HospitalInspections.org

Based on observation and interview it was determined that the facility failed to maintain the separation between the Hospital and Cancer Center.

Findings include:

It was observed on 08/07/2012, at approximately 02:42 PM, that there are unprotected penetrations in the 2 hour fire barrier at Closet 3118A.

It was observed on 08/08/2012, at approximately 09:55 AM, that there are unprotected penetrations in the 2 hour fire barrier at Room 1203.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the separation between the Hospital and Medical Office Building, MOB.

Findings include:

It was observed on 07/25/2012, at approximately 01:35 PM, that there are unprotected penetrations in the 2 hour fire barrier on the 3rd floor, above the ceiling at room 3B48.

It was observed on 07/26/2012, at approximately 05:05 PM, that an electrical box is installed ands penetrate the 2 hour rated fire barrier wall above the double doors 2108C leading into the MOB, 2nd floor.

It was observed on 08/03/2012, at approximately 02:05 PM, that there is an unprotected penetration of the 2 hour fire barrier by electrical conduit above the ceiling at door G27, Ground Floor.

It was observed on 08/07/2012, at approximately 11:20 AM, that there are unprotected penetrations in the concrete masonry wall at the support beam at the Environmental Services Service Dock.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the separation between the Hospital and Medical Office Building, MOB.

Findings include:

It was observed on 07/27/2012, at approximately 09:00 AM, that there is an unprotected penetration in the 2 hour fire barrier above the drop ceiling at room 2074C.

It was observed on 07/27/2012, at approximately 09:07 AM, that there is an unprotected penetration in the 2 hour fire barrier above the drop ceiling in the Endo 6 procedure room.

It was observed on 07/27/2012, at approximately 09:15 AM, that there is an improperly protected penetration in the 2 hour fire barrier in Room BR2070.

It was observed on 07/27/2012, at approximately 09:20 AM, that there are unprotected penetrations in the 2 hour fire barrier above the ceiling at Door 2079.

It was observed on 07/27/2012, at approximately 09:30 AM, that there are improperly protected penetrations in the 2 hour fire barrier at Rooms 2089, 2089A.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the construction type of the building.

Findings include:

It was observed on 07/25/2012, at approximately 03:45 PM, that in the concealed plumbing access area of the Patient Birthing Rooms a combustible yellow foam material has been used to fill the space between the bath tubs and the concrete floor.

It was observed on 07/26/2012, at approximately 05:00 PM, that required fireproofing material is missing from structural steel in Electrical Room 2037.

It was observed on 07/27/2012, at approximately 08:00 AM, that the fire doors at 2044C, 2nd floor, do not latch in the closed position.

It was observed on 08/02/2012, at approximately 03:40 PM, that there is an unprotected penetration of the floor/ceiling assembly above the ceiling at CA14.

It was observed on 08/07/2012, at approximately 11:40 AM, that required fireproofing is missing from structural steel in the Boiler Room above the boiler.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain smoke tight corridors.

Findings include:

It was observed on 07/25/2012, at approximately 03:03 PM, that the corridor wall at the Birthing Suite has unprotected penetrations by wires above the door to the Suite.
It was observed on 07/26/2012, at approximately 06:15 PM, that there are unprotected penetrations of the corridor wall near the metal stud at door 2B78D, 2nd floor.

It was observed on 07/27/2012, at approximately 10:17 AM, that there are unprotected penetrations of the corridor wall above the door to the Surgery Suite.

It was observed on 07/27/2012, at approximately 10:25 AM, that there are unprotected penetrations of the corridor wall by a network cable above Door 2B37, 2nd floor.

It was observed on 07/31/2012, at approximately 10:40 AM, that the corridor wall separating the Emergency Department Lobby from the Emergency Suite is not complete near Door 1C51.

It was observed on 07/31/2012, at approximately 01:15 PM, that there are unprotected penetrations of the corridor wall in the area of Room 0001.

It was observed on 07/31/2012, at approximately 01:17 PM, that the corridor wall has unprotected penetrations at the CT and MRI Rooms.

It was observed on 08/02/2012, at approximately 03:26 PM, that there is a hole in the corridor wall at GA16.

It was observed on 08/07/2012, at approximately 12:25 PM, that there are unprotected penetrations of the corridor wall in the Engineering Department at Door GD05.

It was observed on 08/07/2012, at approximately 12:32 PM, that there unprotected penetrations in the corridor wall at Door GDO6.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain corridor openings to resist the passage of smoke.

Findings include:

It was observed on 07/25/2012, at approximately 12:31 PM, that corridor door 3B50 is not equipped with a functioning means to keep the door closed.

