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Based on observation and interview, the facility failed to maintain communicating door openings and the proper fire resistance rating of two hour fire-resistant common walls on three of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:05 PM revealed penetrations in the common wall above the doors at the 4 South elevators.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:05 PM, confirmed the penetrations in the common wall.

2. Observation on March 29, 2010, at 3:00 PM revealed the fire doors in the 3rd
Floor separation wall at the Medical Office Building (MOB) Bridge did not close/latch into the frame.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 3:00 PM, confirmed the doors did not close/latch.

3. Observation on March 30, 2010, at 9:30 AM revealed three (3) conduit penetrations in the separation wall above the fire doors outside the 2nd Floor elevators.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:30 AM, confirmed the conduit penetrations.

4. Observation on March 30, 2010, at 9:55 AM revealed an unsealed penetration, at the 4th Floor double corridor doors, outside the IT Room, around red wires on left wall.

Interview with the Director of Plant Operations on March 30, 2010, at 9:55 AM confirmed that the above condition exists.

Based on observation and interview, the facility failed to maintain communicating door openings and the proper fire resistance rating of two hour fire-resistant common walls in numerous locations, on three (3) of six (6) floors.

Findings include:

1. Observation on March 29, 2010, at 1:40 PM revealed the Ground Floor cross-corridor doors between the Main Building (01 Component) and the New Addition (03 Component), by the Mail Room, lacked 1 ½ hour fire-rated doors. In addition, the doors would not properly close and latch in the frame.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 1:40 PM, confirmed the above deficiency.

2. Observation on March 29, 2010, between 1:45 PM and 2:21 PM revealed the following unsealed penetrations of the Ground Floor common wall between the 01 and 03 Components:

a) 1:45 PM, numerous penetrations inside and around conduits and inside an approximate ½ inch hole, located above the cross-corridor doors, by the Mail Room, in the Main Building;
b) 2:10 PM, inside two, approximate 1" cored holes and between the top flange and duct work, located in the corridor, across from the New Addition elevators 11 and 12, above smoke damper control M1-28;
c) 2:21 PM, around three silver MC cables and inside and around a conduit with red and white wire, above the cross-corridor doors, by elevators 9 and 10, in the New Addition main corridor.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:21 PM, confirmed the unsealed penetrations.

3. Observation on March 30, 2010, between 8:55 AM and 10:33 AM revealed the following unsealed penetrations of the Ground Floor 2-hour fire wall:

a) 8:55 AM, inside two (2) pipes above the heater control box on the 1st floor Loading Dock.
b) 9:03 AM, various locations inside the 1st Floor kitchen on opposite side of corridor.
c) 10:15 AM, inside and around a conduit above double firewall doors next to the 1st Floor elevator.
d) 10:19 AM, inside and around MC cable above a strobe light in the 1st Floor corridor outside of the Laboratory.
e) 10:33 AM, numerous areas around conduit, wires, & MC cables of the 1st Floor firewall, at the bulkhead between the two security offices.

Interview with the Plant Operations Manager on March 30, 2010, at 10:33 AM confirmed the unsealed penetrations.

4. Observation on March 30, 2010, at 9:09 AM revealed that the Ground Floor Decontamination Room corridor door would not properly close and latch in the frame.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 9:09 AM, confirmed the door would not properly close and latch.

5. Observation on March 30, 2010, at 9:45 AM revealed an unsealed penetration, over the 4th Floor double corridor doors outside the IT Room, inside two 4" conduits and outside one of the two.

Interview with the Director of Plant Operations on March 30, 2010, at 9:45 AM confirmed that the above condition exists.

6. Observation on March 30, 2010, at 10:41 AM revealed that the 1st Floor corridor double doors near the elevator and security office required a coordinator.

Interview with the Plant Operations Manager on March 30, 2010, at 10:41 AM confirmed the doors required a coordinator.

7. Observation on March 30, 2010, at 1:27 PM revealed that the 1st Floor door next to the Kitchen Dry Storage and exit stairs would not close and latch into the frame.

Interview with the Plant Operations Manager on March 30, 2010, at 1:27 PM confirmed the door would not close and latch.

8. Observation on March 30, 2010, at 1:55 PM revealed two (2) penetrations in the 2-hour wall, to the right immediately inside the door, in the 2nd Floor Mechanical Room.

Interview with the Chief Safety Officer and Mechanical Technician on March 30, 2010, at 1:55 PM confirmed the penetrations.

9. Observation on March 30, 2010, at 2:15 PM revealed an unsealed penetration, in the back corner of the 2nd Floor Physical and Occupational Therapy Office where the drywall, from above the corridor doorway, was not sealed to the back wall.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 2:15 PM, confirmed the unsealed penetration.

10. Observation on March 30, 2010, at 2:20 PM revealed the block of the 2-hour wall was broken in the corner inside the Director Manager's Office.

Interview with the Chief Safety Officer and Mechanical Technician on March 30, 2010, at 2:20 PM confirmed the broken block wall.

11. Observation on March 31, 2010, between 8:59 AM and 9:33 AM revealed the following unsealed penetrations of the Ground Floor 2-hour fire wall:

a) 8:59 AM, inside a small pipe between the Laboratory and double firewall doors and to the right of a mirror.
b) 9:21 AM, around and inside pipes in the 1st floor Laboratory Hood Room.
c) 9:33 AM, inside a cement block penetration in the 1st Floor Pharmacy above the computer terminals.

Interview with the Plant Operations Manager on March 31, 2010, at the above times confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain proper building construction type in numerous areas in two (2) of six (6) floors.

Findings include:

1. Observation on March 29, 2010, between 1:51 PM and 2:13 PM revealed missing fire spray on structural beams during the following times and at the following locations:

a) 1:51 PM, missing fire spray on a structural beam in two locations at the Ground/1st Floor firewall next to the Sprinkler Room and above a wall mural.
b) 2:53 PM, missing fire spray on a structural beam in the Ground/1st Floor Morgue restroom.
c) 2:13 PM, missing fire spray on a structural beam above door to copier room in Ground/1st Floor Central Storage Room.

Interview with the Plant Operations Manager on March 29, 2010, at the above times confirmed the missing fire spray on structural beams.

2. Observation on March 30, 2010, at 9:50 AM revealed that there was an unprotected structural steel beam, above the New Addition Ground Floor cross-corridor doors, by the Mail Room.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 9:50 AM, confirmed the unprotected steel beam.

3. Observation on March 30, 2010, at 11:00 AM in the 2nd Floor Medical Records Room revealed missing fire spray on a structural beam, above the "charts to be filed" section of shelving.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:00 AM confirmed the missing fire spray.

4. Observation on March 30, 2010, at 11:06 AM in the 2nd Floor new Medical Records Room revealed missing fire spray on a structural beam, above the clock.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:06 AM confirmed the missing fire spray.

Based on observation and interview, the facility failed to provide the proper fire resistance rating for structural steel on two of four floors.

Findings include:

1. Observation on March 29, 2010, at 1:40 PM revealed that there was an unprotected structural steel beam, above the New Addition Ground Floor cross-corridor doors, by the Mail Room.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 1:40 PM, confirmed the unprotected steel beam.

2. Observation on March 29, 2010, at 1:55 PM revealed that there were two (2) unprotected structural steel beams, above the 5th Floor elevator rooms, across the threshold of the exit door, and the cross beam next to the door.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 1:55 PM, confirmed the unprotected steel beams.

3. Observation on March 30, 2010, at 9:50 AM revealed that there was an unprotected structural steel beam, on the 4th Floor corridor, outside IT Room as seen through the inspection door.

Interview with the Director of Plant Operations on March 30, 2010, at 9:50 AM confirmed the missing fire proofing.

Based on observation and interview, the facility failed to maintain the required construction of corridor walls on two floors.

Findings include:

1. Observation on March 30, 2010, at 9:22 AM revealed there was an unsealed corridor wall penetration above the suspended ceiling on the 4th Floor, at Patient Room 414.

Interview with the Director of Plant Operations on March 30, 2010, at 9:22 AM confirmed the corridor wall penetrations.

2. Observation on March 30, 2010, at 10:20 AM revealed there was an unsealed corridor wall penetration above the suspended ceiling, inside a 2" conduit on the 3rd Floor, in the Elevator Lobby, over the Exit Stairs Door.

Interview with the Director of Plant Operations on March 30, 2010, at 10:20 AM confirmed the corridor wall penetrations.

3. Observation on March 30, 2010, at 11:20 AM revealed there was an unsealed corridor wall penetration above the suspended ceiling, inside a conduit on the 3rd Floor, in the corridor at the Linen Chute Room and Surgical Waiting Area.

Interview with the Director of Plant Operations on March 30, 2010, at 11:20 AM confirmed the corridor wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings to be smoke resistant.

Findings include:

1. Observation on March 30, 2010, at 8:55 AM revealed a gap greater than 1/8 inch between the meeting edges of the double doors entering the 3rd Floor Endoscopy suite.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 8:55 AM confirmed the gap between the doors.

2. Observation on March 30, 2010, at 9:00 AM revealed gap greater than 1/8 inch between the meeting edges of the double doors entering the 3rd Floor Intensive Care Unit.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:00 AM confirmed the gap between the doors.

Based on observation and interview, the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in two locations, on one of six floors.

Findings include:

1. Observation on March 29, 2010, between 1:30 PM and 3:00 PM revealed that the following doors on the 5th Floor had the following deficiencies:

a) 2:15 PM, Patient Room 517, had a gap greater than 1/4 inch between the door face and the door stop:
b) 2:18 PM, Patient Room 515, had a gap greater than 1/4 inch between the door face and the door stop:
c) 2:20 PM, Patient Room 507, had a gap greater than 1/4 inch between the door face and the door stop:
d) 2:25 PM, Patient Room 501, was hitting the frame and not closing and latching properly.
e) 2:30 PM, Patient Room 520, had a gap greater than 1/4 inch between the door face and the door stop:
f) 2:35 PM, Patient Room 522, had a gap greater than 1/4 inch between the door face and the door stop:

Interview with the Director of Plant Operations on March 29, 2010, at the times and locations stated above confirmed that the above conditions exist.

2. Observation on March 30, 2010, between 9:00 AM and 9:30 AM revealed that the following doors, on the 4th Floor, had the following deficiencies:

a) 9:04 AM, Patient Room 411, had a gap greater than 1/4 inch between the door face and the door stop:
b) 9:04 AM, Patient Room 411, required a positive latching adjustment to properly close and latch in its frame.
c) 9:04 AM, Patient Room 407, had a gap greater than 1/4 inch between the door face and the door stop:
d) 9:15 AM, Patient Room 406, had a gap greater than 1/4 inch between the door face and the door stop:
e) 9:27 AM, Data Closet across from Patient Room 422, revealed that the corridor double doors were not equipped with positive latching hardware on both doors. One door was equipped with a manual flush bolt only, and that door had to be closed with the manual flush bolt activated before the other door would close and latch. At the time of the survey, both doors were open.

Interview with the Director of Plant Operations on March 30, 2010, at the times and locations stated above confirmed that the above conditions exist.

4. Observation on March 30, 2010, at 11:45 AM revealed the 2nd Floor staff lounge at the Nurses' Station did not close/latch.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:45 AM confirmed that the door did not latch.

5. Observation on March 30, 2010, at 4:05 PM revealed that the double corridor doors, to the 4th Floor Behavioral Health Dining Room, were not smoke tight at the meeting edge when in the closed position.

Interview with the Director of Maintenance on March 30, 2010, at 4:05 PM revealed that the above condition exists.

6. Observation on March 30, 2010, at 1:45 PM revealed that the Ground Floor Electrical Closet double corridor doors, by Diagnostic Imaging Front Desk, had a gap greater than 1/8 inch at the meeting edge when in the closed position.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 1:45 PM confirmed that the doors would not resist the passage of smoke.

