetration around the fire alarm strobe light in the 3rd floor Electrical Room T303.

Interview with the Director of Plant Operations on March 24, 2014, at 2:03 PM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of an exit component enclosure, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:55 PM revealed the Ground Floor stairtower door #WS301, at the (South) OB/GYN Clinic, was held open with cardboard wedged between the door face and the door stop.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:55 PM confirmed the door would not close and latch.

Based on observation and interview, it was determined the facility failed to maintain stairway openings in one location, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 12:34 PM revealed 2nd floor stairtower door TST2 required a latching adjustment to properly close and latch in the frame.

Interview with the Director of Plant Operations on March 24, 2014, at 12:34 PM confirmed the door did not latch.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of exit component enclosures, in one location, on one of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 10:47 AM revealed the exit stairtower door located in the ground floor Boiler Room was equipped with panic hardware.

Interview with the Director of Plant Operations on March 25, 2014, at 10:47 AM confirmed the door lacked fire exit hardware.

Based on observation and interview, it was determined the facility failed to ensure stairways used as exits were not used for any purpose which has the potential to interfere with egress, in one location, on one of five floors of this component.

Findings include:

1. Observation on March 26, 2014, at 2:05 PM revealed an electrical conduit from Sub-Station 1 enters Stair SS1 on the 1st floor, passes through the landing and exits the stair on the 2nd floor.

Interview with the Director of Plant Operations on March 26, 2014, at 2:05 PM confirmed the electric installation passes through the stair and does not service the stair.

Based on observation and interview, it was determined the facility failed to provide exit components according to the regulations, for one of six exits within this component.

Findings include:

1. Observation on March 26, 2014, at 12:30 PM revealed the width of SS4 corridor was 34 inches inside the stair tower.

Interview with the Vice President for Support Services on March 26, 2014, at 12:30 PM confirmed the stair width and identified the facility has an FSES reviewed on March 26, 2014, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain battery powered emergency lighting in one location, on one of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 11:27 AM revealed two sets of battery powered emergency lights in the ground floor Fan Room failed to remain lit when tested.

Interview with the Director of Plant Operations on March 25, 2014, at 11:27 AM confirmed the lights failed to remain lit when tested.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in one location, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:40 PM revealed an electrical conduit was supported by sprinkler piping in the 1st floor corridor, by Stair #WS2.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 1:40 PM confirmed the conduit was supported by the sprinkler piping.

Based on observation and interview, it was determined the facility failed to maintain unobstructed sprinkler coverage in one location, on one of four floors of this component.

1. Observation on March 25, 2014, at 9:22 AM revealed surface-mounted light fixtures were mounted within 12 inches of a sprinkler head, extending below the deflector of the head, in the ground floor (South) Maintenance Shop S030.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 9:22 AM confirmed the obstructed sprinkler head.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in five locations, on five of five floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:05 PM revealed an antenna cable hanging on a sprinkler pipe in the 4th floor Attic.

Interview with Maintenance Man 1 on March 24, 2014, at 1:05 PM confirmed the antenna cable was supported by the sprinkler pipe.

2. Observation on March 25, 2014, at 10:33 AM revealed a gray cable, zip-tied in three locations, to a sprinkler pipe above the "Bus Tie Circuit Breaker" in the ground floor Main Switchgear Room.

Interview with the Director of Plant Operations on March 25, 2014, at 10:33 AM confirmed the cable was supported by the sprinkler system.

3. Observation on March 25, 2014, at 10:40 AM revealed the 3rd floor ICU to OR corridor has quick response and standard sprinkler heads installed within the same compartment.

Interview with Maintenance Man 1 on March 25, 2014, at 10:40 AM confirmed the quick response and standard sprinkler heads were installed within the same compartment.

4. Observation on March 25, 2014, at 11:02 AM revealed a pair of 4" X 4" electrical junction boxes piggy-backed and attached to the sprinkler pipe, above the 2nd floor exit door labeled NS3.