It was observed on 07/25/2012, at approximately 03:15 PM, that the corridor door to patient Room B367 is not equipped with a functioning means to keep the door closed.

It was observed on 07/25/2012, at approximately 03:50 PM, that the corridor door to patient Room 360 is not equipped with a functioning means to keep the door closed.

It was observed on 07/27/2012, at approximately 10:25 AM, that the strike is missing from the door jamb at Door 2B37, disabling the means to keep the door closed.

It was observed on 07/31/2012, at approximately 10:30 AM, that the smoke door 1C41 in the corridor between the Emergency Department Suite from the waiting area has been removed.

It was observed on 07/27/2012, at approximately 11:45 AM, that corridor door A201, is not equipped with a functioning means to keep the door closed.

It was observed on 07/31/2012, at approximately 02:50 PM, that the arm is missing from the door closer on the corridor door to the Cardiac Cauterization Procedure Room.

It was observed on 08/02/2012, at approximately 01:38 PM, that the isolation kit hanging on the door creates an impediment to the closing of Patient Room Door A125.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain corridor openings to resist the passage of smoke.

Findings include:

It was observed on 08/07/2012, at approximately 02:00 PM, that corridor door 3206 is not equipped with functioning means to keep the door closed.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the required fire resistance rating of shafts.

Findings include:

It was observed on 07/27/2012, at approximately 08:27 AM, that there is an unprotected penetration to the shaft wall at room 2090 near the patient registration area.

It was observed on 07/27/2012, at approximately 09:45 AM, that there is an improperly protected penetration of the Stairway F wall, 2nd floor.

It was observed on 08/02/2012, at approximately 09:54 AM, that there are unprotected penetrations in the elevator shaft wall of Elevator 5.

It was observed on 08/02/2012, at approximately 10:35 AM, that there is an unprotected penetration of the shaft wall at the conduit for the call button switch of Elevator 9.

It was observed on 08/02/2012, at approximately 11:20 AM, that there are unprotected penetrations in the shaft wall at the conduit for the call button switch at the basement and level 2 of Elevator 1.

It was observed on 08/02/2012, at approximately 11:37 AM, that there are unprotected penetrations in the shaft wall of Elevator 7.

It was observed on 08/03/2012, at approximately 12:30 PM, that there are unprotected penetrations of the 2 hour vertical shaft wall assembly near the ground floor as observed from the sub-basement level of the building.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the required fire resistance rating of shafts.

Findings include:

It was observed on 08/17/2012, at approximately 09:35 AM, that there are unprotected penetrations in the shaft wall assembly in the Cancer Center Elevator Shaft.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the marked access to exits in the building.

Findings include:

It was observed on 07/31/2012, at approximately 11:40 AM, that the exit and directional signs in the Emergency Room Suite, do not provide the necessary direction to the nearest exit.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the marked access to exits in the building.

Findings include:

It was observed on 08/08/2012, at approximately 11:32 AM, that the exit and directional sign is not in place at the exit discharge from Stair A, Ground Floor.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating of smoke barriers.

Findings include:

It was observed on 07/31/2012, at approximately 10:08 AM, that there is an unprotected penetration in the smoke barrier wall above the ceiling at 1C56A, near the ductwork.

It was observed on 08/02/2012, at approximately 03:00 PM, that the smoke barrier wall has a 2 by 2 foot hole in the wall above the ceiling at GA39.

It was observed on 08/03/2012, at approximately 10:05 AM, that there is an unprotected penetration in the smoke barrier and another penetration is sealed with different types of sealant above the ceiling at the pair of doors GB861.

It was observed on 08/03/2012, at approximately 10:45 AM, that there is an unprotected penetration of the smoke barrier near the wiring tray above the pair of doors GB86A.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain smoke tight and self-closing doors in the smoke barrier.

Findings include:

It was observed on 07/26/2012, at approximately 05:45 PM, that the door coordinator does not function on the Sterile corridor doors in the smoke barrier at Operating Room 8.

It was observed on 07/31/2012, at approximately 11:33 AM, that the door in the smoke barrier on the right at 1C22B, is not equipped with a means to keep it in place.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to properly protect identified hazardous areas.

Findings include:

It was observed on 07/25/2012, at approximately 12:30 PM, that the old cafeteria dish washing room 3B51 is being used as a storage room, and the door is not self closing.

It was observed on 07/26/2012, at approximately 05:58 PM, that there is an unprotected penetration in the wall above the door near the ductwork in Equipment Room D.

It was observed on 07/31/2012, at approximately 11:11 AM, that a large hole has been cut in the wall of Clean Linen Storage Room 1C30G.

