HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain vertical openings in two locations, affecting two of nine floors.

Findings include:

1. Observation on January 15, 2014, between 9:27 a.m. and 11:46 a.m. revealed the below vertical opening deficiencies:

a. 9:27 AM, two unsealed penetrations of the floor slab assembly within the first floor Laundry Chute Room;
b. 11:46 AM, an unsealed penetration of the floor slab assembly within the basement-level, Pharmacy Lounge.
Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, at 12:30 p.m. revealed the door to the basement-level former reception area, within the temporary main entrance, lacked a self-closing device (used for storage purposes).

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the door lacked a self-closing device.

Based on observation and interview, it was determined the facility failed to maintain exit stair towers in multiple locations, affecting three of nine floors.

Findings include:

1. Observation on January 15, 2014, between 9:47 a.m. and 11:40 a.m. revealed the below exit stair deficiencies:

a. 9:47 AM, an unsealed penetration of the protected passageway, within the first floor I.T. Closet;
b. 9:50 AM, the Family Waiting Room door, within the protected passageway, was held open by a chair;
c. 11:38 AM, the B-Wing Doctor's Stair Tower door lacked positive latching, the lock set had been removed, an additional strip of unapproved, non-fire resistive wood, had been added to the width of the door and the door had multiple unsealed penetrations;
d. 11:40 AM, a temporary construction gate within the B-Wing Doctor's Stair Tower was constructed of combustible wood materials.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the above stair tower deficiencies.

Based on observation and interview, it was determined the facility failed to install and maintain illuminated exit signage in four locations, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, between 10:25 a.m. and 12:33 p.m. revealed the following locations lacked illuminated exit signage:

a. 10:25 AM, within the first floor protected passageway exit (old Main Lobby area);
b. 10:44 AM, within the first floor portion of the Colfax Stair Tower, to direct occupants down one floor, to discharge location;
c. 10:50 AM, within the first floor B-Wing exit access corridor, beyond the smoke barrier doors.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the lack of illuminated exit signage.

Based on observation and interview, it was determined the facility failed to install illuminated exit signage in one location, affecting one of one floors.

Findings include:

1. Observation on January 15, 2014, at 9:33 a.m. revealed the common wall doors within the Emergency Department lacked illuminated exit signage.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the lack of illuminated exit signage.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, at 12:53 p.m. revealed storage within eighteen inches of a sprinkler head in the basement-level Medical Records rear storage room.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the obstructed sprinkler coverage.

Based on observation and interview, it was determined the facility failed to install and maintain the heating, ventilation, and air conditioning systems in one location, affecting two of nine floors.

Findings include:

1. Observation on January 15, 2014, at 1:22 p.m. revealed the exhaust duct within the 2nd Floor AC-13 Mechanical Room lacked a fire damper, retaining angles, and access panel for maintenance and inspection purposes.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, the duct was not protected.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in one location, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, at 12:58 p.m. revealed oxygen and vacuum piping within the second floor linen chute room was unprotected from physical damage.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the oxygen and vacuum piping were not protected.

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, at 11:44 a.m. revealed a junction box lacked a cover plate in the basement-level Pharmacy Lounge.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the junction box lacked a cover plate.

Based on observation and interview, it was determined the facility failed to maintain vertical openings in two locations, affecting two of nine floors.

Findings include:

1. Observation on January 15, 2014, between 9:27 a.m. and 11:46 a.m. revealed the below vertical opening deficiencies:

a. 9:27 AM, two unsealed penetrations of the floor slab assembly within the first floor Laundry Chute Room;
b. 11:46 AM, an unsealed penetration of the floor slab assembly within the basement-level, Pharmacy Lounge.
Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, at 12:30 p.m. revealed the door to the basement-level former reception area, within the temporary main entrance, lacked a self-closing device (used for storage purposes).

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the door lacked a self-closing device.

Based on observation and interview, it was determined the facility failed to maintain exit stair towers in multiple locations, affecting three of nine floors.

Findings include:

1. Observation on January 15, 2014, between 9:47 a.m. and 11:40 a.m. revealed the below exit stair deficiencies:

a. 9:47 AM, an unsealed penetration of the protected passageway, within the first floor I.T. Closet;
b. 9:50 AM, the Family Waiting Room door, within the protected passageway, was held open by a chair;
c. 11:38 AM, the B-Wing Doctor's Stair Tower door lacked positive latching, the lock set had been removed, an additional strip of unapproved, non-fire resistive wood, had been added to the width of the door and the door had multiple unsealed penetrations;
d. 11:40 AM, a temporary construction gate within the B-Wing Doctor's Stair Tower was constructed of combustible wood materials.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the above stair tower deficiencies.

Based on observation and interview, it was determined the facility failed to install and maintain illuminated exit signage in four locations, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, between 10:25 a.m. and 12:33 p.m. revealed the following locations lacked illuminated exit signage:

a. 10:25 AM, within the first floor protected passageway exit (old Main Lobby area);
b. 10:44 AM, within the first floor portion of the Colfax Stair Tower, to direct occupants down one floor, to discharge location;
c. 10:50 AM, within the first floor B-Wing exit access corridor, beyond the smoke barrier doors.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the lack of illuminated exit signage.

Based on observation and interview, it was determined the facility failed to install illuminated exit signage in one location, affecting one of one floors.

Findings include:

1. Observation on January 15, 2014, at 9:33 a.m. revealed the common wall doors within the Emergency Department lacked illuminated exit signage.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the lack of illuminated exit signage.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, at 12:53 p.m. revealed storage within eighteen inches of a sprinkler head in the basement-level Medical Records rear storage room.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the obstructed sprinkler coverage.

Based on observation and interview, it was determined the facility failed to install and maintain the heating, ventilation, and air conditioning systems in one location, affecting two of nine floors.

Findings include:

1. Observation on January 15, 2014, at 1:22 p.m. revealed the exhaust duct within the 2nd Floor AC-13 Mechanical Room lacked a fire damper, retaining angles, and access panel for maintenance and inspection purposes.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, the duct was not protected.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in one location, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, at 12:58 p.m. revealed oxygen and vacuum piping within the second floor linen chute room was unprotected from physical damage.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the oxygen and vacuum piping were not protected.

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of nine floors.

Findings include:

1. Observation on January 15, 2014, at 11:44 a.m. revealed a junction box lacked a cover plate in the basement-level Pharmacy Lounge.

Exit interview with the Facilities Manager between 12:40 p.m. and 1:00 p.m. on January 16, 2014, confirmed the junction box lacked a cover plate.