Interview with Maintenance Man 1 on March 25, 2014, at 11:02 AM confirmed the pair of 4" X 4" electrical junction boxes attached to the sprinkler pipe.

5. Observation on March 26, 2014, at 9:53 AM revealed two sprinkler heads within six feet of each other in the 1st floor Office N132A.

Interview with the Director of Plant Operations on March 26, 2014, at 9:53 AM confirmed the improper spacing of sprinkler heads.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in three locations, on three of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 10:42 AM revealed a fire extinguisher location indicator present without the corresponding fire extinguisher in the ground floor Boiler Room.

Interview with the Director of Plant Operations on March 25, 2014, at 10:42 AM confirmed the incorrect location of the fire extinguisher indicator and the subsequent correction of the deficiency at the time of the survey.

2. Observation on March 25, 2014, at 2:55 PM revealed the fire extinguisher in the 1st floor Security Office had not been inspected since August 7, 2013.

Interview with the Director of Plant Operations on March 25, 2014, at 2:55 PM confirmed the missing inspections.

3. Observation on March 26, 2014, at 1:40 PM revealed the fire extinguisher in the 3rd floor Sub-Sterile Room, between Operating Room 9 and 10, had not been inspected since January 8, 2014.

Interview with the Director of Plant Operations on March 26, 2014, at 1:40 PM confirmed the missing inspection.

Based on observation and interview, it was determined the facility failed to maintain portable space heaters in one location, on one of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 3:01 PM revealed two portable space heaters were being used in the Rapid Treatment Area, within the Emergency Department.

Interview with the Director of Plant Operations on March 25, 2014, at 3:01 PM confirmed the use of space heaters in a patient care area.

Based on observation and interview, it was determined the facility failed to ensure that exit access corridors were maintained clear and unobstructed, on one of four floors of this component.

Findings include:

1. Observation on March 25, 2014, between 1:20 PM and 2:05 PM revealed the storage of two beds in the 3rd floor (Old West) corridor to the Endoscopy Suite and by the smoke doors, Old West to the West Building.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 2:05 PM confirmed the beds obstructed the corridors.

Based on observation and interview, it was determined the facility failed to maintain exit access corridors clear and unobstructed in three locations, on three of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 10:45 AM revealed a desk with chairs was stored in the 3rd floor exit access corridor near room N329.

Interview with Maintenance Man 1 on March 25, 2014, at 10:45 AM confirmed the storage in the corridor.

2. Observation on March 26, 2014, between 9:20 AM and 9:30 AM revealed hand sanitizing dispensers, mounted on floor stands, obstructed corridors in the following locations:

a. 9:20 AM, 2nd floor Staff Elevator Lobby, by the vending machines;
b. 9:30 AM, 2nd floor Visitor's Elevator Lobby, by the restrooms and telephone closet N275.

Interview with the Supervisor of Plant Operations on March 26, 2014, at 9:30 AM confirmed the obstructed corridors.

3. Observation on March 26, 2014, at 10:17 AM revealed two litters and an equipment cart were stored in the 1st floor exit access corridor near the Intervention Radiology Room.

Interview with Maintenance Man 1 on March 26, 2014, at 10:17 AM confirmed the storage in the corridor.

Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstructions or impediments in one instance, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:40 PM revealed a four-wheeled IT cart was obstructing the Ground Level Stairtower (WS401) door.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:40 PM confirmed the obstructed exit door.

Based on observation and interview, it was determined the facility failed to properly store mobile trash collection receptacles greater than 32-gallon capacity when left unattended in two locations, on one of four floors of this component.

Findings include:

1. Observation on March 25, 2014, at 1:30 PM revealed two trash containers, greater than 32 gallon capacity, were stored in the 3rd Floor south egress corridor, outside the ORs.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 1:30 PM confirmed the trash containers were stored outside of a protected hazardous storage area.

2. Observation on March 25, 2014, at 1:45 PM revealed a trash container, greater than 32 gallon capacity, was stored in the 3rd Floor (Old West) Staff Lounge.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 1:45 PM confirmed the trash container was stored outside of a protected hazardous storage area.