It was observed on 07/31/2012, at approximately 11:14 AM, that there are multiple unprotected penetrations in the wall of the soiled linen room 1C30E.

It was observed on 08/02/2012, at approximately 11:06 AM, that there is a hole in the rated ceiling above the autoclaves in the Sterilization Room.

It was observed on 08/03/2012, at approximately 01:38 PM, that the door to storage room 3B32D will not latch in the closed position.

It was observed on 08/07/2012, at approximately 11:27 AM, that there are unprotected penetrations of the fire rated wall at the support beam of the flammable materials
storage room.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to properly protect identified hazardous areas.

Findings include:

It was observed on 08/07/2012, at approximately 03:05 PM, that there are unprotected penetrations in the wall of Supply Storage Room 225.
It was observed that on 08/07/2012, at approximately 04:00 PM, that that there are unprotected penetrations of the wall in Storage Room 1428.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain exits readily accessible.

Findings include:

It was observed on 08/02/2012, at approximately 03:20 PM, that there is not an all weather path to the public way from the ground floor exit discharge of stairway B.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain horizontal exits.

Findings include:

It was observed on 07/27/2012, at approximately 08:15 AM, that a means of egress from the Endo Procedure area exits to a area that is being used as a Horizontal Exit, and the exit is not rated.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the emergency lighting.

Findings include:

It was observed that on 07/31/2012, at approximately 02:25 PM, that that the emergency illumination task lights are not working in the CT Procedure rooms and the CT Equipment Control Area.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the written plan for protection.

Findings include:

It was observed on 07/25/2012, at approximately 02:50 PM, that staff at the 3rd floor, East Nursing Station, could not locate the Emergency Operations Plan upon request.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview the facility failed to maintain the fire alarm system in accordance with NFPA 72.

Findings include:

It was observed on 08/03/2012, at approximately 11:00 AM, that the Fire Alarm System visual notification device is obstructed by storage on shelving in the Kitchen Dry Storage Room.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to install the sprinkler system in accordance with NFPA 13.

Findings include:

It was observed on 07/25/2012, at approximately 11:08 AM, that the 4th
floor mechanical room does not have fire sprinkler protection under ductwork that is
greater than 4 feet in width.

It was observed on 07/25/2012, at approximately 11:10 AM, that storage
is located under an open stairway to the upper level of the Elevator Machine
Room that did not have fire sprinkler protection.

It was observed on 07/25/2012, at approximately 12:27 PM, that the fire
sprinkler heads in the 3rd floor cafeteria, above the salad bar are spaced less
than 6 feet on center. (NFPA 13, Section 5.6.3.4)

It was observed on 07/25/2012, at approximately 01:57 PM, that the
corridor soffit near the exterior windows across from Room 308 does not have fire
sprinkler protection.

It was observed on 07/27/2012, at approximately 11:41 AM, that the
corridor soffit near the exterior windows across from Room 208 does not have fire
sprinkler protection.

It was observed on 07/31/2012, at approximately 11:34 AM, that there is
not adequate fire sprinkler protection in the room on the far side of the smoke
detector, Room 1C26E.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to install the sprinkler system in accordance with NFPA 13.

Findings include:

It was observed that on 08/07/2012, at approximately 02:37 PM, that that the rooftop mechanical room did not have fire sprinkler protection under ductwork that is greater than 4 feet in width.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the required automatic sprinkler systems in a reliable operating condition.

Findings include:

It was observed on 07/31/2012, at approximately 11:09 AM, that there is
an unsealed space between the fire sprinkler head escutcheon and the ceiling panel in Call Room 1C31A.

It was observed on 07/31/2012, at approximately 01:05 PM, that a bundle of network cable wires are supported by the fire sprinkler piping above the corridor ceiling at 1C01A, Radiology Department. [NFPA 13, Section 6-1.1.5]

It was observed on 07/31/2012, at approximately 01:23 PM, that the fire sprinkler protection does not have a draft stop installed at the vertical opening above the MRI Control Equipment, in the Equipment Room. [NFPA 13, Section 5-13.4]

It was observed on 07/31/2012, at approximately 02:20 PM, that the escutcheons were not in place on the fire sprinkler heads Radiology Department Patient, Holding Area. [NFPA 13, Section 3-2.7.2]

It was observed on 07/31/2012, at approximately 02:55 PM, that 2 recessed fire sprinkler heads are obstructed by ceiling mounted medical equipment in the Angioplasty Procedure Room. [NFPA 25, Section 2-2.1.2]

