HospitalInspections.org

Based on observation it was determined that the facility failed does not meet the construction type in accordance with the LSC, sections 18.1.6.2, 18, 18.1.6.3, 18.2.5.1. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 11:00 AM, observed unprotected structural supporting trusses throughout the 2nd, 3rd, and 4th floor of the North Tower. The building does not meet the intended and required construction requirements of a Type 1(332) structure. The trusses supporting the floor load above are bare metal with no evidence of fire proofing on or around them.

Based on observation it was determined that the facility failed to provide corridor walls that could provide a barrier to limit the transfer of smoke 18.3.6.1, 18.3.6.2. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 9:10 AM, unprotected penetrations of wire through the corridor wall of the basement paper recycle room.
2. At approximately 9:15 AM, unprotected penetrations of wire through the corridor wall of the basement MERS room.
3. At approximately 9:20 AM, unprotected penetrations of wire through the corridor wall of the basement Housekeeping room.
4. At approximately 9:25 AM, unprotected penetrations of piping through the corridor wall of the basement clean linen storage room and a piece of the corridor wall side missing.
5. At approximately 9:45 AM, unprotected penetrations of the basement laundry corridor wall by piping.
6. At approximately 10:00 AM, unprotected penetrations of the basement TV room corridor wall by piping and wires.
7. At approximately 10:20 AM, a piece of the corridor wall is missing at the UPS room.
8. At approximately 11:20 AM, the corridor wall near rooms 105 and 107 is not to the deck above.

On 5-4-10, the following observations were made:

North Tower

1. At approximately 11:10 AM, the Administrative area corridor wall penetrations of wires and conduit are not protected in an approved manner.
2. At approximately 11:20 AM, the corridor wall near rooms 204 through 210 does not extend to the deck above.

South Tower

1. At approximately 11:35 AM, the unprotected penetrations of wires and piping through the Central Storage room corridor wall, above the doors.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility.

On 5-4-10, the following observations were made:

North Tower
1. Between 9:00 and 10:00 AM, observed the doors to the following rooms would not positive
latch when closed: 238, 232, 221, 211, 301.

On 5-6-10, the following observations were made:

North Tower

1. At approximately 11:20 AM, the corridor door to locker 226 is missing all the required door hardware. The door will not positive latch and is not smoke tight.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 9:30 AM, the main corridor door of the basement linen storage room blocked in the open position with a trash can and no positive latching hardware on both corridor doors.
2. At approximately 9:40 AM, the basement Laundry room door does not close and latch due to missing hardware.
3. At approximately 11:25 AM, the positive latching is missing from the corridor to room 114.

Based on observation the facility failed to provide 2-hour fire resistive separation (connecting four stories or more) or 1-hour fire resistive separation (single story building & sprinklered buildings up to three stories in height) for the vertical openings in accordance with the LSC section 18.3.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 5-6-10 the following observations were made:

North Tower

1. At about 10:15 AM, observed the glazing in the 4 story building east stairway door is cracked.
2. At about 11:40 AM, the glazing for stairway G is not fire rated.


On 4-30-10 the following observations were made:

South Tower

1. At about 11:45 AM, observed the glazing for the east stairway door is missing.

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect all occupants of the facility.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 10:00 AM, the 4th floor exit sign for stairway B is parallel with the wall and cannot be seen from down the corridor.
2. At approximately 10:45 AM, observed no exit signage in the 2nd floor dining room.
3. At approximately 12:35 PM, observed no exit sign near the nurse station to guide occupants to the urgent care lobby.

Based on observation the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could potentially affect occupants of the facility.

Findings include:

On 4-30-10, the following observations were made:

North Tower

1. At approximately 9:55 AM, unsealed penetrations of the smoke barrier near the TV service room by wires and piping.
2. At approximately 9:55 AM, the smoke barrier door near the TV service room has a broken self closing device and is held open by a floor wedge.
3. At approximately 11:00 AM, unprotected penetrations of wires and piping through the smoke barrier between the center tower and the south wing and the doors did not fully close.
4. At approximately 11:05 AM, unprotected penetration of wires through the smoke barrier near room 110.
5. At approximately 11:35 AM, unprotected penetrations of wires through the smoke barrier near the copy room.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 1200 the unprotected penetrations on wires, conduit and piping through the smoke barrier near room 187.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 10:05 AM, the door hardware to room G-58 storage room is missing and the door is not smoke resistant.
2. At approximately 10:10 AM, the locker room corridor door self closing device is broken and the hardware is missing.
3. At approximately 10:25 AM, the men's locker room corridor door was held open.
4. At approximately 10:30 AM, the housekeeping closet near the men ' s locker room is missing the positive latching hardware.
5. At approximately 10:35 AM, the latching hardware for the storage room door near the Maintenance room is missing.
6. At approximately 10:45 AM, 5 gallons of oil based paints in the storage room near the Maintenance room are not in approved storage cabinet.
7. At approximately 11:55 AM, the patient clothing storage room is unorganized. Bulk clothing is thrown throughout the room.
8. At approximately 11:55 AM, the positive latching door hardware for the corridor door for the patient clothing storage room is missing, leaving a hole in the door.