7. Observation on March 30, 2010, at 1:45 PM the door to Medical/Surgical Room #216 on the 2nd Floor revealed a gap greater than 1/4 inch between the door and the door stop when in the closed position.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 1:45 PM confirmed the door gap.

8. Observation on March 30, 2010, between 1:45 PM and 1:55 PM revealed the following doors to to have gaps greater than 1/4 inch between the door and the door stop when in the closed position: (Note: This area is closed.)

a) 214, 212, 208, 204, 201.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 1:55 PM confirmed the door gaps.

9. Observation on March 31, 2010, at 9:05 AM revealed that the Ground Floor Main Cafeteria double corridor doors lacked positive latching hardware on both doors. One door was equipped with a dead-bolt. In addition, the doors had a gap greater than 1/8 inch at the meeting edge when in the closed position.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 9:05 AM confirmed the door hardware and that the doors would not resist the passage of smoke.

10. Observation on March 30, 2010, at 10:40 AM revealed two (2) penetrations from hardware removal in the 2nd Floor door of the office of the Chief Medical Officer.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 10:40 AM confirmed the door penetrations.

Based on observation and interview, the facility failed to protect openings through the floor assembly in one location, on one of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:55 PM revealed that there was an unsealed penetration of both the floor slab and ceiling slab behind Chiller #2 in the 5th Floor Mechanical Room.

Interview with the Director of Plant Operations on March 29, 2010, at 2:55 PM confirmed the unsealed floor/ceiling penetration.

Based on observation and interview, the facility failed to protect openings through the ceiling/floor assembly in four locations, on two of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:45 PM revealed that there was an unsealed penetration of the floor slab above the Ground Floor Fire/Security Communication Room, inside a 4" sleeve.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:45 PM confirmed the unsealed floor/ceiling penetration.

2. Observation on March 29, 2010, at 3:10 PM revealed ceiling penetrations in the 3rd Floor electrical closet across from Procedure Room A.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 3:10 PM, confirmed the ceiling penetrations.

3. Observation on March 30, 2010, at 9:20 AM revealed one (1) conduit penetration in the 3rd Floor electrical closet floor at the Nurses' Station on the ICU/MICU side.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:20 AM, confirmed the floor penetration.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls in one location, on one of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:17 PM revealed the unsealed smoke barrier penetrations around the topside of a conduit and around the left side of duct work, between the flange and drywall, located above the cross-corridor doors by elevators 11 and 12.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:17 PM confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls, on two of five floors.

Findings include:

1. Observation on March 29, 2010, at 2:20 PM revealed penetrations around M/C cable, conduit, and cable, over the double corridor doors on the 5th Floor, outside Patient Room 515.

Interview with the Director of Plant Operations on March 29, 2010, at 2:20 PM confirmed that the above condition exists.

2. Observation on March 30, 2010, between 10:47 AM and 1:30 PM revealed the following Ground Floor unsealed smoke barrier penetrations:

a) 10:47 AM, above duct work in North Tower Registration;
b) 11:46 AM, inside an approximate three inch metal sleeve with yellow wires and around the top side of a white insulated pipe, located above the cross-corridor doors, by X-Ray Room 11;
c) 1:30 PM, around a green MC cable and inside two conduits with gray and red wires, located in the corridor above the door to the Radiology File Room.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 1:30 PM confirmed the unsealed penetrations.

3. Observation on March 30, 2010, at 10:30 AM revealed a sprinkler pipe and open conduit penetrations in the 2nd Floor smoke barrier at the elevators.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 10:30 AM confirmed the smoke barrier penetrations.

4. Observation on March 30, 2010, at 11:26 AM revealed an abandoned pneumatic tube and an open six inch (6) conduit penetration in the 2nd Floor smoke barrier at the Medical Records Room.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:26 AM confirmed the smoke barrier penetrations.

5. Observation on March 30, 2010, at 1:40 PM revealed wire penetrations in the 2nd Floor smoke barrier at Room #216.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 1:40 PM confirmed the smoke barrier penetrations.

6. Observation on March 30, 2010, at 2:05 PM revealed a six (6) inch pipe penetration in the 2nd Floor smoke barrier in Room #215.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 2:05 PM confirmed the smoke barrier penetration.

Based on observation and interview, the facility failed to maintain door openings in smoke barriers on one floor.

Findings include:

1. Observation on March 29, 2010, at 2:20 PM revealed the double corridor smoke barrier doors, on the 5th Floor outside Patient Room 515, needed a coordinator adjustment to close properly.

Interview with the Director of Plant Operations on March 29, 2010, at 2:20 PM confirmed the above condition exists.

2. Observation on March 30, 2010, at 10:17 AM revealed the corridor smoke barrier door, on the 3rd Floor to the Surgical Waiting Area, was being held open by an unauthorized door hold-open device (wooden chock).

Interview with the Director of Plant Operations on March 30, 2010, at 10:17 AM confirmed the above condition exists.

3. Observation on March 30, 2010, at 10:20 AM revealed the corridor smoke barrier door, on the 3rd Floor, from the Surgical Waiting Area to behind the Information Desk, was being held open by an unauthorized door hold-open device (wooden chock).

Interview with the Director of Plant Operations on March 30, 2010, at 10:20 AM confirmed the above condition exists.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of hazardous areas on three of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:35 PM revealed an unsealed penetration of the one hour fire-rated 4th Floor Soiled Utility room in the wall above the sink, across from Room #465.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:35 PM confirmed the unsealed penetration.

2. Observation on March 29, 2010, at 2:40 PM revealed the 4th Floor Equipment Storage room door did not close/latch, across from Room #464.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:40 PM confirmed the door did not latch.

3. Observation on March 29, 2010, at 2:50 PM revealed an unsealed penetration of the one hour fire-rated Ground Floor Soiled Workroom, inside and around a metal sleeve containing a green MC cable, located in the shared Environmental Services Closet wall.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:50 PM confirmed the unsealed penetration.

4. Observation on March 30, 2010, at 9:45 AM revealed an unsealed penetration of the one hour fire-rated shared wall, with shell space, across from the 2nd Floor Ladies Room.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:45 AM confirmed the unsealed penetration.

5. Observation on March 30, 2010, at 9:50 AM revealed an open conduit in the 2nd Floor one hour fire-rated shared wall, with shell space, near the strobe light.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:50 AM confirmed the unsealed penetration.

6. Observation on March 30, 2010, at 10:15 AM revealed two (2) penetrations and one (1) wire penetration of the side walls of the 2nd Floor Soiled Utility Room across from Room #253.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 10:15 AM confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of hazardous areas, on four (4) of six (6) floors.

Findings include:

1. Observation on March 29, 2010, at 2:09 PM revealed the door to the 1st Floor Boiler Room, next to the Non-Flammable Paint Storage Room, did not have a closure and did not close and latch into its frame.

Interview with the Plant Operations Manager on March 29, 2010, at 2:09 PM PM confirmed there was no closure and the door would not close and latch.

2. Observation on March 30, 2010, at 9:15 AM revealed the Storage Room double doors, across from Patient Room 404 on the 4th Floor, revealed that the doors were not equipped with positive latching hardware on both doors. One door was equipped with a manual flush bolt only, and that door had to be closed with the manual flush bolt activated before the other door could close and latch. At the time of the survey, both doors were open.

Interview with the Director of Plant Operations on March 30, 2010, at 9:15 AM confirmed that the above condition exists.

3. Observation on March 30, 2010, at 11:20 AM revealed a penetration in the corridor wall to the 2nd Floor Medical Records Room, across from the fire hose cabinet.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:20 AM confirmed the penetration in the wall.

4. Observation on March 30, 2010, at 11:25 AM revealed an orange flex conduit and wire penetrations into the wall to the 2nd Floor Medical Records Room, at the smoke barrier.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:25 AM confirmed the penetration in the wall.

5. Observation on March 30, 2010, at 11:40 AM revealed a large area of two (2) walls, (the back and side walls) missing block in the 2nd Floor Obstetrical/Gynecological storage Room.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:40 AM confirmed the missing block.

6. Observation on March 30, 2010, at 11:48 AM revealed penetrations in two (2) walls, (the front and side walls) across from Room #236 in the 2nd Floor Maternity.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:48 AM confirmed the penetrations.

7. Observation on March 30, 2010, at 11:50 AM revealed the storage double doors, across from Room #242 in 2nd Floor Maternity, had a gap greater than 1/8 inch at the meeting edges of the doors, and the doors did not close/latch.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:50 AM confirmed the gap and non-latching of the doors.

8. Observation on March 30, 2010, between 1:47 PM and 2:07 PM, revealed the following 3rd Floor Operating Room (OR) unsealed penetrations:

a) 1:47 PM, various locations on all four walls in OR Soiled Utility Room.
b) 2:07 PM, area where all four walls meet ceiling in OR Laundry Chute Room.

Interview with the Plant Operations Manager on March 30, 2010, at the above times, confirmed the unsealed penetrations.

9. Observation on March 30, 2010, at 1:50 PM revealed missing block and open conduits in the storage room across from Room #204 on the 2nd Floor.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 1:50 PM confirmed the penetrations of block and conduits.

10. Observation on March 31, 2010, between 8:50 AM and 9:27 AM, revealed the following Ground Floor unsealed penetrations:

a) 8:50 AM, above the Phoenix Cafe sign, block was broken away from around the duct going through the wall.
b) 9:00 AM, in the room where the duct for the air conditioning unit is located, the wall was broken away from around the entire duct.
c) 9:22 AM, penetration around the duct entering the flammable storage room from the Main Pharmacy, in the Lab.
d) 9:25 AM, duct tape was covering the end of an abandoned pipe between the Main Pharmacy and the Flammables Storage Room, viewed from the Main Pharmacy side;
e) 9:27 AM, inside a conduit with black insulated copper lines, through the shared Laboratory/Pharmacy wall, located in the Main Pharmacy.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 9:27 AM confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of hazardous areas and failed to ensure that doors to hazardous areas were self-closing in one location, on one of four floors.

Findings include:

1. Observation on March 31, 2010, at 8:45 AM revealed that the door closure was removed to the Ground Floor Snack Bar corridor door, which is part of the Gift Shop hazardous area enclosure.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 8:45 AM confirmed that the closure was removed.

2. Observation on March 31, 2010, at 8:45 AM revealed a large unsealed penetration over the Ground Floor Snack Bar kitchen hood, below and above the ceiling tile, which is part of the Gift Shop hazardous area enclosure.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 8:45 AM confirmed the unsealed penetration.

Based on observation and interview, the facility failed to maintain the fire resistance rating of exit components to provide a continuous path of escape.

Findings include:

1. Observation on March 29, 2010, at 2:40 PM revealed the Ground Floor Main Building Security Office, by the New Addition, lacked a 1 ½ hour fire-rated door and door frame.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:40 PM, confirmed the above deficiency.

2. Observation on March 30, 2010, at 9:21 AM revealed an approximate one inch by twelve inch (1" x 12") opening, at the top of the shared stair tower wall, in the 3rd Floor Electrical Closet at the Nurses' Station on the ICU/MICU side.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:21 AM, confirmed the stair wall penetration.

3. Observation on March 30, 2010, at 11:30 AM revealed two (2) penetrations, and three (3) wire penetrations into the stair tower foyer, next to the 2nd Floor service elevator #2.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:30 AM confirmed the penetrations in the wall.