It was observed on 07/31/2012, at approximately 03:08 PM, that the fire sprinkler heads in Ultrasound Procedure Room 3 are spaced less than 6 feet on center. [NFPA 13, Section 5.6.3.4)]

It was observed on 07/31/2012, at approximately 03:20 PM, that the fire sprinkler heads in the Radio Film File Room are spaced less than 6 feet on center. [NFPA 13, Section 5.6.3.4)]

It was observed on 07/31/2012, at approximately 03:42 PM, that the fire sprinkler heads in the Ultrasound Technician Room, West Side, are spaced less than 6 feet on center. [NFPA 13, Section 5.6.3.4)]

It was observed on 08/02/2012, at approximately 09:54 AM, that the fire sprinkler heads are loaded with lint on the lower level of elevator shaft 4/5. [NFPA 25, Section 2-2.1.1]

It was observed on 08/02/2012, at approximately 02:35 PM, that the sidewall fire sprinkler heads are not installed with the deflectors parallel to the ceiling in the Pharmacy Work Area. [NFPA 13, Section 5-7.4.2.1]

It was observed on 08/03/2012, at approximately 09:45 AM, that there is an unsealed space between the fire sprinkler head escutcheon and the ceiling panel in Room GB01A.

It was observed on 08/03/2012, at approximately 10:45 AM, that electrical cables are supported by the fire sprinkler piping above the corridor ceiling at GB86A. [NFPA 13, Section 6-1.1.5]

It was observed on 08/03/2012, at approximately 10:57 AM, that the fire sprinkler heads are loaded with lint near refrigerator 2 in the kitchen catering area. [NFPA 25, Section 2-2.1.1]

It was observed on 08/03/2012, at approximately 12:05 PM, that multiple fire sprinkler heads are loaded with lint in the Laundry. [NFPA 25, Section 2-2.1.1]

It was observed on 08/03/2012, at approximately 12:11 PM, that the fire sprinkler protection does not have a draft stop installed at the vertical opening above the Laundry Equipment, in the Laundry. [NFPA 13, Section 5-13.4]

It was observed on 08/03/2012, at approximately 12:20 PM, that access to the fire sprinkler system control valves are obstructed by storage in Room GC13, Ground Floor. [NFPA 25, Section 9-3.3.2]

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the HVAC system.

Findings include:

It was noted during record review on 08/09/2012, at approximately 11:00 AM, that some of the smoke dampers in the Hospital could not be tested due to access to the damper.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating for the walls of the linen chute.

Findings include:

It was observed on 08/02/2012, at approximately 02:25 PM, that the linen chute does not have a continuous enclosure that extends to the ceiling of the storage room to maintain the fire separation. [NFPA 82, Section 3-2.3]

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain exits readily accessible.

Findings include:

It was observed on 08/09/2012, at approximately 02:42 PM, that the ramp from the side egress door to the public way, does not have a handrail as required by Section 7.2.2.4.2.
The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to ensure that the requirements of NFPA 70 were met.

Findings include:

It was observed on 07/25/2012, at approximately 12:25 PM, that the drink refrigeration cooler power cord in the 3rd floor cafeteria is plugged into an extension cord. [NFPA 70, Section 400-8(1)]

It was observed on 07/25/2012, at approximately 01:57 PM, that an approved cover plate is not provided for an electrical junction box above the ceiling in the lobby corridor near room A 301 on the 3rd floor. [NFPA 70, Section 370-28(c)]

It was observed on 07/25/2012, at approximately 02:25 PM, that electrical panel R1N-3A2A, located on the 3rd floor is not properly marked to identify the purpose or use on the circuit directory. [NFPA 70, Section 384.13]

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to ensure that the requirements of NFPA 70 were met.

Findings include:

It was observed on 08/07/2012, at approximately 01:23 PM, that 2 power strips are being used in series in Room 3205. [NFPA 70, Section 400-7(b)].

It was observed on 08/07/2012, at approximately 01:23 PM, that an extension cord is being used as permanent wiring. [NFPA 70, Section 400-8(1)]

It was observed on 08/07/2012, at approximately 02:10 PM, that an approved cover plate is not provided for an electrical junction box above the corridor ceiling at Room 3313, 3rd floor. [NFPA 70, Section 370-28(c)]

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to install Alcohol Based Hand Rubs in accordance with all requirements.

Findings include:

It was observed on 07/25/2012, at approximately 02:05 PM, that an alcohol based hand rub dispenser is located over an electrical outlet in Patient Room A312.

It was observed on 07/25/2012, at approximately 02:10 PM, that an alcohol based hand rub dispenser is located over an electrical outlet in Patient Room A314.