On 5-4-10, the following observations were made:

North Tower

1. At approximately 11:50 AM, the laundry dryer exhaust vent pipe is disconnected.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 12:20 PM, the corridor door to storage room 176 was held open with a rack of empty oxygen cylinders.

Based on observation and review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility.

On 5-4-10, the following observations were made:

North Tower

1. At approximately 10:55 AM, when asked, the staff did not know the whereabouts of the emergency evacuation plans.

Based on observation and review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 12:55 PM, by review of records, the facility could not produce any smoke detector sensitivity test records.

Based on observation and review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 10:20 AM, the 3rd floor is missing many lay-in ceiling tiles. The tiles have been removed to replace damaged tiles elsewhere in the hospital. The condition has the potential to not allow the sprinklers to operate as designed in the event of a fire.

Based on observation the facility failed to provide protection of medical gases in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility.

On 5-4-10, the following observations were made:

North Tower

1. At approximately 11:30 AM, observed 16 free standing " E " sized oxygen cylinders in a storage room near the west end of the Administrator corridor. 11 cylinders were in racks.
2. At approximately 11:35 AM, the above oxygen storage room is constructed to provide the required 1 hour fire resistance rating. The door is not fire rated, missing the self closing device and holes are drilled in the door.

Based on observation and review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 9:35 AM, no battery powered emergency lighting in the basement emergency generator equipment room.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of this room.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 10:25 AM, exposed wiring in a light fixture in the men ' s locker room.

Based on observation and review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

Both Towers

1. At approximately 12:20 PM, the facility could not provide documentation of responsibilities in the event of the automatic sprinkler being out of service for 4 or more hours.

Based on observation and review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

Both Towers

1. At approximately 12:25 PM, the facility could not provide documentation of responsibilities in the event of the fire alarm being out of service for 4 or more hours.

Based on observation the facility failed to provide systems in accordance with the LSC sections 18.5.3, 9.4. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, at approximately 11:00 AM, the following observations were made: Observed an accumulation of combustible trash and debris in the elevator pit.

Based on observation it was determined that the facility failed does not meet the construction type in accordance with the LSC, sections 18.1.6.2, 18, 18.1.6.3, 18.2.5.1. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 11:00 AM, observed unprotected structural supporting trusses throughout the 2nd, 3rd, and 4th floor of the North Tower. The building does not meet the intended and required construction requirements of a Type 1(332) structure. The trusses supporting the floor load above are bare metal with no evidence of fire proofing on or around them.

Based on observation it was determined that the facility failed to provide corridor walls that could provide a barrier to limit the transfer of smoke 18.3.6.1, 18.3.6.2. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 9:10 AM, unprotected penetrations of wire through the corridor wall of the basement paper recycle room.
2. At approximately 9:15 AM, unprotected penetrations of wire through the corridor wall of the basement MERS room.
3. At approximately 9:20 AM, unprotected penetrations of wire through the corridor wall of the basement Housekeeping room.
4. At approximately 9:25 AM, unprotected penetrations of piping through the corridor wall of the basement clean linen storage room and a piece of the corridor wall side missing.
5. At approximately 9:45 AM, unprotected penetrations of the basement laundry corridor wall by piping.
6. At approximately 10:00 AM, unprotected penetrations of the basement TV room corridor wall by piping and wires.
7. At approximately 10:20 AM, a piece of the corridor wall is missing at the UPS room.
8. At approximately 11:20 AM, the corridor wall near rooms 105 and 107 is not to the deck above.

On 5-4-10, the following observations were made:

North Tower

1. At approximately 11:10 AM, the Administrative area corridor wall penetrations of wires and conduit are not protected in an approved manner.
2. At approximately 11:20 AM, the corridor wall near rooms 204 through 210 does not extend to the deck above.

South Tower

1. At approximately 11:35 AM, the unprotected penetrations of wires and piping through the Central Storage room corridor wall, above the doors.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility.

On 5-4-10, the following observations were made:

North Tower
1. Between 9:00 and 10:00 AM, observed the doors to the following rooms would not positive
latch when closed: 238, 232, 221, 211, 301.

On 5-6-10, the following observations were made:

North Tower

1. At approximately 11:20 AM, the corridor door to locker 226 is missing all the required door hardware. The door will not positive latch and is not smoke tight.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 9:30 AM, the main corridor door of the basement linen storage room blocked in the open position with a trash can and no positive latching hardware on both corridor doors.
2. At approximately 9:40 AM, the basement Laundry room door does not close and latch due to missing hardware.
3. At approximately 11:25 AM, the positive latching is missing from the corridor to room 114.