4. Observation on March 31, 2010, between 9:00 AM and 10:00 AM, revealed the following deficiencies for the North Stair Tower #1, next to Radiology, on the Ground Floor.

a) 9:00 AM, on the Mechanical Room side, a speaker was recessed into the concrete block wall degrading the 2-hour status.
b) 9:05 AM, on the Mechanical Room side, an unsealed penetration around a conduit.
c) 9:30 AM, between the Stair Tower and the Mechanical Room, a 1 1/2 -hour rated door had been removed, the opening was then in-filled with metal studs and a single layer of 5/8 " wallboard on each side, degrading the 2-hour status.

Interview with the Director of Plant Operations on March 30, 2010, at 10:00 AM confirmed the above deficiencies.

Based on observation and interview, the facility failed to ensure that stairways used as exits were not used for any purpose which has the potential to interfere with egress for one instance on the Ground Floor.

Findings include:

1. Observation on March 31, 2010, at 9:15 AM revealed that there was storage of a five foot long, four-inch diameter piece of conduit (Approx. size), in the North Stair Tower #1

Interview with the Director of Plant Operations on March 31, 2010, at 9:15 AM confirmed the above storage.

2. Observation on March 31, 2010, at 9:15 AM revealed that there was data wiring running through North Stair Tower #1

Interview with the Director of Plant Operations on March 31, 2010, at 9:15 AM confirmed the above condition.

Based on observation and interview, the facility failed to ensure that exit access was maintained readily accessible to a public way at one exit discharge within the entire facility.

Findings include:

Observation on March 30, 2010, at 2:45 PM, revealed that the 1st Floor exit egress outside of the Plant Operations Office was blocked by six (6) large laundry storage bins.

Interview with the Director of Plant Operations on March 30, 2010, at 2:45 PM confirmed the bins were blocking the exit egress.

Based on observation and interview, the facility failed to ensure that exit access corridors were maintained clear and unobstructed in two (2) locations on two (2) of six (6) floors.

Findings include:

1. Observation on March 30, 2010, between 9:00 AM and 10:00 AM, revealed the following obstruction on the 4th Floor, on both East to West corridors: in the North, two blood pressure machines, and in the South, two blood pressure machines and a wheel chair.

Interview with the Director of Plant Operations on March 30, 2010, at 10:00 AM confirmed the above storage in the corridor.

2. Observation on March 30, 2010, at 11:53 AM revealed six (6) large laundry storage bins in the 1st Floor corridor near the Plant Operations Office.

Interview with the Director of Plant Operations on March 30, 2010, at 11:53 AM confirmed the bins obstructed the corridor.

Based on observation and interview, the facility failed to ensure that emergency lighting was properly tested and maintained in one (1) location on one (1) of six (6) floors.

Findings include:

Observation on March 30, 2010, at 10:49 AM revealed an emergency back-up light in the 1st Floor shell space had an inoperative battery.

Interview with the Plant Operations Manager on March 30, 2010, at 10:49 AM confirmed the inoperative battery back-up light.

Based on observation and interview, the facility failed to ensure fire alarm components were installed or maintained properly in one (1) room on one (1) of six (6) floors.

Findings include:

Observation on March 30, 2010, at 3:33 PM revealed that there was one (1) smoke detector placed in a plastic bag in the 1st Floor Maintenance Room, near the door and next to the Plant Operations Office.

Interview with the Plant Operations Manager on March 30, 2010, at 3:33 PM confirmed the smoke detector was placed in a plastic bag.

Based on documentation review, observation and/or interview, the facility failed to maintain required fire alarm system or smoke detectors throughout the entire facility.

Findings include:

1. Documentation review on March 29, 2010, between 10:00 AM and 12:30 PM revealed 13 smoke detectors failed during the facility's last sensitivity inspection by Simplex on 3/8/10 and were not repaired/replaced.

Interview with the Plant Operations Manager on March 29, 2010, at 12:30 PM confirmed that the facility had no documentation reflecting that the smoke detectors had been repaired or replaced.

2. Observation on March 30, 2010, at 9:30 AM revealed that a new smoke detector had been installed within the airflow of a ceiling diffuser, on the 4th Floor in the East End Connector corridor.

Interview with the Director of Plant Operations on March 30, 2010, at 9:30 AM confirmed the above condition exists.

3. Observation on March 30, 2010, at 10:15 AM revealed the ceiling-mounted smoke detector was not properly mounted to its box on the 3rd Floor, at the Information Desk.

Interview with the Director of Plant Operations on March 30, 2010, at 10:15 AM confirmed the above condition exists.

Based on observation and interview, it was determined the facility failed to maintain the required automatic sprinkler system on one of four floors.

Findings include:

1. Observation on March 30, 2010, at 9:05 AM in the 3rd Floor Intensive Care Unit Equipment Storage Room, revealed speaker wire being supported by a sprinkler pipe.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:05 AM confirmed the speaker wire on sprinkler pipe.

2. Observation on March 30, 2010, at 9:15 AM in the 3rd Floor Soiled Utility Room, across from Room #354, revealed communication wire attached to a sprinkler pipe hanger.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:15 AM confirmed the wire attached to the sprinkler pipe hanger.

Based on observation, documentation review and interview it was determined the facility failed to provide an automatic sprinkler system which is continuously maintained in reliable operating condition and inspected and tested in accordance with NFPA 101, 19.7.6, NFPA 13, and NFPA 25, 1999 editions throughout the entire facility.

Findings include:

1. Document review on March 29, 2010, between 10:00 AM and 12:30 PM, revealed the Simplex 3/8/10 report identified numerous deficiencies, such as: check valves and alarm valves were due for inspection, kitchen cleaning supply room and elevator #2 tamper switches failed, 1st and 2nd floor tamper switches could not be located, etc. No corrective action was taken by the facility.

Interview with the Plant Operations Manager on March 29, 2010, at 12:30 PM confirmed that the facility had no documentation reflecting the sprinkler system deficiencies were corrected.

2. Observation on March 30, 2010, at 11:05 AM in the new Medical Records Room, revealed wires and flex conduit being supported by sprinkler pipe.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:05 AM confirmed the wire and conduit on sprinkler pipe.

3. Observation on March 30, 2010, at 11:15 AM in Respiratory Therapy, revealed an accumulation of lint/dust on one sprinkler head in the room.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:15 AM confirmed the lint/dust on a sprinkler head.

Based on observation and interview,the facility failed to maintain portable fire extinguishers in accordance with the regulations for two extinguishers, on one of six floors.

Findings include:

1. Observation on March 31, 2010, at 8:45 AM revealed that a trash can was blocking access to the fire extinguisher in the Ground Floor Snack Bar.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 8:45 AM confirmed the blocked extinguisher.

2. Observation on March 31, 2010, at 9:00 AM revealed that the "K" type fire extinguisher, located in the Ground Floor Snack Bar Kitchen, was missing an inspection for February 2010. In addition, the extinguisher lacked signage identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 9:00 AM confirmed the missed inspection and lack of signage.

3. Observation on March 31, 2010, at 9:00 AM revealed that the fire extinguisher in the 1st Floor Mechanical Room, by the North Stair Tower, had not been inspected during February or March 2010.

Interview with the Director of Plant Operations on March 30, 2010, at 9:00 AM confirmed the fire extinguisher was not inspected during the last two (2) months.

4. Observation on March 31, 2010, at 9:47 AM revealed that the fire extinguisher in the Security Room had not been inspected during February or March 2010.

Interview with the Plant Operations Manager on March 31, 2010, at 9:47 AM confirmed the fire extinguisher was not inspected during the last two (2) months.

Based on observation and interview, the facility failed to maintain Heating, Ventilating, and Air Conditioning (HVAC) system ductwork through fire-rated walls in accordance with regulations, in two locations, on one of six floors.

Findings include:

1. Observation on March 29, 2010, at 2:40 PM revealed the facility could not verify that combination fire/smoke dampers exist in two HVAC ducts, which penetrated the 2-hour fire resistant common wall and smoke barrier wall, between the 01 and 03 Components, as viewed from the Main Building Security Office. The ducts appeared to have smoke dampers which were disconnected.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:40 PM confirmed the above deficiency.

Based on documentation review and interview, the facility failed to provide documentation reflecting that cooking facilities for the entire facility were protected in accordance with 9.2.3., 19.3.2.6, NFPA 96.

Findings include:

1. Document review on March 29, 2010, between 10:00 AM and 12:30 PM, revealed that the facility lacked documentation that monthly "quick checks" were being performed on the kitchen suppression system.

Interview with the Plant Operations Manager on March 29, 2010, at 12:30 PM confirmed monthly "quick checks" were not performed on the kitchen suppression system.

Based on observation and interview, it was determined that the facility failed to properly maintain the fire protection for trash chutes, incinerators and laundry chutes in one room.

Findings include:

Observation on March 30, 2010, at 2:15 PM revealed a six (6) inch pipe penetration of the ceiling assembly of the Laundry Chute Terminal Room.

Interview with the Chief Safety Officer and Electrician on March 30, 2010, at 2:15 PM confirmed the penetration.

Based on observation and interview, it was determined the facility failed to provide medical gas storage and administration areas in accordance with NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition, in three (3) rooms on two (2) of six (6) floors.

Findings include:

1. Observation on March 30, 2010, at 8:43 AM revealed oxygen "E" cylinders were not segregated empty and full, two oxygen "E" cylinders were not secured, a light switch was less than 60 inches from the floor, the door did not close and latch into the frame and there were two large penetrations above the door, around pipes as viewed from the corridor.

Interview with the Plant Operations Manager on March 30, 2010, at 8:43 AM confirmed the Oxygen Storage Room deficiencies.

2. Observation on March 30, 2010, at 11:10 AM in the Respiratory Therapy Room revealed numerous Oxygen "H" cylinders being stored in the room. The room was being used as therapy/office space and was not rated for the storage of oxygen. The door was rated for 20 minutes, electrical outlets and switches were within five (5) feet of the floor surface. The room lacked required signage providing the minimum wording: CAUTION OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING. The sign must be conspicuously displayed and readable from a distance of 5 feet.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:10 AM confirmed oxygen was stored in the room.

3. Observation on March 30, 2010, at 1:37 PM revealed an unsecured oxygen "E" cylinder in the 3rd Floor OR #7.

Interview with the Plant Operations Manager on March 30, 2010, at 1:37 PM confirmed the unsecured oxygen "E" cylinder.

Based on observation and interview, the facility failed to maintain oxygen storage locations in one room, on one of four floors.

Findings include:

1. Observation on March 30, 2010, at 9:15 AM revealed the following Ground Floor ER Equipment Storage/Oxygen Storage deficiencies:

a) the room lacked required precautionary signage providing the minimum wording: CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. The sign must be conspicuously displayed and readable from a distance of 5 feet.
b) the oxygen cylinders were not separated or labeled full and empty.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 9:15 AM confirmed the lack of signage and unseparated cylinders.

Based on observation and interview, the facility failed to maintain the piped-in medical gas system in one room of one floor.

Findings include:

Observation on March 29, 2010, at 2:15 PM, revealed the medical gas and vacuum lines in the ceiling in the 4th Floor Inpatient Dialysis required visible labels.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:15 PM confirmed the absence of visible labels.

Based on observation and interview, the facility failed to maintain the piped-in medical gas systems in accordance with the regulations in three (3) locations, on one (1) of six (6) floors.

Findings include:

1. Observation on March 30, 2010, at 9:05 AM revealed dissimilar metal (steel wire) was in direct contact with copper medical gas piping in the 1st Floor Kitchen, above the refrigerator.

Interview with the Plant Operations Manager on March 30, 2010, at 9:05 AM confirmed the steel wire on the medical gas piping.

2. Observation on March 30, 2010, between 10:45 AM and 11:46 AM, revealed that in the following locations, dissimilar metals were in direct contact with copper medical gas piping:

a) 10:45 AM, medical gas piping was resting on a steel strut in the Ground Floor Gift Shop;
b) 11:46 AM, MC cables were resting on medical gas piping above the Ground Floor cross-corridor doors, outside of X-Ray Room 11.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 11:46 AM confirmed that the metal strut and cables were in direct contact with medical gas lines.