It was observed on 07/25/2012, at approximately 03:50 PM, that an alcohol based hand rub dispenser is located over an electrical outlet in Patient Room B367.

It was observed on 07/27/2012, at approximately 11:15 AM, that an alcohol based hand rub dispenser is located over an electrical outlet in Patient Room A237.

It was observed on 07/31/2012, at approximately 11:52 AM, that an alcohol based hand rub dispenser is located over an electrical light switch in the Emergency Room Discharge Area 1C40B.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the separation between the Hospital and Cancer Center.

Findings include:

It was observed on 08/07/2012, at approximately 02:42 PM, that there are unprotected penetrations in the 2 hour fire barrier at Closet 3118A.

It was observed on 08/08/2012, at approximately 09:55 AM, that there are unprotected penetrations in the 2 hour fire barrier at Room 1203.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the separation between the Hospital and Medical Office Building, MOB.

Findings include:

It was observed on 07/25/2012, at approximately 01:35 PM, that there are unprotected penetrations in the 2 hour fire barrier on the 3rd floor, above the ceiling at room 3B48.

It was observed on 07/26/2012, at approximately 05:05 PM, that an electrical box is installed ands penetrate the 2 hour rated fire barrier wall above the double doors 2108C leading into the MOB, 2nd floor.

It was observed on 08/03/2012, at approximately 02:05 PM, that there is an unprotected penetration of the 2 hour fire barrier by electrical conduit above the ceiling at door G27, Ground Floor.

It was observed on 08/07/2012, at approximately 11:20 AM, that there are unprotected penetrations in the concrete masonry wall at the support beam at the Environmental Services Service Dock.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the separation between the Hospital and Medical Office Building, MOB.

Findings include:

It was observed on 07/27/2012, at approximately 09:00 AM, that there is an unprotected penetration in the 2 hour fire barrier above the drop ceiling at room 2074C.

It was observed on 07/27/2012, at approximately 09:07 AM, that there is an unprotected penetration in the 2 hour fire barrier above the drop ceiling in the Endo 6 procedure room.

It was observed on 07/27/2012, at approximately 09:15 AM, that there is an improperly protected penetration in the 2 hour fire barrier in Room BR2070.

It was observed on 07/27/2012, at approximately 09:20 AM, that there are unprotected penetrations in the 2 hour fire barrier above the ceiling at Door 2079.

It was observed on 07/27/2012, at approximately 09:30 AM, that there are improperly protected penetrations in the 2 hour fire barrier at Rooms 2089, 2089A.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the construction type of the building.

Findings include:

It was observed on 07/25/2012, at approximately 03:45 PM, that in the concealed plumbing access area of the Patient Birthing Rooms a combustible yellow foam material has been used to fill the space between the bath tubs and the concrete floor.

It was observed on 07/26/2012, at approximately 05:00 PM, that required fireproofing material is missing from structural steel in Electrical Room 2037.

It was observed on 07/27/2012, at approximately 08:00 AM, that the fire doors at 2044C, 2nd floor, do not latch in the closed position.

It was observed on 08/02/2012, at approximately 03:40 PM, that there is an unprotected penetration of the floor/ceiling assembly above the ceiling at CA14.

It was observed on 08/07/2012, at approximately 11:40 AM, that required fireproofing is missing from structural steel in the Boiler Room above the boiler.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain smoke tight corridors.

Findings include:

It was observed on 07/25/2012, at approximately 03:03 PM, that the corridor wall at the Birthing Suite has unprotected penetrations by wires above the door to the Suite.
It was observed on 07/26/2012, at approximately 06:15 PM, that there are unprotected penetrations of the corridor wall near the metal stud at door 2B78D, 2nd floor.

It was observed on 07/27/2012, at approximately 10:17 AM, that there are unprotected penetrations of the corridor wall above the door to the Surgery Suite.

It was observed on 07/27/2012, at approximately 10:25 AM, that there are unprotected penetrations of the corridor wall by a network cable above Door 2B37, 2nd floor.

It was observed on 07/31/2012, at approximately 10:40 AM, that the corridor wall separating the Emergency Department Lobby from the Emergency Suite is not complete near Door 1C51.

It was observed on 07/31/2012, at approximately 01:15 PM, that there are unprotected penetrations of the corridor wall in the area of Room 0001.

It was observed on 07/31/2012, at approximately 01:17 PM, that the corridor wall has unprotected penetrations at the CT and MRI Rooms.

It was observed on 08/02/2012, at approximately 03:26 PM, that there is a hole in the corridor wall at GA16.

It was observed on 08/07/2012, at approximately 12:25 PM, that there are unprotected penetrations of the corridor wall in the Engineering Department at Door GD05.