Based on observation the facility failed to provide 2-hour fire resistive separation (connecting four stories or more) or 1-hour fire resistive separation (single story building & sprinklered buildings up to three stories in height) for the vertical openings in accordance with the LSC section 18.3.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 5-6-10 the following observations were made:

North Tower

1. At about 10:15 AM, observed the glazing in the 4 story building east stairway door is cracked.
2. At about 11:40 AM, the glazing for stairway G is not fire rated.


On 4-30-10 the following observations were made:

South Tower

1. At about 11:45 AM, observed the glazing for the east stairway door is missing.

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect all occupants of the facility.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 10:00 AM, the 4th floor exit sign for stairway B is parallel with the wall and cannot be seen from down the corridor.
2. At approximately 10:45 AM, observed no exit signage in the 2nd floor dining room.
3. At approximately 12:35 PM, observed no exit sign near the nurse station to guide occupants to the urgent care lobby.

Based on observation the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could potentially affect occupants of the facility.

Findings include:

On 4-30-10, the following observations were made:

North Tower

1. At approximately 9:55 AM, unsealed penetrations of the smoke barrier near the TV service room by wires and piping.
2. At approximately 9:55 AM, the smoke barrier door near the TV service room has a broken self closing device and is held open by a floor wedge.
3. At approximately 11:00 AM, unprotected penetrations of wires and piping through the smoke barrier between the center tower and the south wing and the doors did not fully close.
4. At approximately 11:05 AM, unprotected penetration of wires through the smoke barrier near room 110.
5. At approximately 11:35 AM, unprotected penetrations of wires through the smoke barrier near the copy room.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 1200 the unprotected penetrations on wires, conduit and piping through the smoke barrier near room 187.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 10:05 AM, the door hardware to room G-58 storage room is missing and the door is not smoke resistant.
2. At approximately 10:10 AM, the locker room corridor door self closing device is broken and the hardware is missing.
3. At approximately 10:25 AM, the men's locker room corridor door was held open.
4. At approximately 10:30 AM, the housekeeping closet near the men ' s locker room is missing the positive latching hardware.
5. At approximately 10:35 AM, the latching hardware for the storage room door near the Maintenance room is missing.
6. At approximately 10:45 AM, 5 gallons of oil based paints in the storage room near the Maintenance room are not in approved storage cabinet.
7. At approximately 11:55 AM, the patient clothing storage room is unorganized. Bulk clothing is thrown throughout the room.
8. At approximately 11:55 AM, the positive latching door hardware for the corridor door for the patient clothing storage room is missing, leaving a hole in the door.

On 5-4-10, the following observations were made:

North Tower

1. At approximately 11:50 AM, the laundry dryer exhaust vent pipe is disconnected.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 12:20 PM, the corridor door to storage room 176 was held open with a rack of empty oxygen cylinders.

Based on observation and review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility.

On 5-4-10, the following observations were made:

North Tower

1. At approximately 10:55 AM, when asked, the staff did not know the whereabouts of the emergency evacuation plans.

Based on observation and review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 12:55 PM, by review of records, the facility could not produce any smoke detector sensitivity test records.

Based on observation and review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility.

On 5-6-10, the following observations were made:

South Tower

1. At approximately 10:20 AM, the 3rd floor is missing many lay-in ceiling tiles. The tiles have been removed to replace damaged tiles elsewhere in the hospital. The condition has the potential to not allow the sprinklers to operate as designed in the event of a fire.

Based on observation the facility failed to provide protection of medical gases in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility.

On 5-4-10, the following observations were made:

North Tower

1. At approximately 11:30 AM, observed 16 free standing " E " sized oxygen cylinders in a storage room near the west end of the Administrator corridor. 11 cylinders were in racks.
2. At approximately 11:35 AM, the above oxygen storage room is constructed to provide the required 1 hour fire resistance rating. The door is not fire rated, missing the self closing device and holes are drilled in the door.

Based on observation and review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 9:35 AM, no battery powered emergency lighting in the basement emergency generator equipment room.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of this room.

On 4-30-10, the following observations were made:

North Tower

1. At approximately 10:25 AM, exposed wiring in a light fixture in the men ' s locker room.

Based on observation and review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

Both Towers

1. At approximately 12:20 PM, the facility could not provide documentation of responsibilities in the event of the automatic sprinkler being out of service for 4 or more hours.

Based on observation and review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility.

On 4-30-10, the following observations were made:

Both Towers

1. At approximately 12:25 PM, the facility could not provide documentation of responsibilities in the event of the fire alarm being out of service for 4 or more hours.