3. Observation on March 30, 2010, at 11:05 AM in the new Medical Records Room revealed wires and flex conduit being supported by medical gas lines.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:05 AM confirmed the wire and conduit on medical gas lines.

Based on documentation review and interview, the facility failed to maintain relative humidity levels, in anesthetizing locations, in accordance with regulations.

Findings include:

1. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM revealed that the relative humidity levels for the Operating Rooms and Cath Labs over the months of January, March, and December 2009 were less than 35% and as low as 15% at various times during the month.

Interview with the Director of Plant Operations on March 29, 2010, at 12:30 PM confirmed that relative humidity levels were not maintained at or above 35%.

Based on documentation review and interview, the facility failed to maintain relative humidity levels, in anesthetizing locations, in accordance with regulations.

Findings include:

1. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM, revealed that the relative humidity levels for the Operating Rooms and Cath Labs over the months of January, March, and December 2009 were less than 35% and as low as 15% at various times during the month.

Interview with the Director of Plant Operations on March 29, 2010, at 12:30 PM confirmed that relative humidity levels were not maintained at or above 35%.

28 Pa. Code § 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. § 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal,State and local laws and regulations. The facility failed to provide adequate floor plans for the Licensure Survey.

Findings include:

Observation of floor plans on March 29-31, 2010, revealed the facility's floor plans did not indicate rated walls for storage, soiled utilities, medical gas, and shafts; did not differentiate between smoke and fire walls, and horizontal exits and exits were not clearly noted.

Interview with the Director of Plant Operations on March 31, 2010, at 11:30 AM confirmed the floor plans were not sufficient for the purpose of this survey.

Based on observation and interview, the facility failed to maintain medical gas alarm panels in one location, on one of four floors.

Findings include:

1. Observation on March 30, 2010, at 9:32 AM revealed that the medical gas alarm panel, located at the Ground Floor back Emergency Room Nurses' Station, was in alarm and silenced. The oxygen was in a low alarm, reading 13 PSIG. Interview with the Facilities Coordinator revealed that the panel had been malfunctioning and had been identified as needing repaired or replaced.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 9:32 AM confirmed the above medical gas panel deficiency.

Based on documentation review and interview, the facility failed to maintain the emergency generators which supplies emergency power for the entire building.

Findings include:

1. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM, revealed that emergency generator #1 (Olympian) and emergency generator #3 (Onan) were not visually inspected weekly for 4 weeks, between March and April 2009.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 12:30 PM confirmed the missing visual inspections.

2. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM, revealed the following emergency generator deficiencies, as identified by Premium Power Services, during annual load-bank testing:

a) Generator #1 (Olympian) - report dated 4/16/09, identified that the intake and exhaust louvers did not operate properly;
b) Generator #2 (Onan) - report dated 4/16/09, and another preventive maintenance report dated 11/12/09, identified that the engine temperature gauge was not functioning properly; the engine starting batteries needed to be replaced; and the engine block heater was imperative.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 12:30 PM confirmed the generator deficiencies above and the lack of documentation identifying corrective actions.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and/or equipment on one of four floors.

Findings include:

1. Observation on March 29, 2010, at 3:05 PM revealed an open exposed electrical box from the removal of an EXIT sign, in the ceiling at the fire doors in the 3rd Floor Bridge.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 3:05 PM confirmed the open electrical box.

2. Observation on March 30, 2010, at 9:55 AM revealed two open electrical Heating, Ventilating and Air Conditioning (HVAC) control boxes, on the 4th Floor Elevator Lobby by #9.

Interview with the Director of Plant Operations on March 30, 2010, at 9:55 AM confirmed that the above condition exists.

Based on observation and interview, the facility failed to maintain the proper use of electrical wiring and equipment, surge protectors, receptacle multipliers and/or extension cords in various locations throughout the facility.

Findings include:

1. Observation on March 29, 2010, between 11:52 AM and 2:10 PM, revealed the following improper electrical wiring and use of surge protectors and extension cords:

a) 11:52 AM , an open Elbee, and an eight (8) inch fire alarm box in the 2nd Floor East Mechanical Room.
b) 11:54 AM, an open electrical box above the 2nd Floor Nursery windows.
c) 1:45 PM, a refrigerator was plugged into a surge protector, which was plugged into an extension cord, in the Penthouse.
d)) 1:50 PM, a surface-mounted metal electrical receptacle box was being powered by temporary SJ cord, in the Penthouse.
e) 1:50 PM, an electrical junction box was missing a cover plate, above the lights inside the caged enclosure, in the Penthouse.
f) 1:55 PM, an electrical space heater was wire nutted to THNN wire and then jumped off of a cartage fuse box, inside the caged enclosure, in the Penthouse.
g) 2:10 PM, an open electrical box at the 2nd Floor smoke barrier at Room #215.

Interview with the Director of Plant Operations, Chief Safety Officer and Electrician on March 29, 2010, at the times stated above, confirmed the improper electrical wiring and misuse of surge protectors and extension cords.

2 Observation on March 29, 2010, between 1:41 PM and 2:37 PM, revealed the following electrical system deficiencies:

a) 1:41 PM, open electrical junction box in 1st Floor corridor outside Laundry Room and above wall-mounted electrical outlet.
b) 2:01 PM, three (3) extension cords powering two fans and one light in Boiler Room.
c) 2:37 PM, surge protector used to power a microwave in the Environmental Services Lounge.

Interview with the Plant Operations Manager on March 29, 2010, at the times stated above, confirmed the improper electrical wiring and misuse of surge protectors and extension cords.

3. Observation on March 29, 2010, at 2:20 PM revealed temporary Romex wiring, above the ceiling on the 5th Floor in the South, East West Corridor.

Interview with the Director of Plant Operations on March 29, 2010, at 2:20 PM confirmed the improper electrical wiring.

4. Observation on March 29, 2010, at 2:40 PM revealed that a large electrical junction box was missing a cover plate in the Ground Floor Security Office.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:40 PM confirmed the missing cover plate.

5. Observation on March 29, 2010, at 2:55 PM revealed that an electrical junction box was missing a cover plate in the 5th Floor Mechanical Room over Chiller #1.

Interview with the Director of Plant Operations on March 29, 2010, at 2:55 PM confirmed the missing cover plate.

6. Observation on March 30, 2010, between 8:55 AM and 9:10 AM, revealed the following improper electrical wiring and use of surge protectors and extension cords on the 4th Floor:

a) 8:55 AM, temporary wiring and unterminated M/C cable above the suspended ceiling, in the Elevator Lobby by #1.
b) 9:00 AM, a power tap was used in the office of Director of Marketing and Public Relations.
c) 9:10 AM, extension cords were being used in various locations and surge protectors were daisy chained, in the Bio Med Office.

Interview with the Director of Plant Operations on March 29, 2010, at the times stated above, confirmed the improper electrical wiring.

7. Observation on March 30, 2010, between 8:57 AM and 10:01 AM, revealed the following electrical system deficiencies:

a) 8:57 AM, open electrical junction box near a ceiling light in 1st Floor Kitchen Storage Room next to Auxiliary Office.
b) 9:37 AM, large orange extension cord used to power refrigeration equipment in the 1st Floor Lab.
c) 9:41 AM, three (3) extension cords used to power small refrigerators in 1st Floor Lab.
d) 9:55 AM, surge protector used to power coffee pots, microwave, and toaster in 1st Floor Lab Lounge.
e) 9:57 AM, extension cord used to power refrigerator in 1st Floor Lab Lounge.
f) 10:01 AM, extension cord used to power AC pump in 1st Floor Lab Blood Bank.

Interview with the Plant Operations Manager on March 30, 2010, at the times stated above, confirmed the improper electrical wiring.

8. Observation on March 30, 2010, at 10:45 AM in the 2nd floor Medical Records Room revealed a fan plugged in to an outlet multiplier, which was plugged into a surge protector.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 10:45 AM confirmed the improper use of electrical components.

9. Observation on March 30, 2010, between 10:30 AM and 12:00 PM, revealed the following improper electrical wiring and use of surge protectors and extension cords on the 3rd Floor:

a) 10:30 AM, old ICU Suite, exposed wires which were not properly terminated in electrical junction boxes throughout.
b) 11:05 AM, Family ICU Waiting Area, an extension cord was powering a surge protector that was used for a Fish Tank.
c) 11:20 AM, corridor outside Linen Chute and Surgical Waiting, exposed wires which were not properly terminated in electrical junction boxes throughout.
d) 11:25 AM, corridor outside Linen Chute and Surgical Waiting, revealed that there was Romex wiring running above the suspended ceiling.
e) 11:45 AM, OR Staff Lounge, multi use of extension cords and the misuse of many surge protectors (daisy chained) to power refrigerator, microwave toaster, and toaster oven.
f) 11:50 AM, corridor outside Pre-op, wall-mounted electrical panel boxes NL1 and CE2B were unlocked.

Interview with the Director of Plant Operations on March 30, 2010, at the times and locations stated above, confirmed the improper use of electrical components.

10. Observation on March 30, 2010, between 10:45 AM and 2:12 PM, revealed the following improper electrical wiring and use of surge protectors and extension cords:

a) 10:45 AM, electrical junction box was missing a cover plate, above the Ground Floor Gift Shop suspended ceiling, along the back wall.
b) 10:46 AM, electrical junction box was missing a cover plate, above the Ground Floor North Tower Registration suspended ceiling, opposite the old Film Processing Room.
c) 10:47 AM, a refrigerator was plugged into a surge protector, in Ground Floor North Tower Registration.
d) 10:58 AM, electrical junction box was missing a cover plate, above the Ground Floor cross-corridor double doors, on the backside of elevators 4 and 5.
e) 11:45 AM, temporary wiring and lighting were found above the suspended ceiling, in the Ground Floor Physicians' Reading Room, back left office.
f) 11:46 AM, electrical junction box was missing a cover plate, above the Ground Floor cross-corridor double doors, by X-Ray Room 11.
g) 1:35 PM, an extension cord was used for an under-the-counter light, at the Ground Floor Patient Holding desk.
h) 2:00 PM, the cover was missing from a large heating unit, in the Ground Floor North Stair Tower #1, by Radiology.
i) 2:12 PM, a microwave was plugged into a surge protector, in the 2nd Floor Physical and Occupational Therapy Office.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 2:12 PM confirmed the improper electrical wiring and misuse of surge protectors and extension cords.

11. Observation on March 30, 2010, between 1:39 PM and 2:23 PM, revealed surge protectors used to power medical test equipment in the 3rd Floor OR #7, OR#8, and OR#6.

Interview with the Plant Operations Manager on March 30, 2010, at 2:23 PM confirmed the improper use of surge protectors.

12. Observation on March 31, 2010, at 9:00 AM revealed that a heat lamp was plugged into an extension cord in the Ground Floor Snack Shop.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 9:00 AM confirmed the improper use of the extension cord.

13. Observation on March 31, 2010, at 9:00 AM revealed that an electrical junction box was missing a cover plate in the Ground Floor Mechanical, by the North Stair Tower #1.

Interview with the Director of Plant Operations on March 31, 2010, at 9:00 AM confirmed the missing cover plate.

Based on observation and interview, the facility failed to install Alcohol Based Hand Rub (ABHR) dispensers in accordance with the regulations, in one location on the 4th Floor.

Findings include:

1. Observation on March 30, 2010, at 9:20 AM revealed that an ABHR dispenser was installed over an electrical receptacle, on the 4th Floor in Patient Room 412.

Interview with the Director of Plant Operations on March 30, 2010, at 9:20 AM confirmed the ABHR dispenser location.