Based on observation and interview, it was determined the facility failed to properly store soiled linen and trash collection receptacles greater than 32-gallon capacity in one location, on one of five floors of this component.

Findings include:

1. Observation on March 26, 2014, at 10:30 AM revealed one soiled linen, trash and hazardous waste bins, totaling greater than 32 gallons, were stored in the 1st floor Interventional Radiology Room, within a 64-square foot area, outside of a protected hazardous storage area.

Interview with Maintenance Man 1 on March 26, 2014, at 10:30 AM confirmed the storage outside of a protected hazardous storage area.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage in one location, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:01 PM revealed three unsecured oxygen cylinders in 1st floor Shower Room W147.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:01 PM confirmed the unsecured cylinders.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system, in five locations, on three of five floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:25 PM revealed MC cables were in direct contact with the oxygen medical gas lines in 4th floor Patient Room N411.

Interview with Maintenance Man 1 on March 24, 2014, at 1:25 PM confirmed the medical gas lines were in direct contact with dissimilar metals.

2. Observation on March 25, 2014, at 10:15 AM revealed MC cables were in direct contact with the oxygen medical gas lines in 3rd floor Patient Room N313.

Interview with Maintenance Man 1 on March 25, 2014, at 10:15 AM confirmed the medical gas lines were in direct contact with dissimilar metals.

3. Observation on March 25, 2014, at 10:25 AM revealed MC cables were in direct contact with the oxygen medical gas lines in 3rd floor Patient Room N338.

Interview with Maintenance Man 1 on March 25, 2014, at 10:25 AM confirmed the medical gas lines were in direct contact with dissimilar metals.

4. Observation on March 25, 2014, at 11:40 AM revealed a steel support bracket, in direct contact with oxygen medical gas lines, on the 2nd floor above the double doors labeled NSD 210.

Interview with Maintenance Man 1 on March 25, 2014, at 11:40 AM confirmed the medical gas lines were in direct contact with dissimilar metals.

5. Observation on March 25, 2014, at 1:25 PM revealed ductwork was in direct contact with oxygen medical gas lines in 2nd floor Room N230.

Interview with Maintenance Man 1 on March 25, 2014, at 1:25 PM confirmed the medical gas lines were in direct contact with dissimilar metals.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems in two locations, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:50 PM revealed exposed wires from an M/C cable were not terminated in an electrical junction box in the ground floor (Old West) Mechanical Room #W052, over control SCU07.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:50 PM confirmed the exposed wires.

2. Observation on March 24, 2014, at 3:15 PM revealed various electrical junction boxes lacked cover plates, in the ground floor (South) Mechanical Room S010.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 3:15 PM confirmed the missing cover plates.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems in two locations, on two of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 12:45 PM revealed an electrical junction box that lacked a cover plate on the 3rd floor, over exit sign #W307.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 12:45 PM confirmed the missing cover plate.

2. Observation on March 24, 2014, at 1:40 PM revealed exposed wires from an M/C cable were not terminated in an electrical junction box, by 1st Floor Stairs WS2.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 1:40 PM confirmed the exposed wires.

Based on observation and interview, it was determined the facility failed to maintain electrical equipment in two locations, on one of five floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:25 PM revealed the use of an extension cord to power a tv in the 4th floor break room, behind the Nurses' Station.

Interview with Maintenance Man 1 on March 24, 2014, at 1:25 PM confirmed the use of an extension cord to power a tv.

2. Observation on March 24, 2014, at 1:40 PM revealed damage to the wall plugs and receptacles in 4th floor Patient Room N405 by the bed and nightstand.

Interview with Maintenance Man 1 on March 24, 2014, at 1:40 PM confirmed the bed and nightstand were causing damage to the wall plugs and receptacles.

Based on observation and interview, it was determined the facility failed to properly install alcohol based hand rub (ABHR) dispensers in one location, on one of four floors of this component.

Findings include:

1. Observation on March 25, 2014, at 9:55 AM revealed an ABHR dispenser installed directly over an electric receptacle in the 4th floor corridor, next to Room T467.