It was observed on 08/07/2012, at approximately 12:32 PM, that there unprotected penetrations in the corridor wall at Door GDO6.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain corridor openings to resist the passage of smoke.

Findings include:

It was observed on 07/25/2012, at approximately 12:31 PM, that corridor door 3B50 is not equipped with a functioning means to keep the door closed.

It was observed on 07/25/2012, at approximately 03:15 PM, that the corridor door to patient Room B367 is not equipped with a functioning means to keep the door closed.

It was observed on 07/25/2012, at approximately 03:50 PM, that the corridor door to patient Room 360 is not equipped with a functioning means to keep the door closed.

It was observed on 07/27/2012, at approximately 10:25 AM, that the strike is missing from the door jamb at Door 2B37, disabling the means to keep the door closed.

It was observed on 07/31/2012, at approximately 10:30 AM, that the smoke door 1C41 in the corridor between the Emergency Department Suite from the waiting area has been removed.

It was observed on 07/27/2012, at approximately 11:45 AM, that corridor door A201, is not equipped with a functioning means to keep the door closed.

It was observed on 07/31/2012, at approximately 02:50 PM, that the arm is missing from the door closer on the corridor door to the Cardiac Cauterization Procedure Room.

It was observed on 08/02/2012, at approximately 01:38 PM, that the isolation kit hanging on the door creates an impediment to the closing of Patient Room Door A125.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain corridor openings to resist the passage of smoke.

Findings include:

It was observed on 08/07/2012, at approximately 02:00 PM, that corridor door 3206 is not equipped with functioning means to keep the door closed.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the required fire resistance rating of shafts.

Findings include:

It was observed on 07/27/2012, at approximately 08:27 AM, that there is an unprotected penetration to the shaft wall at room 2090 near the patient registration area.

It was observed on 07/27/2012, at approximately 09:45 AM, that there is an improperly protected penetration of the Stairway F wall, 2nd floor.

It was observed on 08/02/2012, at approximately 09:54 AM, that there are unprotected penetrations in the elevator shaft wall of Elevator 5.

It was observed on 08/02/2012, at approximately 10:35 AM, that there is an unprotected penetration of the shaft wall at the conduit for the call button switch of Elevator 9.

It was observed on 08/02/2012, at approximately 11:20 AM, that there are unprotected penetrations in the shaft wall at the conduit for the call button switch at the basement and level 2 of Elevator 1.

It was observed on 08/02/2012, at approximately 11:37 AM, that there are unprotected penetrations in the shaft wall of Elevator 7.

It was observed on 08/03/2012, at approximately 12:30 PM, that there are unprotected penetrations of the 2 hour vertical shaft wall assembly near the ground floor as observed from the sub-basement level of the building.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the required fire resistance rating of shafts.

Findings include:

It was observed on 08/17/2012, at approximately 09:35 AM, that there are unprotected penetrations in the shaft wall assembly in the Cancer Center Elevator Shaft.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the marked access to exits in the building.

Findings include:

It was observed on 07/31/2012, at approximately 11:40 AM, that the exit and directional signs in the Emergency Room Suite, do not provide the necessary direction to the nearest exit.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the marked access to exits in the building.

Findings include:

It was observed on 08/08/2012, at approximately 11:32 AM, that the exit and directional sign is not in place at the exit discharge from Stair A, Ground Floor.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating of smoke barriers.

Findings include:

It was observed on 07/31/2012, at approximately 10:08 AM, that there is an unprotected penetration in the smoke barrier wall above the ceiling at 1C56A, near the ductwork.

It was observed on 08/02/2012, at approximately 03:00 PM, that the smoke barrier wall has a 2 by 2 foot hole in the wall above the ceiling at GA39.

It was observed on 08/03/2012, at approximately 10:05 AM, that there is an unprotected penetration in the smoke barrier and another penetration is sealed with different types of sealant above the ceiling at the pair of doors GB861.

It was observed on 08/03/2012, at approximately 10:45 AM, that there is an unprotected penetration of the smoke barrier near the wiring tray above the pair of doors GB86A.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain smoke tight and self-closing doors in the smoke barrier.

Findings include:

It was observed on 07/26/2012, at approximately 05:45 PM, that the door coordinator does not function on the Sterile corridor doors in the smoke barrier at Operating Room 8.

It was observed on 07/31/2012, at approximately 11:33 AM, that the door in the smoke barrier on the right at 1C22B, is not equipped with a means to keep it in place.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to properly protect identified hazardous areas.