Based on observation and interview, the facility failed to install Alcohol Based Hand Rub (ABHR) dispensers in accordance with the regulations, in various locations throughout the Ground Floor Emergency Room Suite.

Findings include:

1. Observation on March 30, 2010, between 9:26 AM and 9:40 AM, revealed that ABHR dispensers were installed adjacent to electrical switches at the Ground Floor Main ER Nurses' Station and in various exam rooms throughout the ER.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 9:40 AM confirmed the ABHR dispenser locations.

Based on observation and interview, the facility failed to maintain communicating door openings and the proper fire resistance rating of two hour fire-resistant common walls on three of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:05 PM revealed penetrations in the common wall above the doors at the 4 South elevators.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:05 PM, confirmed the penetrations in the common wall.

2. Observation on March 29, 2010, at 3:00 PM revealed the fire doors in the 3rd
Floor separation wall at the Medical Office Building (MOB) Bridge did not close/latch into the frame.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 3:00 PM, confirmed the doors did not close/latch.

3. Observation on March 30, 2010, at 9:30 AM revealed three (3) conduit penetrations in the separation wall above the fire doors outside the 2nd Floor elevators.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:30 AM, confirmed the conduit penetrations.

4. Observation on March 30, 2010, at 9:55 AM revealed an unsealed penetration, at the 4th Floor double corridor doors, outside the IT Room, around red wires on left wall.

Interview with the Director of Plant Operations on March 30, 2010, at 9:55 AM confirmed that the above condition exists.

Based on observation and interview, the facility failed to maintain communicating door openings and the proper fire resistance rating of two hour fire-resistant common walls in numerous locations, on three (3) of six (6) floors.

Findings include:

1. Observation on March 29, 2010, at 1:40 PM revealed the Ground Floor cross-corridor doors between the Main Building (01 Component) and the New Addition (03 Component), by the Mail Room, lacked 1 ½ hour fire-rated doors. In addition, the doors would not properly close and latch in the frame.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 1:40 PM, confirmed the above deficiency.

2. Observation on March 29, 2010, between 1:45 PM and 2:21 PM revealed the following unsealed penetrations of the Ground Floor common wall between the 01 and 03 Components:

a) 1:45 PM, numerous penetrations inside and around conduits and inside an approximate ½ inch hole, located above the cross-corridor doors, by the Mail Room, in the Main Building;
b) 2:10 PM, inside two, approximate 1" cored holes and between the top flange and duct work, located in the corridor, across from the New Addition elevators 11 and 12, above smoke damper control M1-28;
c) 2:21 PM, around three silver MC cables and inside and around a conduit with red and white wire, above the cross-corridor doors, by elevators 9 and 10, in the New Addition main corridor.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:21 PM, confirmed the unsealed penetrations.

3. Observation on March 30, 2010, between 8:55 AM and 10:33 AM revealed the following unsealed penetrations of the Ground Floor 2-hour fire wall:

a) 8:55 AM, inside two (2) pipes above the heater control box on the 1st floor Loading Dock.
b) 9:03 AM, various locations inside the 1st Floor kitchen on opposite side of corridor.
c) 10:15 AM, inside and around a conduit above double firewall doors next to the 1st Floor elevator.
d) 10:19 AM, inside and around MC cable above a strobe light in the 1st Floor corridor outside of the Laboratory.
e) 10:33 AM, numerous areas around conduit, wires, & MC cables of the 1st Floor firewall, at the bulkhead between the two security offices.

Interview with the Plant Operations Manager on March 30, 2010, at 10:33 AM confirmed the unsealed penetrations.

4. Observation on March 30, 2010, at 9:09 AM revealed that the Ground Floor Decontamination Room corridor door would not properly close and latch in the frame.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 9:09 AM, confirmed the door would not properly close and latch.

5. Observation on March 30, 2010, at 9:45 AM revealed an unsealed penetration, over the 4th Floor double corridor doors outside the IT Room, inside two 4" conduits and outside one of the two.

Interview with the Director of Plant Operations on March 30, 2010, at 9:45 AM confirmed that the above condition exists.

6. Observation on March 30, 2010, at 10:41 AM revealed that the 1st Floor corridor double doors near the elevator and security office required a coordinator.

Interview with the Plant Operations Manager on March 30, 2010, at 10:41 AM confirmed the doors required a coordinator.

7. Observation on March 30, 2010, at 1:27 PM revealed that the 1st Floor door next to the Kitchen Dry Storage and exit stairs would not close and latch into the frame.

Interview with the Plant Operations Manager on March 30, 2010, at 1:27 PM confirmed the door would not close and latch.

8. Observation on March 30, 2010, at 1:55 PM revealed two (2) penetrations in the 2-hour wall, to the right immediately inside the door, in the 2nd Floor Mechanical Room.

Interview with the Chief Safety Officer and Mechanical Technician on March 30, 2010, at 1:55 PM confirmed the penetrations.

9. Observation on March 30, 2010, at 2:15 PM revealed an unsealed penetration, in the back corner of the 2nd Floor Physical and Occupational Therapy Office where the drywall, from above the corridor doorway, was not sealed to the back wall.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 2:15 PM, confirmed the unsealed penetration.

10. Observation on March 30, 2010, at 2:20 PM revealed the block of the 2-hour wall was broken in the corner inside the Director Manager's Office.

Interview with the Chief Safety Officer and Mechanical Technician on March 30, 2010, at 2:20 PM confirmed the broken block wall.

11. Observation on March 31, 2010, between 8:59 AM and 9:33 AM revealed the following unsealed penetrations of the Ground Floor 2-hour fire wall:

a) 8:59 AM, inside a small pipe between the Laboratory and double firewall doors and to the right of a mirror.
b) 9:21 AM, around and inside pipes in the 1st floor Laboratory Hood Room.
c) 9:33 AM, inside a cement block penetration in the 1st Floor Pharmacy above the computer terminals.

Interview with the Plant Operations Manager on March 31, 2010, at the above times confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain proper building construction type in numerous areas in two (2) of six (6) floors.

Findings include:

1. Observation on March 29, 2010, between 1:51 PM and 2:13 PM revealed missing fire spray on structural beams during the following times and at the following locations:

a) 1:51 PM, missing fire spray on a structural beam in two locations at the Ground/1st Floor firewall next to the Sprinkler Room and above a wall mural.
b) 2:53 PM, missing fire spray on a structural beam in the Ground/1st Floor Morgue restroom.
c) 2:13 PM, missing fire spray on a structural beam above door to copier room in Ground/1st Floor Central Storage Room.

Interview with the Plant Operations Manager on March 29, 2010, at the above times confirmed the missing fire spray on structural beams.

2. Observation on March 30, 2010, at 9:50 AM revealed that there was an unprotected structural steel beam, above the New Addition Ground Floor cross-corridor doors, by the Mail Room.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 9:50 AM, confirmed the unprotected steel beam.

3. Observation on March 30, 2010, at 11:00 AM in the 2nd Floor Medical Records Room revealed missing fire spray on a structural beam, above the "charts to be filed" section of shelving.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:00 AM confirmed the missing fire spray.

4. Observation on March 30, 2010, at 11:06 AM in the 2nd Floor new Medical Records Room revealed missing fire spray on a structural beam, above the clock.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:06 AM confirmed the missing fire spray.

Based on observation and interview, the facility failed to provide the proper fire resistance rating for structural steel on two of four floors.

Findings include:

1. Observation on March 29, 2010, at 1:40 PM revealed that there was an unprotected structural steel beam, above the New Addition Ground Floor cross-corridor doors, by the Mail Room.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 1:40 PM, confirmed the unprotected steel beam.

2. Observation on March 29, 2010, at 1:55 PM revealed that there were two (2) unprotected structural steel beams, above the 5th Floor elevator rooms, across the threshold of the exit door, and the cross beam next to the door.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 1:55 PM, confirmed the unprotected steel beams.

3. Observation on March 30, 2010, at 9:50 AM revealed that there was an unprotected structural steel beam, on the 4th Floor corridor, outside IT Room as seen through the inspection door.

Interview with the Director of Plant Operations on March 30, 2010, at 9:50 AM confirmed the missing fire proofing.

Based on observation and interview, the facility failed to maintain the required construction of corridor walls on two floors.

Findings include:

1. Observation on March 30, 2010, at 9:22 AM revealed there was an unsealed corridor wall penetration above the suspended ceiling on the 4th Floor, at Patient Room 414.

Interview with the Director of Plant Operations on March 30, 2010, at 9:22 AM confirmed the corridor wall penetrations.

2. Observation on March 30, 2010, at 10:20 AM revealed there was an unsealed corridor wall penetration above the suspended ceiling, inside a 2" conduit on the 3rd Floor, in the Elevator Lobby, over the Exit Stairs Door.

Interview with the Director of Plant Operations on March 30, 2010, at 10:20 AM confirmed the corridor wall penetrations.

3. Observation on March 30, 2010, at 11:20 AM revealed there was an unsealed corridor wall penetration above the suspended ceiling, inside a conduit on the 3rd Floor, in the corridor at the Linen Chute Room and Surgical Waiting Area.

Interview with the Director of Plant Operations on March 30, 2010, at 11:20 AM confirmed the corridor wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings to be smoke resistant.

Findings include:

1. Observation on March 30, 2010, at 8:55 AM revealed a gap greater than 1/8 inch between the meeting edges of the double doors entering the 3rd Floor Endoscopy suite.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 8:55 AM confirmed the gap between the doors.

2. Observation on March 30, 2010, at 9:00 AM revealed gap greater than 1/8 inch between the meeting edges of the double doors entering the 3rd Floor Intensive Care Unit.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:00 AM confirmed the gap between the doors.

Based on observation and interview, the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in two locations, on one of six floors.

Findings include:

1. Observation on March 29, 2010, between 1:30 PM and 3:00 PM revealed that the following doors on the 5th Floor had the following deficiencies:

a) 2:15 PM, Patient Room 517, had a gap greater than 1/4 inch between the door face and the door stop:
b) 2:18 PM, Patient Room 515, had a gap greater than 1/4 inch between the door face and the door stop:
c) 2:20 PM, Patient Room 507, had a gap greater than 1/4 inch between the door face and the door stop:
d) 2:25 PM, Patient Room 501, was hitting the frame and not closing and latching properly.
e) 2:30 PM, Patient Room 520, had a gap greater than 1/4 inch between the door face and the door stop:
f) 2:35 PM, Patient Room 522, had a gap greater than 1/4 inch between the door face and the door stop:

Interview with the Director of Plant Operations on March 29, 2010, at the times and locations stated above confirmed that the above conditions exist.

2. Observation on March 30, 2010, between 9:00 AM and 9:30 AM revealed that the following doors, on the 4th Floor, had the following deficiencies:

a) 9:04 AM, Patient Room 411, had a gap greater than 1/4 inch between the door face and the door stop:
b) 9:04 AM, Patient Room 411, required a positive latching adjustment to properly close and latch in its frame.
c) 9:04 AM, Patient Room 407, had a gap greater than 1/4 inch between the door face and the door stop:
d) 9:15 AM, Patient Room 406, had a gap greater than 1/4 inch between the door face and the door stop:
e) 9:27 AM, Data Closet across from Patient Room 422, revealed that the corridor double doors were not equipped with positive latching hardware on both doors. One door was equipped with a manual flush bolt only, and that door had to be closed with the manual flush bolt activated before the other door would close and latch. At the time of the survey, both doors were open.

Interview with the Director of Plant Operations on March 30, 2010, at the times and locations stated above confirmed that the above conditions exist.

4. Observation on March 30, 2010, at 11:45 AM revealed the 2nd Floor staff lounge at the Nurses' Station did not close/latch.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:45 AM confirmed that the door did not latch.