Interview with the Director of Plant Operations on March 25, 2014, at 9:55 AM confirmed the dispenser was installed above an electrical receptacle.

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

Findings include:

1. Observation on March 25, 2014, at 9:12 AM revealed an unsealed penetration inside and around a conduit, above 4th floor door T4C1 in the Patient Tower.

Interview with the Director of Plant Operations on March 25, 2014, at 9:12 AM confirmed the unsealed penetration.

2. Observation on March 25, 2014, at 9:40 AM revealed 3rd floor cross corridor doors NFD 304 entering the South component, would not close and latch completely when released.

Interview with Maintenance Man 1 on March 25, 2014, at 9:40 AM confirmed the cross corridor doors NFD 304, would not close and latch completely.

3. Observation on March 25, 2014, at 9:47 AM revealed an unsealed penetration between the top of the drywall and the I beam, above the 3rd floor double doors TFD 301, entering Component 56.

Interview with Maintenance Man 1 on March 25, 2014, at 9:47 AM confirmed the drywall was incomplete to the I-beam.

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

Findings include:

1. Observation on March 25, 2014, at 9:20 AM revealed a section of the fire-rated ceiling assembly was missing in the ground (South) Substation 2/3.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 9:20 AM confirmed the missing ceiling.

2. Observation on March 25, 2014, at 9:22 AM revealed various unsealed penetrations of the fire-rated ceiling assembly in the ground (South) Maintenance Shop S030.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 9:22 AM confirmed the unsealed penetrations.

3. Observation on March 26, 2014, at 12:30 PM revealed the building construction type, a three-story, Type III(211), did not meet the requirements of the 2000 Life Safety Code for an existing health care facility. A building of this construction type cannot exceed two stories in height.

Interview with the Vice President for Support Services on March 26, 2014, at 12:30 PM confirmed the construction type and identified that the facility has an FSES reviewed on March 26, 2014, addressing this issue.

Based on observation and interview, it was determined the facility failed to protect openings through the fire rated floor assembly in one location, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:20 PM revealed the following deficiencies in the two-hour fire rated floor/ceiling assembly in the 2nd Floor Mechanical Closet #W242:

a) unsealed penetration inside of 2-inch conduit, above the nurse call gear;
b) unsealed penetration around an orange data line, under Electrical Panel #LP 120-W2A;
c) the fire rated ceiling access door was not in the closed position.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 1:20 PM confirmed the unsealed floor and ceiling penetrations.

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating for structural steel, in one location, on one of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 2:15 PM revealed multiple areas of exposed structural steel, on various beams located above the suspended ceiling, by ground floor Room N050 and near the elevator.

Interview with the Director of Plant Operations on March 25, 2014, at 2:15 PM confirmed the unprotected steel.

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

Findings include:

1. Observation on March 24, 2014, between 1:05 PM and 2:20 PM revealed the following corridor door deficiencies:

a. 2nd floor Patient Room W269 required an adjustment to properly close and latch in its frame;
b. 2nd floor Patient Room W276 required an adjustment to properly close and latch in its frame;
c. 1st floor Patient Room W165 required an adjustment to properly close and latch in its frame;
d. 1st floor Patient Room W167 required an adjustment to properly close and latch in its frame;
e. 1st floor Patient Room W169 would not close and latch due to a computer electrical cord plugged into the patient room receptacle;
f. 1st floor Patient Room W172 required an adjustment to properly close and latch in its frame;
g. 1st floor Patient Room W154 had a gap greater than 1/2 inch between the door face and the door stop;
h. 1st floor Patient Room W159 had a gap greater than 1/2 inch between the door face and the door stop;
i. 1st floor Patient Room W155 had a gap greater than 1/2 inch between the door face and the door stop;
j. 1st floor Patient Room W153 had a gap greater than 1/2 inch between the door face and the door stop.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:20 PM confirmed the corridor door deficiencies.

Based on observation and interview, it was determined the facility failed to maintain latching hardware for corridor doors in one location, on one of four floors of this component.