Findings include:

It was observed on 07/25/2012, at approximately 12:30 PM, that the old cafeteria dish washing room 3B51 is being used as a storage room, and the door is not self closing.

It was observed on 07/26/2012, at approximately 05:58 PM, that there is an unprotected penetration in the wall above the door near the ductwork in Equipment Room D.

It was observed on 07/31/2012, at approximately 11:11 AM, that a large hole has been cut in the wall of Clean Linen Storage Room 1C30G.

It was observed on 07/31/2012, at approximately 11:14 AM, that there are multiple unprotected penetrations in the wall of the soiled linen room 1C30E.

It was observed on 08/02/2012, at approximately 11:06 AM, that there is a hole in the rated ceiling above the autoclaves in the Sterilization Room.

It was observed on 08/03/2012, at approximately 01:38 PM, that the door to storage room 3B32D will not latch in the closed position.

It was observed on 08/07/2012, at approximately 11:27 AM, that there are unprotected penetrations of the fire rated wall at the support beam of the flammable materials
storage room.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to properly protect identified hazardous areas.

Findings include:

It was observed on 08/07/2012, at approximately 03:05 PM, that there are unprotected penetrations in the wall of Supply Storage Room 225.
It was observed that on 08/07/2012, at approximately 04:00 PM, that that there are unprotected penetrations of the wall in Storage Room 1428.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain exits readily accessible.

Findings include:

It was observed on 08/02/2012, at approximately 03:20 PM, that there is not an all weather path to the public way from the ground floor exit discharge of stairway B.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain horizontal exits.

Findings include:

It was observed on 07/27/2012, at approximately 08:15 AM, that a means of egress from the Endo Procedure area exits to a area that is being used as a Horizontal Exit, and the exit is not rated.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the emergency lighting.

Findings include:

It was observed that on 07/31/2012, at approximately 02:25 PM, that that the emergency illumination task lights are not working in the CT Procedure rooms and the CT Equipment Control Area.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the written plan for protection.

Findings include:

It was observed on 07/25/2012, at approximately 02:50 PM, that staff at the 3rd floor, East Nursing Station, could not locate the Emergency Operations Plan upon request.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview the facility failed to maintain the fire alarm system in accordance with NFPA 72.

Findings include:

It was observed on 08/03/2012, at approximately 11:00 AM, that the Fire Alarm System visual notification device is obstructed by storage on shelving in the Kitchen Dry Storage Room.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to install the sprinkler system in accordance with NFPA 13.

Findings include:

It was observed on 07/25/2012, at approximately 11:08 AM, that the 4th
floor mechanical room does not have fire sprinkler protection under ductwork that is
greater than 4 feet in width.

It was observed on 07/25/2012, at approximately 11:10 AM, that storage
is located under an open stairway to the upper level of the Elevator Machine
Room that did not have fire sprinkler protection.

It was observed on 07/25/2012, at approximately 12:27 PM, that the fire
sprinkler heads in the 3rd floor cafeteria, above the salad bar are spaced less
than 6 feet on center. (NFPA 13, Section 5.6.3.4)

It was observed on 07/25/2012, at approximately 01:57 PM, that the
corridor soffit near the exterior windows across from Room 308 does not have fire
sprinkler protection.

It was observed on 07/27/2012, at approximately 11:41 AM, that the
corridor soffit near the exterior windows across from Room 208 does not have fire
sprinkler protection.

It was observed on 07/31/2012, at approximately 11:34 AM, that there is
not adequate fire sprinkler protection in the room on the far side of the smoke
detector, Room 1C26E.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to install the sprinkler system in accordance with NFPA 13.

Findings include:

It was observed that on 08/07/2012, at approximately 02:37 PM, that that the rooftop mechanical room did not have fire sprinkler protection under ductwork that is greater than 4 feet in width.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the required automatic sprinkler systems in a reliable operating condition.

Findings include:

It was observed on 07/31/2012, at approximately 11:09 AM, that there is
an unsealed space between the fire sprinkler head escutcheon and the ceiling panel in Call Room 1C31A.