5. Observation on March 30, 2010, at 4:05 PM revealed that the double corridor doors, to the 4th Floor Behavioral Health Dining Room, were not smoke tight at the meeting edge when in the closed position.

Interview with the Director of Maintenance on March 30, 2010, at 4:05 PM revealed that the above condition exists.

6. Observation on March 30, 2010, at 1:45 PM revealed that the Ground Floor Electrical Closet double corridor doors, by Diagnostic Imaging Front Desk, had a gap greater than 1/8 inch at the meeting edge when in the closed position.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 1:45 PM confirmed that the doors would not resist the passage of smoke.

7. Observation on March 30, 2010, at 1:45 PM the door to Medical/Surgical Room #216 on the 2nd Floor revealed a gap greater than 1/4 inch between the door and the door stop when in the closed position.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 1:45 PM confirmed the door gap.

8. Observation on March 30, 2010, between 1:45 PM and 1:55 PM revealed the following doors to to have gaps greater than 1/4 inch between the door and the door stop when in the closed position: (Note: This area is closed.)

a) 214, 212, 208, 204, 201.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 1:55 PM confirmed the door gaps.

9. Observation on March 31, 2010, at 9:05 AM revealed that the Ground Floor Main Cafeteria double corridor doors lacked positive latching hardware on both doors. One door was equipped with a dead-bolt. In addition, the doors had a gap greater than 1/8 inch at the meeting edge when in the closed position.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 9:05 AM confirmed the door hardware and that the doors would not resist the passage of smoke.

10. Observation on March 30, 2010, at 10:40 AM revealed two (2) penetrations from hardware removal in the 2nd Floor door of the office of the Chief Medical Officer.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 10:40 AM confirmed the door penetrations.

Based on observation and interview, the facility failed to protect openings through the floor assembly in one location, on one of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:55 PM revealed that there was an unsealed penetration of both the floor slab and ceiling slab behind Chiller #2 in the 5th Floor Mechanical Room.

Interview with the Director of Plant Operations on March 29, 2010, at 2:55 PM confirmed the unsealed floor/ceiling penetration.

Based on observation and interview, the facility failed to protect openings through the ceiling/floor assembly in four locations, on two of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:45 PM revealed that there was an unsealed penetration of the floor slab above the Ground Floor Fire/Security Communication Room, inside a 4" sleeve.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:45 PM confirmed the unsealed floor/ceiling penetration.

2. Observation on March 29, 2010, at 3:10 PM revealed ceiling penetrations in the 3rd Floor electrical closet across from Procedure Room A.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 3:10 PM, confirmed the ceiling penetrations.

3. Observation on March 30, 2010, at 9:20 AM revealed one (1) conduit penetration in the 3rd Floor electrical closet floor at the Nurses' Station on the ICU/MICU side.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:20 AM, confirmed the floor penetration.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls in one location, on one of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:17 PM revealed the unsealed smoke barrier penetrations around the topside of a conduit and around the left side of duct work, between the flange and drywall, located above the cross-corridor doors by elevators 11 and 12.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:17 PM confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls, on two of five floors.

Findings include:

1. Observation on March 29, 2010, at 2:20 PM revealed penetrations around M/C cable, conduit, and cable, over the double corridor doors on the 5th Floor, outside Patient Room 515.

Interview with the Director of Plant Operations on March 29, 2010, at 2:20 PM confirmed that the above condition exists.

2. Observation on March 30, 2010, between 10:47 AM and 1:30 PM revealed the following Ground Floor unsealed smoke barrier penetrations:

a) 10:47 AM, above duct work in North Tower Registration;
b) 11:46 AM, inside an approximate three inch metal sleeve with yellow wires and around the top side of a white insulated pipe, located above the cross-corridor doors, by X-Ray Room 11;
c) 1:30 PM, around a green MC cable and inside two conduits with gray and red wires, located in the corridor above the door to the Radiology File Room.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 1:30 PM confirmed the unsealed penetrations.

3. Observation on March 30, 2010, at 10:30 AM revealed a sprinkler pipe and open conduit penetrations in the 2nd Floor smoke barrier at the elevators.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 10:30 AM confirmed the smoke barrier penetrations.

4. Observation on March 30, 2010, at 11:26 AM revealed an abandoned pneumatic tube and an open six inch (6) conduit penetration in the 2nd Floor smoke barrier at the Medical Records Room.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:26 AM confirmed the smoke barrier penetrations.

5. Observation on March 30, 2010, at 1:40 PM revealed wire penetrations in the 2nd Floor smoke barrier at Room #216.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 1:40 PM confirmed the smoke barrier penetrations.

6. Observation on March 30, 2010, at 2:05 PM revealed a six (6) inch pipe penetration in the 2nd Floor smoke barrier in Room #215.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 2:05 PM confirmed the smoke barrier penetration.

Based on observation and interview, the facility failed to maintain door openings in smoke barriers on one floor.

Findings include:

1. Observation on March 29, 2010, at 2:20 PM revealed the double corridor smoke barrier doors, on the 5th Floor outside Patient Room 515, needed a coordinator adjustment to close properly.

Interview with the Director of Plant Operations on March 29, 2010, at 2:20 PM confirmed the above condition exists.

2. Observation on March 30, 2010, at 10:17 AM revealed the corridor smoke barrier door, on the 3rd Floor to the Surgical Waiting Area, was being held open by an unauthorized door hold-open device (wooden chock).

Interview with the Director of Plant Operations on March 30, 2010, at 10:17 AM confirmed the above condition exists.

3. Observation on March 30, 2010, at 10:20 AM revealed the corridor smoke barrier door, on the 3rd Floor, from the Surgical Waiting Area to behind the Information Desk, was being held open by an unauthorized door hold-open device (wooden chock).

Interview with the Director of Plant Operations on March 30, 2010, at 10:20 AM confirmed the above condition exists.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of hazardous areas on three of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:35 PM revealed an unsealed penetration of the one hour fire-rated 4th Floor Soiled Utility room in the wall above the sink, across from Room #465.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:35 PM confirmed the unsealed penetration.

2. Observation on March 29, 2010, at 2:40 PM revealed the 4th Floor Equipment Storage room door did not close/latch, across from Room #464.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:40 PM confirmed the door did not latch.

3. Observation on March 29, 2010, at 2:50 PM revealed an unsealed penetration of the one hour fire-rated Ground Floor Soiled Workroom, inside and around a metal sleeve containing a green MC cable, located in the shared Environmental Services Closet wall.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:50 PM confirmed the unsealed penetration.

4. Observation on March 30, 2010, at 9:45 AM revealed an unsealed penetration of the one hour fire-rated shared wall, with shell space, across from the 2nd Floor Ladies Room.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:45 AM confirmed the unsealed penetration.

5. Observation on March 30, 2010, at 9:50 AM revealed an open conduit in the 2nd Floor one hour fire-rated shared wall, with shell space, near the strobe light.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:50 AM confirmed the unsealed penetration.

6. Observation on March 30, 2010, at 10:15 AM revealed two (2) penetrations and one (1) wire penetration of the side walls of the 2nd Floor Soiled Utility Room across from Room #253.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 10:15 AM confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of hazardous areas, on four (4) of six (6) floors.

Findings include:

1. Observation on March 29, 2010, at 2:09 PM revealed the door to the 1st Floor Boiler Room, next to the Non-Flammable Paint Storage Room, did not have a closure and did not close and latch into its frame.

Interview with the Plant Operations Manager on March 29, 2010, at 2:09 PM PM confirmed there was no closure and the door would not close and latch.

2. Observation on March 30, 2010, at 9:15 AM revealed the Storage Room double doors, across from Patient Room 404 on the 4th Floor, revealed that the doors were not equipped with positive latching hardware on both doors. One door was equipped with a manual flush bolt only, and that door had to be closed with the manual flush bolt activated before the other door could close and latch. At the time of the survey, both doors were open.

Interview with the Director of Plant Operations on March 30, 2010, at 9:15 AM confirmed that the above condition exists.

3. Observation on March 30, 2010, at 11:20 AM revealed a penetration in the corridor wall to the 2nd Floor Medical Records Room, across from the fire hose cabinet.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:20 AM confirmed the penetration in the wall.

4. Observation on March 30, 2010, at 11:25 AM revealed an orange flex conduit and wire penetrations into the wall to the 2nd Floor Medical Records Room, at the smoke barrier.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:25 AM confirmed the penetration in the wall.

5. Observation on March 30, 2010, at 11:40 AM revealed a large area of two (2) walls, (the back and side walls) missing block in the 2nd Floor Obstetrical/Gynecological storage Room.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:40 AM confirmed the missing block.

6. Observation on March 30, 2010, at 11:48 AM revealed penetrations in two (2) walls, (the front and side walls) across from Room #236 in the 2nd Floor Maternity.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:48 AM confirmed the penetrations.

7. Observation on March 30, 2010, at 11:50 AM revealed the storage double doors, across from Room #242 in 2nd Floor Maternity, had a gap greater than 1/8 inch at the meeting edges of the doors, and the doors did not close/latch.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:50 AM confirmed the gap and non-latching of the doors.

8. Observation on March 30, 2010, between 1:47 PM and 2:07 PM, revealed the following 3rd Floor Operating Room (OR) unsealed penetrations:

a) 1:47 PM, various locations on all four walls in OR Soiled Utility Room.
b) 2:07 PM, area where all four walls meet ceiling in OR Laundry Chute Room.

Interview with the Plant Operations Manager on March 30, 2010, at the above times, confirmed the unsealed penetrations.

9. Observation on March 30, 2010, at 1:50 PM revealed missing block and open conduits in the storage room across from Room #204 on the 2nd Floor.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 1:50 PM confirmed the penetrations of block and conduits.

10. Observation on March 31, 2010, between 8:50 AM and 9:27 AM, revealed the following Ground Floor unsealed penetrations:

a) 8:50 AM, above the Phoenix Cafe sign, block was broken away from around the duct going through the wall.
b) 9:00 AM, in the room where the duct for the air conditioning unit is located, the wall was broken away from around the entire duct.
c) 9:22 AM, penetration around the duct entering the flammable storage room from the Main Pharmacy, in the Lab.
d) 9:25 AM, duct tape was covering the end of an abandoned pipe between the Main Pharmacy and the Flammables Storage Room, viewed from the Main Pharmacy side;
e) 9:27 AM, inside a conduit with black insulated copper lines, through the shared Laboratory/Pharmacy wall, located in the Main Pharmacy.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 9:27 AM confirmed the unsealed penetrations.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of hazardous areas and failed to ensure that doors to hazardous areas were self-closing in one location, on one of four floors.

Findings include:

1. Observation on March 31, 2010, at 8:45 AM revealed that the door closure was removed to the Ground Floor Snack Bar corridor door, which is part of the Gift Shop hazardous area enclosure.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 8:45 AM confirmed that the closure was removed.

2. Observation on March 31, 2010, at 8:45 AM revealed a large unsealed penetration over the Ground Floor Snack Bar kitchen hood, below and above the ceiling tile, which is part of the Gift Shop hazardous area enclosure.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 8:45 AM confirmed the unsealed penetration.

Based on observation and interview, the facility failed to maintain the fire resistance rating of exit components to provide a continuous path of escape.

Findings include:

1. Observation on March 29, 2010, at 2:40 PM revealed the Ground Floor Main Building Security Office, by the New Addition, lacked a 1 ½ hour fire-rated door and door frame.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:40 PM, confirmed the above deficiency.

2. Observation on March 30, 2010, at 9:21 AM revealed an approximate one inch by twelve inch (1" x 12") opening, at the top of the shared stair tower wall, in the 3rd Floor Electrical Closet at the Nurses' Station on the ICU/MICU side.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:21 AM, confirmed the stair wall penetration.