Findings include:

1. Observation on March 25, 2014, at 10:00 AM revealed the door to 4th floor Room T484 required a latching adjustment to properly close and latch in the frame.

Interview with the Director of Plant Operations on March 25, 2014, at 10:00 AM confirmed the door did not latch.

Based on observation and interview, it was determined the facility failed to maintain latching hardware for corridor doors, in two locations, on one of five floors of this component.

Findings include:

1. Observation on March 26, 2014, at 9:27 AM revealed 1st floor door N128 required a latching adjustment to properly close and latch in the frame.

Interview with the Director of Plant Operations on March 26, 2014, at 9:27 AM confirmed the door did not latch.

2. Observation on March 26, 2014, at 9:46 AM revealed the double doors to the 1st Floor Radiology Department (N132A) required a coordinator adjustment to properly close and latch in the frame.

Interview with the Director of Plant Operations on March 26, 2014, at 9:46 AM confirmed the doors did not latch.

Based on observation and interview, it was determined the facility failed to protect openings through the floor assembly in two locations, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:50 PM revealed various unsealed penetrations through the floor/ceiling, in the ground floor Mechanical Room #W052.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:50 PM confirmed these unsealed ceiling penetrations.

2. Observation on March 24, 2014, at 3:10 PM revealed unsealed penetrations of the floor/ceiling above the storage cabinet, in the ground floor Sub Station 4 #S001.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 3:10 PM confirmed the unsealed ceiling penetrations.

Based on observation and interview, it was determined the facility failed to provide properly sized smoke compartments, on four of four floors of this component.

Findings include:

1. Observation on March 26, 2014, at 12:30 PM revealed that smoke compartments throughout the building were extended zones, exceeding 22,500 square feet.

Interview with the Vice President for Support Services on March 26, 2014, at 12:30 PM confirmed the extended smoke compartments and identified that the facility has an FSES reviewed on March 26, 2014, addressing this issue.

Based on observation and interview, it was determined the facility failed to provide properly sized smoke compartments, on three of five floors of this component.

Findings include:

1. Observation on March 26, 2014, at 9:00 AM revealed that smoke compartments 1, 3, 5, 6, and 7 were extended zones, exceeding 22,500 square feet.

Interview with the Vice President for Support Services on March 26, 2014, at 9:00 AM confirmed the extended smoke zones and identified the facility has an FSES reviewed on March 26, 2014, addressing this issue.

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

Findings include:

1. Observation on March 25, 2014, at 1:35 PM revealed the following unsealed smoke barrier penetrations in 2nd Floor Room N228:

a) around a 3" pipe on the rear wall;
b) on the right hand wall were the smoke wall meets from the adjoining room.

Interview with Maintenance Man 1 on March 25, 2014, at 1:35 PM confirmed the unsealed smoke barrier penetrations.

Based on observation and interview, it was determined the facility failed to maintain hazardous area door openings and walls in one location, on one of four floors of the component.

Findings include:

1. Observation on March 25, 2014, at 10:15 AM revealed that a 2nd floor patient treatment room (South) #S030, had been converted to a Storage Room. The room did not meet the requirements for storage.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 10:15 AM confirmed the room did not meet the requirements for a storage room.

Based on observation and interview, it was determined the facility failed to maintain hazardous area door openings in two locations, on two of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 12:50 PM revealed the corridor door to the 3rd floor Storage Closet #W301B had the closure arm disconnected.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 12:50 PM confirmed the disconnected self-closure.

2. Observation on March 24, 2014, at 2:00 PM revealed the 1st floor Tub Room had been converted to a Storage Room for dialysis supplies and did not meet the requirements for storage.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:00 PM confirmed the room did not meet the requirements for a hazardous storage area.

Based on observation and interview, it was determined the facility failed to ensure hazardous areas were protected by one-hour fire rated construction in one location, affecting one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:03 PM revealed an unsealed penetration around the fire alarm strobe light in the 3rd floor Electrical Room T303.