It was observed on 07/31/2012, at approximately 01:05 PM, that a bundle of network cable wires are supported by the fire sprinkler piping above the corridor ceiling at 1C01A, Radiology Department. [NFPA 13, Section 6-1.1.5]

It was observed on 07/31/2012, at approximately 01:23 PM, that the fire sprinkler protection does not have a draft stop installed at the vertical opening above the MRI Control Equipment, in the Equipment Room. [NFPA 13, Section 5-13.4]

It was observed on 07/31/2012, at approximately 02:20 PM, that the escutcheons were not in place on the fire sprinkler heads Radiology Department Patient, Holding Area. [NFPA 13, Section 3-2.7.2]

It was observed on 07/31/2012, at approximately 02:55 PM, that 2 recessed fire sprinkler heads are obstructed by ceiling mounted medical equipment in the Angioplasty Procedure Room. [NFPA 25, Section 2-2.1.2]

It was observed on 07/31/2012, at approximately 03:08 PM, that the fire sprinkler heads in Ultrasound Procedure Room 3 are spaced less than 6 feet on center. [NFPA 13, Section 5.6.3.4)]

It was observed on 07/31/2012, at approximately 03:20 PM, that the fire sprinkler heads in the Radio Film File Room are spaced less than 6 feet on center. [NFPA 13, Section 5.6.3.4)]

It was observed on 07/31/2012, at approximately 03:42 PM, that the fire sprinkler heads in the Ultrasound Technician Room, West Side, are spaced less than 6 feet on center. [NFPA 13, Section 5.6.3.4)]

It was observed on 08/02/2012, at approximately 09:54 AM, that the fire sprinkler heads are loaded with lint on the lower level of elevator shaft 4/5. [NFPA 25, Section 2-2.1.1]

It was observed on 08/02/2012, at approximately 02:35 PM, that the sidewall fire sprinkler heads are not installed with the deflectors parallel to the ceiling in the Pharmacy Work Area. [NFPA 13, Section 5-7.4.2.1]

It was observed on 08/03/2012, at approximately 09:45 AM, that there is an unsealed space between the fire sprinkler head escutcheon and the ceiling panel in Room GB01A.

It was observed on 08/03/2012, at approximately 10:45 AM, that electrical cables are supported by the fire sprinkler piping above the corridor ceiling at GB86A. [NFPA 13, Section 6-1.1.5]

It was observed on 08/03/2012, at approximately 10:57 AM, that the fire sprinkler heads are loaded with lint near refrigerator 2 in the kitchen catering area. [NFPA 25, Section 2-2.1.1]

It was observed on 08/03/2012, at approximately 12:05 PM, that multiple fire sprinkler heads are loaded with lint in the Laundry. [NFPA 25, Section 2-2.1.1]

It was observed on 08/03/2012, at approximately 12:11 PM, that the fire sprinkler protection does not have a draft stop installed at the vertical opening above the Laundry Equipment, in the Laundry. [NFPA 13, Section 5-13.4]

It was observed on 08/03/2012, at approximately 12:20 PM, that access to the fire sprinkler system control valves are obstructed by storage in Room GC13, Ground Floor. [NFPA 25, Section 9-3.3.2]

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the HVAC system.

Findings include:

It was noted during record review on 08/09/2012, at approximately 11:00 AM, that some of the smoke dampers in the Hospital could not be tested due to access to the damper.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating for the walls of the linen chute.

Findings include:

It was observed on 08/02/2012, at approximately 02:25 PM, that the linen chute does not have a continuous enclosure that extends to the ceiling of the storage room to maintain the fire separation. [NFPA 82, Section 3-2.3]

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain exits readily accessible.

Findings include:

It was observed on 08/09/2012, at approximately 02:42 PM, that the ramp from the side egress door to the public way, does not have a handrail as required by Section 7.2.2.4.2.
The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to ensure that the requirements of NFPA 70 were met.

Findings include:

It was observed on 07/25/2012, at approximately 12:25 PM, that the drink refrigeration cooler power cord in the 3rd floor cafeteria is plugged into an extension cord. [NFPA 70, Section 400-8(1)]

It was observed on 07/25/2012, at approximately 01:57 PM, that an approved cover plate is not provided for an electrical junction box above the ceiling in the lobby corridor near room A 301 on the 3rd floor. [NFPA 70, Section 370-28(c)]

It was observed on 07/25/2012, at approximately 02:25 PM, that electrical panel R1N-3A2A, located on the 3rd floor is not properly marked to identify the purpose or use on the circuit directory. [NFPA 70, Section 384.13]

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to ensure that the requirements of NFPA 70 were met.

Findings include:

It was observed on 08/07/2012, at approximately 01:23 PM, that 2 power strips are being used in series in Room 3205. [NFPA 70, Section 400-7(b)].

It was observed on 08/07/2012, at approximately 01:23 PM, that an extension cord is being used as permanent wiring. [NFPA 70, Section 400-8(1)]

It was observed on 08/07/2012, at approximately 02:10 PM, that an approved cover plate is not provided for an electrical junction box above the corridor ceiling at Room 3313, 3rd floor. [NFPA 70, Section 370-28(c)]

The above were observed and confirmed by Engineering Staff and the Safety Officer.