3. Observation on March 30, 2010, at 11:30 AM revealed two (2) penetrations, and three (3) wire penetrations into the stair tower foyer, next to the 2nd Floor service elevator #2.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:30 AM confirmed the penetrations in the wall.

4. Observation on March 31, 2010, between 9:00 AM and 10:00 AM, revealed the following deficiencies for the North Stair Tower #1, next to Radiology, on the Ground Floor.

a) 9:00 AM, on the Mechanical Room side, a speaker was recessed into the concrete block wall degrading the 2-hour status.
b) 9:05 AM, on the Mechanical Room side, an unsealed penetration around a conduit.
c) 9:30 AM, between the Stair Tower and the Mechanical Room, a 1 1/2 -hour rated door had been removed, the opening was then in-filled with metal studs and a single layer of 5/8 " wallboard on each side, degrading the 2-hour status.

Interview with the Director of Plant Operations on March 30, 2010, at 10:00 AM confirmed the above deficiencies.

Based on observation and interview, the facility failed to ensure that stairways used as exits were not used for any purpose which has the potential to interfere with egress for one instance on the Ground Floor.

Findings include:

1. Observation on March 31, 2010, at 9:15 AM revealed that there was storage of a five foot long, four-inch diameter piece of conduit (Approx. size), in the North Stair Tower #1

Interview with the Director of Plant Operations on March 31, 2010, at 9:15 AM confirmed the above storage.

2. Observation on March 31, 2010, at 9:15 AM revealed that there was data wiring running through North Stair Tower #1

Interview with the Director of Plant Operations on March 31, 2010, at 9:15 AM confirmed the above condition.

Based on observation and interview, the facility failed to ensure that exit access was maintained readily accessible to a public way at one exit discharge within the entire facility.

Findings include:

Observation on March 30, 2010, at 2:45 PM, revealed that the 1st Floor exit egress outside of the Plant Operations Office was blocked by six (6) large laundry storage bins.

Interview with the Director of Plant Operations on March 30, 2010, at 2:45 PM confirmed the bins were blocking the exit egress.

Based on observation and interview, the facility failed to ensure that exit access corridors were maintained clear and unobstructed in two (2) locations on two (2) of six (6) floors.

Findings include:

1. Observation on March 30, 2010, between 9:00 AM and 10:00 AM, revealed the following obstruction on the 4th Floor, on both East to West corridors: in the North, two blood pressure machines, and in the South, two blood pressure machines and a wheel chair.

Interview with the Director of Plant Operations on March 30, 2010, at 10:00 AM confirmed the above storage in the corridor.

2. Observation on March 30, 2010, at 11:53 AM revealed six (6) large laundry storage bins in the 1st Floor corridor near the Plant Operations Office.

Interview with the Director of Plant Operations on March 30, 2010, at 11:53 AM confirmed the bins obstructed the corridor.

Based on observation and interview, the facility failed to ensure that emergency lighting was properly tested and maintained in one (1) location on one (1) of six (6) floors.

Findings include:

Observation on March 30, 2010, at 10:49 AM revealed an emergency back-up light in the 1st Floor shell space had an inoperative battery.

Interview with the Plant Operations Manager on March 30, 2010, at 10:49 AM confirmed the inoperative battery back-up light.

Based on observation and interview, the facility failed to ensure fire alarm components were installed or maintained properly in one (1) room on one (1) of six (6) floors.

Findings include:

Observation on March 30, 2010, at 3:33 PM revealed that there was one (1) smoke detector placed in a plastic bag in the 1st Floor Maintenance Room, near the door and next to the Plant Operations Office.

Interview with the Plant Operations Manager on March 30, 2010, at 3:33 PM confirmed the smoke detector was placed in a plastic bag.

Based on documentation review, observation and/or interview, the facility failed to maintain required fire alarm system or smoke detectors throughout the entire facility.

Findings include:

1. Documentation review on March 29, 2010, between 10:00 AM and 12:30 PM revealed 13 smoke detectors failed during the facility's last sensitivity inspection by Simplex on 3/8/10 and were not repaired/replaced.

Interview with the Plant Operations Manager on March 29, 2010, at 12:30 PM confirmed that the facility had no documentation reflecting that the smoke detectors had been repaired or replaced.

2. Observation on March 30, 2010, at 9:30 AM revealed that a new smoke detector had been installed within the airflow of a ceiling diffuser, on the 4th Floor in the East End Connector corridor.

Interview with the Director of Plant Operations on March 30, 2010, at 9:30 AM confirmed the above condition exists.

3. Observation on March 30, 2010, at 10:15 AM revealed the ceiling-mounted smoke detector was not properly mounted to its box on the 3rd Floor, at the Information Desk.

Interview with the Director of Plant Operations on March 30, 2010, at 10:15 AM confirmed the above condition exists.

Based on observation and interview, it was determined the facility failed to maintain the required automatic sprinkler system on one of four floors.

Findings include:

1. Observation on March 30, 2010, at 9:05 AM in the 3rd Floor Intensive Care Unit Equipment Storage Room, revealed speaker wire being supported by a sprinkler pipe.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:05 AM confirmed the speaker wire on sprinkler pipe.

2. Observation on March 30, 2010, at 9:15 AM in the 3rd Floor Soiled Utility Room, across from Room #354, revealed communication wire attached to a sprinkler pipe hanger.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:15 AM confirmed the wire attached to the sprinkler pipe hanger.

Based on observation, documentation review and interview it was determined the facility failed to provide an automatic sprinkler system which is continuously maintained in reliable operating condition and inspected and tested in accordance with NFPA 101, 19.7.6, NFPA 13, and NFPA 25, 1999 editions throughout the entire facility.

Findings include:

1. Document review on March 29, 2010, between 10:00 AM and 12:30 PM, revealed the Simplex 3/8/10 report identified numerous deficiencies, such as: check valves and alarm valves were due for inspection, kitchen cleaning supply room and elevator #2 tamper switches failed, 1st and 2nd floor tamper switches could not be located, etc. No corrective action was taken by the facility.

Interview with the Plant Operations Manager on March 29, 2010, at 12:30 PM confirmed that the facility had no documentation reflecting the sprinkler system deficiencies were corrected.

2. Observation on March 30, 2010, at 11:05 AM in the new Medical Records Room, revealed wires and flex conduit being supported by sprinkler pipe.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:05 AM confirmed the wire and conduit on sprinkler pipe.

3. Observation on March 30, 2010, at 11:15 AM in Respiratory Therapy, revealed an accumulation of lint/dust on one sprinkler head in the room.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:15 AM confirmed the lint/dust on a sprinkler head.

Based on observation and interview,the facility failed to maintain portable fire extinguishers in accordance with the regulations for two extinguishers, on one of six floors.

Findings include:

1. Observation on March 31, 2010, at 8:45 AM revealed that a trash can was blocking access to the fire extinguisher in the Ground Floor Snack Bar.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 8:45 AM confirmed the blocked extinguisher.

2. Observation on March 31, 2010, at 9:00 AM revealed that the "K" type fire extinguisher, located in the Ground Floor Snack Bar Kitchen, was missing an inspection for February 2010. In addition, the extinguisher lacked signage identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 9:00 AM confirmed the missed inspection and lack of signage.

3. Observation on March 31, 2010, at 9:00 AM revealed that the fire extinguisher in the 1st Floor Mechanical Room, by the North Stair Tower, had not been inspected during February or March 2010.

Interview with the Director of Plant Operations on March 30, 2010, at 9:00 AM confirmed the fire extinguisher was not inspected during the last two (2) months.

4. Observation on March 31, 2010, at 9:47 AM revealed that the fire extinguisher in the Security Room had not been inspected during February or March 2010.

Interview with the Plant Operations Manager on March 31, 2010, at 9:47 AM confirmed the fire extinguisher was not inspected during the last two (2) months.

Based on observation and interview, the facility failed to maintain Heating, Ventilating, and Air Conditioning (HVAC) system ductwork through fire-rated walls in accordance with regulations, in two locations, on one of six floors.

Findings include:

1. Observation on March 29, 2010, at 2:40 PM revealed the facility could not verify that combination fire/smoke dampers exist in two HVAC ducts, which penetrated the 2-hour fire resistant common wall and smoke barrier wall, between the 01 and 03 Components, as viewed from the Main Building Security Office. The ducts appeared to have smoke dampers which were disconnected.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:40 PM confirmed the above deficiency.

Based on documentation review and interview, the facility failed to provide documentation reflecting that cooking facilities for the entire facility were protected in accordance with 9.2.3., 19.3.2.6, NFPA 96.

Findings include:

1. Document review on March 29, 2010, between 10:00 AM and 12:30 PM, revealed that the facility lacked documentation that monthly "quick checks" were being performed on the kitchen suppression system.

Interview with the Plant Operations Manager on March 29, 2010, at 12:30 PM confirmed monthly "quick checks" were not performed on the kitchen suppression system.

Based on observation and interview, it was determined that the facility failed to properly maintain the fire protection for trash chutes, incinerators and laundry chutes in one room.

Findings include:

Observation on March 30, 2010, at 2:15 PM revealed a six (6) inch pipe penetration of the ceiling assembly of the Laundry Chute Terminal Room.

Interview with the Chief Safety Officer and Electrician on March 30, 2010, at 2:15 PM confirmed the penetration.

Based on observation and interview, it was determined the facility failed to provide medical gas storage and administration areas in accordance with NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition, in three (3) rooms on two (2) of six (6) floors.

Findings include:

1. Observation on March 30, 2010, at 8:43 AM revealed oxygen "E" cylinders were not segregated empty and full, two oxygen "E" cylinders were not secured, a light switch was less than 60 inches from the floor, the door did not close and latch into the frame and there were two large penetrations above the door, around pipes as viewed from the corridor.

Interview with the Plant Operations Manager on March 30, 2010, at 8:43 AM confirmed the Oxygen Storage Room deficiencies.

2. Observation on March 30, 2010, at 11:10 AM in the Respiratory Therapy Room revealed numerous Oxygen "H" cylinders being stored in the room. The room was being used as therapy/office space and was not rated for the storage of oxygen. The door was rated for 20 minutes, electrical outlets and switches were within five (5) feet of the floor surface. The room lacked required signage providing the minimum wording: CAUTION OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING. The sign must be conspicuously displayed and readable from a distance of 5 feet.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:10 AM confirmed oxygen was stored in the room.

3. Observation on March 30, 2010, at 1:37 PM revealed an unsecured oxygen "E" cylinder in the 3rd Floor OR #7.

Interview with the Plant Operations Manager on March 30, 2010, at 1:37 PM confirmed the unsecured oxygen "E" cylinder.

Based on observation and interview, the facility failed to maintain oxygen storage locations in one room, on one of four floors.

Findings include:

1. Observation on March 30, 2010, at 9:15 AM revealed the following Ground Floor ER Equipment Storage/Oxygen Storage deficiencies:

a) the room lacked required precautionary signage providing the minimum wording: CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. The sign must be conspicuously displayed and readable from a distance of 5 feet.
b) the oxygen cylinders were not separated or labeled full and empty.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 9:15 AM confirmed the lack of signage and unseparated cylinders.

Based on observation and interview, the facility failed to maintain the piped-in medical gas system in one room of one floor.

Findings include:

Observation on March 29, 2010, at 2:15 PM, revealed the medical gas and vacuum lines in the ceiling in the 4th Floor Inpatient Dialysis required visible labels.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:15 PM confirmed the absence of visible labels.

Based on observation and interview, the facility failed to maintain the piped-in medical gas systems in accordance with the regulations in three (3) locations, on one (1) of six (6) floors.

Findings include:

1. Observation on March 30, 2010, at 9:05 AM revealed dissimilar metal (steel wire) was in direct contact with copper medical gas piping in the 1st Floor Kitchen, above the refrigerator.