Interview with the Director of Plant Operations on March 24, 2014, at 2:03 PM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of an exit component enclosure, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:55 PM revealed the Ground Floor stairtower door #WS301, at the (South) OB/GYN Clinic, was held open with cardboard wedged between the door face and the door stop.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:55 PM confirmed the door would not close and latch.

Based on observation and interview, it was determined the facility failed to maintain stairway openings in one location, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 12:34 PM revealed 2nd floor stairtower door TST2 required a latching adjustment to properly close and latch in the frame.

Interview with the Director of Plant Operations on March 24, 2014, at 12:34 PM confirmed the door did not latch.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of exit component enclosures, in one location, on one of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 10:47 AM revealed the exit stairtower door located in the ground floor Boiler Room was equipped with panic hardware.

Interview with the Director of Plant Operations on March 25, 2014, at 10:47 AM confirmed the door lacked fire exit hardware.

Based on observation and interview, it was determined the facility failed to ensure stairways used as exits were not used for any purpose which has the potential to interfere with egress, in one location, on one of five floors of this component.

Findings include:

1. Observation on March 26, 2014, at 2:05 PM revealed an electrical conduit from Sub-Station 1 enters Stair SS1 on the 1st floor, passes through the landing and exits the stair on the 2nd floor.

Interview with the Director of Plant Operations on March 26, 2014, at 2:05 PM confirmed the electric installation passes through the stair and does not service the stair.

Based on observation and interview, it was determined the facility failed to provide exit components according to the regulations, for one of six exits within this component.

Findings include:

1. Observation on March 26, 2014, at 12:30 PM revealed the width of SS4 corridor was 34 inches inside the stair tower.

Interview with the Vice President for Support Services on March 26, 2014, at 12:30 PM confirmed the stair width and identified the facility has an FSES reviewed on March 26, 2014, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain battery powered emergency lighting in one location, on one of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 11:27 AM revealed two sets of battery powered emergency lights in the ground floor Fan Room failed to remain lit when tested.

Interview with the Director of Plant Operations on March 25, 2014, at 11:27 AM confirmed the lights failed to remain lit when tested.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in one location, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:40 PM revealed an electrical conduit was supported by sprinkler piping in the 1st floor corridor, by Stair #WS2.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 1:40 PM confirmed the conduit was supported by the sprinkler piping.

Based on observation and interview, it was determined the facility failed to maintain unobstructed sprinkler coverage in one location, on one of four floors of this component.

1. Observation on March 25, 2014, at 9:22 AM revealed surface-mounted light fixtures were mounted within 12 inches of a sprinkler head, extending below the deflector of the head, in the ground floor (South) Maintenance Shop S030.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 9:22 AM confirmed the obstructed sprinkler head.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in five locations, on five of five floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:05 PM revealed an antenna cable hanging on a sprinkler pipe in the 4th floor Attic.

Interview with Maintenance Man 1 on March 24, 2014, at 1:05 PM confirmed the antenna cable was supported by the sprinkler pipe.

2. Observation on March 25, 2014, at 10:33 AM revealed a gray cable, zip-tied in three locations, to a sprinkler pipe above the "Bus Tie Circuit Breaker" in the ground floor Main Switchgear Room.

Interview with the Director of Plant Operations on March 25, 2014, at 10:33 AM confirmed the cable was supported by the sprinkler system.

3. Observation on March 25, 2014, at 10:40 AM revealed the 3rd floor ICU to OR corridor has quick response and standard sprinkler heads installed within the same compartment.

Interview with Maintenance Man 1 on March 25, 2014, at 10:40 AM confirmed the quick response and standard sprinkler heads were installed within the same compartment.

4. Observation on March 25, 2014, at 11:02 AM revealed a pair of 4" X 4" electrical junction boxes piggy-backed and attached to the sprinkler pipe, above the 2nd floor exit door labeled NS3.

Interview with Maintenance Man 1 on March 25, 2014, at 11:02 AM confirmed the pair of 4" X 4" electrical junction boxes attached to the sprinkler pipe.