Interview with the Plant Operations Manager on March 30, 2010, at 9:05 AM confirmed the steel wire on the medical gas piping.

2. Observation on March 30, 2010, between 10:45 AM and 11:46 AM, revealed that in the following locations, dissimilar metals were in direct contact with copper medical gas piping:

a) 10:45 AM, medical gas piping was resting on a steel strut in the Ground Floor Gift Shop;
b) 11:46 AM, MC cables were resting on medical gas piping above the Ground Floor cross-corridor doors, outside of X-Ray Room 11.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 11:46 AM confirmed that the metal strut and cables were in direct contact with medical gas lines.

3. Observation on March 30, 2010, at 11:05 AM in the new Medical Records Room revealed wires and flex conduit being supported by medical gas lines.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:05 AM confirmed the wire and conduit on medical gas lines.

Based on documentation review and interview, the facility failed to maintain relative humidity levels, in anesthetizing locations, in accordance with regulations.

Findings include:

1. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM revealed that the relative humidity levels for the Operating Rooms and Cath Labs over the months of January, March, and December 2009 were less than 35% and as low as 15% at various times during the month.

Interview with the Director of Plant Operations on March 29, 2010, at 12:30 PM confirmed that relative humidity levels were not maintained at or above 35%.

Based on documentation review and interview, the facility failed to maintain relative humidity levels, in anesthetizing locations, in accordance with regulations.

Findings include:

1. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM, revealed that the relative humidity levels for the Operating Rooms and Cath Labs over the months of January, March, and December 2009 were less than 35% and as low as 15% at various times during the month.

Interview with the Director of Plant Operations on March 29, 2010, at 12:30 PM confirmed that relative humidity levels were not maintained at or above 35%.

28 Pa. Code § 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. § 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal,State and local laws and regulations. The facility failed to provide adequate floor plans for the Licensure Survey.

Findings include:

Observation of floor plans on March 29-31, 2010, revealed the facility's floor plans did not indicate rated walls for storage, soiled utilities, medical gas, and shafts; did not differentiate between smoke and fire walls, and horizontal exits and exits were not clearly noted.

Interview with the Director of Plant Operations on March 31, 2010, at 11:30 AM confirmed the floor plans were not sufficient for the purpose of this survey.

Based on observation and interview, the facility failed to maintain medical gas alarm panels in one location, on one of four floors.

Findings include:

1. Observation on March 30, 2010, at 9:32 AM revealed that the medical gas alarm panel, located at the Ground Floor back Emergency Room Nurses' Station, was in alarm and silenced. The oxygen was in a low alarm, reading 13 PSIG. Interview with the Facilities Coordinator revealed that the panel had been malfunctioning and had been identified as needing repaired or replaced.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 9:32 AM confirmed the above medical gas panel deficiency.

Based on documentation review and interview, the facility failed to maintain the emergency generators which supplies emergency power for the entire building.

Findings include:

1. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM, revealed that emergency generator #1 (Olympian) and emergency generator #3 (Onan) were not visually inspected weekly for 4 weeks, between March and April 2009.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 12:30 PM confirmed the missing visual inspections.

2. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM, revealed the following emergency generator deficiencies, as identified by Premium Power Services, during annual load-bank testing:

a) Generator #1 (Olympian) - report dated 4/16/09, identified that the intake and exhaust louvers did not operate properly;
b) Generator #2 (Onan) - report dated 4/16/09, and another preventive maintenance report dated 11/12/09, identified that the engine temperature gauge was not functioning properly; the engine starting batteries needed to be replaced; and the engine block heater was imperative.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 12:30 PM confirmed the generator deficiencies above and the lack of documentation identifying corrective actions.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and/or equipment on one of four floors.

Findings include:

1. Observation on March 29, 2010, at 3:05 PM revealed an open exposed electrical box from the removal of an EXIT sign, in the ceiling at the fire doors in the 3rd Floor Bridge.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 3:05 PM confirmed the open electrical box.

2. Observation on March 30, 2010, at 9:55 AM revealed two open electrical Heating, Ventilating and Air Conditioning (HVAC) control boxes, on the 4th Floor Elevator Lobby by #9.

Interview with the Director of Plant Operations on March 30, 2010, at 9:55 AM confirmed that the above condition exists.

Based on observation and interview, the facility failed to maintain the proper use of electrical wiring and equipment, surge protectors, receptacle multipliers and/or extension cords in various locations throughout the facility.

Findings include:

1. Observation on March 29, 2010, between 11:52 AM and 2:10 PM, revealed the following improper electrical wiring and use of surge protectors and extension cords:

a) 11:52 AM , an open Elbee, and an eight (8) inch fire alarm box in the 2nd Floor East Mechanical Room.
b) 11:54 AM, an open electrical box above the 2nd Floor Nursery windows.
c) 1:45 PM, a refrigerator was plugged into a surge protector, which was plugged into an extension cord, in the Penthouse.
d)) 1:50 PM, a surface-mounted metal electrical receptacle box was being powered by temporary SJ cord, in the Penthouse.
e) 1:50 PM, an electrical junction box was missing a cover plate, above the lights inside the caged enclosure, in the Penthouse.
f) 1:55 PM, an electrical space heater was wire nutted to THNN wire and then jumped off of a cartage fuse box, inside the caged enclosure, in the Penthouse.
g) 2:10 PM, an open electrical box at the 2nd Floor smoke barrier at Room #215.

Interview with the Director of Plant Operations, Chief Safety Officer and Electrician on March 29, 2010, at the times stated above, confirmed the improper electrical wiring and misuse of surge protectors and extension cords.

2 Observation on March 29, 2010, between 1:41 PM and 2:37 PM, revealed the following electrical system deficiencies:

a) 1:41 PM, open electrical junction box in 1st Floor corridor outside Laundry Room and above wall-mounted electrical outlet.
b) 2:01 PM, three (3) extension cords powering two fans and one light in Boiler Room.
c) 2:37 PM, surge protector used to power a microwave in the Environmental Services Lounge.

Interview with the Plant Operations Manager on March 29, 2010, at the times stated above, confirmed the improper electrical wiring and misuse of surge protectors and extension cords.

3. Observation on March 29, 2010, at 2:20 PM revealed temporary Romex wiring, above the ceiling on the 5th Floor in the South, East West Corridor.

Interview with the Director of Plant Operations on March 29, 2010, at 2:20 PM confirmed the improper electrical wiring.

4. Observation on March 29, 2010, at 2:40 PM revealed that a large electrical junction box was missing a cover plate in the Ground Floor Security Office.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:40 PM confirmed the missing cover plate.

5. Observation on March 29, 2010, at 2:55 PM revealed that an electrical junction box was missing a cover plate in the 5th Floor Mechanical Room over Chiller #1.

Interview with the Director of Plant Operations on March 29, 2010, at 2:55 PM confirmed the missing cover plate.

6. Observation on March 30, 2010, between 8:55 AM and 9:10 AM, revealed the following improper electrical wiring and use of surge protectors and extension cords on the 4th Floor:

a) 8:55 AM, temporary wiring and unterminated M/C cable above the suspended ceiling, in the Elevator Lobby by #1.
b) 9:00 AM, a power tap was used in the office of Director of Marketing and Public Relations.
c) 9:10 AM, extension cords were being used in various locations and surge protectors were daisy chained, in the Bio Med Office.

Interview with the Director of Plant Operations on March 29, 2010, at the times stated above, confirmed the improper electrical wiring.

7. Observation on March 30, 2010, between 8:57 AM and 10:01 AM, revealed the following electrical system deficiencies:

a) 8:57 AM, open electrical junction box near a ceiling light in 1st Floor Kitchen Storage Room next to Auxiliary Office.
b) 9:37 AM, large orange extension cord used to power refrigeration equipment in the 1st Floor Lab.
c) 9:41 AM, three (3) extension cords used to power small refrigerators in 1st Floor Lab.
d) 9:55 AM, surge protector used to power coffee pots, microwave, and toaster in 1st Floor Lab Lounge.
e) 9:57 AM, extension cord used to power refrigerator in 1st Floor Lab Lounge.
f) 10:01 AM, extension cord used to power AC pump in 1st Floor Lab Blood Bank.

Interview with the Plant Operations Manager on March 30, 2010, at the times stated above, confirmed the improper electrical wiring.

8. Observation on March 30, 2010, at 10:45 AM in the 2nd floor Medical Records Room revealed a fan plugged in to an outlet multiplier, which was plugged into a surge protector.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 10:45 AM confirmed the improper use of electrical components.

9. Observation on March 30, 2010, between 10:30 AM and 12:00 PM, revealed the following improper electrical wiring and use of surge protectors and extension cords on the 3rd Floor:

a) 10:30 AM, old ICU Suite, exposed wires which were not properly terminated in electrical junction boxes throughout.
b) 11:05 AM, Family ICU Waiting Area, an extension cord was powering a surge protector that was used for a Fish Tank.
c) 11:20 AM, corridor outside Linen Chute and Surgical Waiting, exposed wires which were not properly terminated in electrical junction boxes throughout.
d) 11:25 AM, corridor outside Linen Chute and Surgical Waiting, revealed that there was Romex wiring running above the suspended ceiling.
e) 11:45 AM, OR Staff Lounge, multi use of extension cords and the misuse of many surge protectors (daisy chained) to power refrigerator, microwave toaster, and toaster oven.
f) 11:50 AM, corridor outside Pre-op, wall-mounted electrical panel boxes NL1 and CE2B were unlocked.

Interview with the Director of Plant Operations on March 30, 2010, at the times and locations stated above, confirmed the improper use of electrical components.

10. Observation on March 30, 2010, between 10:45 AM and 2:12 PM, revealed the following improper electrical wiring and use of surge protectors and extension cords:

a) 10:45 AM, electrical junction box was missing a cover plate, above the Ground Floor Gift Shop suspended ceiling, along the back wall.
b) 10:46 AM, electrical junction box was missing a cover plate, above the Ground Floor North Tower Registration suspended ceiling, opposite the old Film Processing Room.
c) 10:47 AM, a refrigerator was plugged into a surge protector, in Ground Floor North Tower Registration.
d) 10:58 AM, electrical junction box was missing a cover plate, above the Ground Floor cross-corridor double doors, on the backside of elevators 4 and 5.
e) 11:45 AM, temporary wiring and lighting were found above the suspended ceiling, in the Ground Floor Physicians' Reading Room, back left office.
f) 11:46 AM, electrical junction box was missing a cover plate, above the Ground Floor cross-corridor double doors, by X-Ray Room 11.
g) 1:35 PM, an extension cord was used for an under-the-counter light, at the Ground Floor Patient Holding desk.
h) 2:00 PM, the cover was missing from a large heating unit, in the Ground Floor North Stair Tower #1, by Radiology.
i) 2:12 PM, a microwave was plugged into a surge protector, in the 2nd Floor Physical and Occupational Therapy Office.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 2:12 PM confirmed the improper electrical wiring and misuse of surge protectors and extension cords.

11. Observation on March 30, 2010, between 1:39 PM and 2:23 PM, revealed surge protectors used to power medical test equipment in the 3rd Floor OR #7, OR#8, and OR#6.

Interview with the Plant Operations Manager on March 30, 2010, at 2:23 PM confirmed the improper use of surge protectors.

12. Observation on March 31, 2010, at 9:00 AM revealed that a heat lamp was plugged into an extension cord in the Ground Floor Snack Shop.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 9:00 AM confirmed the improper use of the extension cord.

13. Observation on March 31, 2010, at 9:00 AM revealed that an electrical junction box was missing a cover plate in the Ground Floor Mechanical, by the North Stair Tower #1.

Interview with the Director of Plant Operations on March 31, 2010, at 9:00 AM confirmed the missing cover plate.