5. Observation on March 26, 2014, at 9:53 AM revealed two sprinkler heads within six feet of each other in the 1st floor Office N132A.

Interview with the Director of Plant Operations on March 26, 2014, at 9:53 AM confirmed the improper spacing of sprinkler heads.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in three locations, on three of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 10:42 AM revealed a fire extinguisher location indicator present without the corresponding fire extinguisher in the ground floor Boiler Room.

Interview with the Director of Plant Operations on March 25, 2014, at 10:42 AM confirmed the incorrect location of the fire extinguisher indicator and the subsequent correction of the deficiency at the time of the survey.

2. Observation on March 25, 2014, at 2:55 PM revealed the fire extinguisher in the 1st floor Security Office had not been inspected since August 7, 2013.

Interview with the Director of Plant Operations on March 25, 2014, at 2:55 PM confirmed the missing inspections.

3. Observation on March 26, 2014, at 1:40 PM revealed the fire extinguisher in the 3rd floor Sub-Sterile Room, between Operating Room 9 and 10, had not been inspected since January 8, 2014.

Interview with the Director of Plant Operations on March 26, 2014, at 1:40 PM confirmed the missing inspection.

Based on observation and interview, it was determined the facility failed to maintain portable space heaters in one location, on one of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 3:01 PM revealed two portable space heaters were being used in the Rapid Treatment Area, within the Emergency Department.

Interview with the Director of Plant Operations on March 25, 2014, at 3:01 PM confirmed the use of space heaters in a patient care area.

Based on observation and interview, it was determined the facility failed to ensure that exit access corridors were maintained clear and unobstructed, on one of four floors of this component.

Findings include:

1. Observation on March 25, 2014, between 1:20 PM and 2:05 PM revealed the storage of two beds in the 3rd floor (Old West) corridor to the Endoscopy Suite and by the smoke doors, Old West to the West Building.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 2:05 PM confirmed the beds obstructed the corridors.

Based on observation and interview, it was determined the facility failed to maintain exit access corridors clear and unobstructed in three locations, on three of five floors of this component.

Findings include:

1. Observation on March 25, 2014, at 10:45 AM revealed a desk with chairs was stored in the 3rd floor exit access corridor near room N329.

Interview with Maintenance Man 1 on March 25, 2014, at 10:45 AM confirmed the storage in the corridor.

2. Observation on March 26, 2014, between 9:20 AM and 9:30 AM revealed hand sanitizing dispensers, mounted on floor stands, obstructed corridors in the following locations:

a. 9:20 AM, 2nd floor Staff Elevator Lobby, by the vending machines;
b. 9:30 AM, 2nd floor Visitor's Elevator Lobby, by the restrooms and telephone closet N275.

Interview with the Supervisor of Plant Operations on March 26, 2014, at 9:30 AM confirmed the obstructed corridors.

3. Observation on March 26, 2014, at 10:17 AM revealed two litters and an equipment cart were stored in the 1st floor exit access corridor near the Intervention Radiology Room.

Interview with Maintenance Man 1 on March 26, 2014, at 10:17 AM confirmed the storage in the corridor.

Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstructions or impediments in one instance, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:40 PM revealed a four-wheeled IT cart was obstructing the Ground Level Stairtower (WS401) door.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:40 PM confirmed the obstructed exit door.

Based on observation and interview, it was determined the facility failed to properly store mobile trash collection receptacles greater than 32-gallon capacity when left unattended in two locations, on one of four floors of this component.

Findings include:

1. Observation on March 25, 2014, at 1:30 PM revealed two trash containers, greater than 32 gallon capacity, were stored in the 3rd Floor south egress corridor, outside the ORs.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 1:30 PM confirmed the trash containers were stored outside of a protected hazardous storage area.

2. Observation on March 25, 2014, at 1:45 PM revealed a trash container, greater than 32 gallon capacity, was stored in the 3rd Floor (Old West) Staff Lounge.

Interview with the Supervisor of Plant Operations on March 25, 2014, at 1:45 PM confirmed the trash container was stored outside of a protected hazardous storage area.

Based on observation and interview, it was determined the facility failed to properly store soiled linen and trash collection receptacles greater than 32-gallon capacity in one location, on one of five floors of this component.

Findings include:

1. Observation on March 26, 2014, at 10:30 AM revealed one soiled linen, trash and hazardous waste bins, totaling greater than 32 gallons, were stored in the 1st floor Interventional Radiology Room, within a 64-square foot area, outside of a protected hazardous storage area.

Interview with Maintenance Man 1 on March 26, 2014, at 10:30 AM confirmed the storage outside of a protected hazardous storage area.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage in one location, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:01 PM revealed three unsecured oxygen cylinders in 1st floor Shower Room W147.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:01 PM confirmed the unsecured cylinders.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system, in five locations, on three of five floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:25 PM revealed MC cables were in direct contact with the oxygen medical gas lines in 4th floor Patient Room N411.

Interview with Maintenance Man 1 on March 24, 2014, at 1:25 PM confirmed the medical gas lines were in direct contact with dissimilar metals.

2. Observation on March 25, 2014, at 10:15 AM revealed MC cables were in direct contact with the oxygen medical gas lines in 3rd floor Patient Room N313.

Interview with Maintenance Man 1 on March 25, 2014, at 10:15 AM confirmed the medical gas lines were in direct contact with dissimilar metals.

3. Observation on March 25, 2014, at 10:25 AM revealed MC cables were in direct contact with the oxygen medical gas lines in 3rd floor Patient Room N338.

Interview with Maintenance Man 1 on March 25, 2014, at 10:25 AM confirmed the medical gas lines were in direct contact with dissimilar metals.

4. Observation on March 25, 2014, at 11:40 AM revealed a steel support bracket, in direct contact with oxygen medical gas lines, on the 2nd floor above the double doors labeled NSD 210.

Interview with Maintenance Man 1 on March 25, 2014, at 11:40 AM confirmed the medical gas lines were in direct contact with dissimilar metals.

5. Observation on March 25, 2014, at 1:25 PM revealed ductwork was in direct contact with oxygen medical gas lines in 2nd floor Room N230.

Interview with Maintenance Man 1 on March 25, 2014, at 1:25 PM confirmed the medical gas lines were in direct contact with dissimilar metals.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems in two locations, on one of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 2:50 PM revealed exposed wires from an M/C cable were not terminated in an electrical junction box in the ground floor (Old West) Mechanical Room #W052, over control SCU07.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 2:50 PM confirmed the exposed wires.

2. Observation on March 24, 2014, at 3:15 PM revealed various electrical junction boxes lacked cover plates, in the ground floor (South) Mechanical Room S010.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 3:15 PM confirmed the missing cover plates.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems in two locations, on two of four floors of this component.

Findings include:

1. Observation on March 24, 2014, at 12:45 PM revealed an electrical junction box that lacked a cover plate on the 3rd floor, over exit sign #W307.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 12:45 PM confirmed the missing cover plate.

2. Observation on March 24, 2014, at 1:40 PM revealed exposed wires from an M/C cable were not terminated in an electrical junction box, by 1st Floor Stairs WS2.

Interview with the Supervisor of Plant Operations on March 24, 2014, at 1:40 PM confirmed the exposed wires.

Based on observation and interview, it was determined the facility failed to maintain electrical equipment in two locations, on one of five floors of this component.

Findings include:

1. Observation on March 24, 2014, at 1:25 PM revealed the use of an extension cord to power a tv in the 4th floor break room, behind the Nurses' Station.

Interview with Maintenance Man 1 on March 24, 2014, at 1:25 PM confirmed the use of an extension cord to power a tv.

2. Observation on March 24, 2014, at 1:40 PM revealed damage to the wall plugs and receptacles in 4th floor Patient Room N405 by the bed and nightstand.

Interview with Maintenance Man 1 on March 24, 2014, at 1:40 PM confirmed the bed and nightstand were causing damage to the wall plugs and receptacles.