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Based upon observation and interview, it was determined that the facility failed to maintain the fire resistive rated doors located in Communicating openings of the fire rated walls in two instances within this component.

Findings include:

1. Observation on December 20, 2010, at 1:10 am, revealed Second floor, near PACU in the building separation common/fire wall with the ACC building, the fire rated double doors would not positively latch into the door frame.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the doors failed to positively.

2. Observation on December 21, 2010, at 9:25 am, revealed at the common wall to the Pavilion bridge on the first floor the fire rated double doors would not close properly into the door frame because of leafs was dragging on the carpet.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the carpet impediment to closing the door.

Based on observation and interview, it was determined the facility failed to maintain the two hour fire resistance rating of the building in three instances within this component.

Findings include:

Observations on December 20, 2010, between 9:00 am and 1:35 pm, revealed fire proofing material used to maintain the fire resistance rating on structural steel members was incomplete in the following locations:

a. 9:00 am, fourth floor, next to exit stairway three.
b. 9:15 am, fourth floor, above PTOT door, three structural beams above the suspended ceiling in the corridor.
c. 1:35 pm, B-wing penthouse, far corner column located near A/C 5, missing fire proofing where steel plates are attached.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the structural steel missing fire proofing.

Based upon observation and interview, it was determined the facility failed to maintain the corridor walls to meet the required one half hour fire resistance rating to the deck above in partially sprinklered buildings on two of five floors within this component.

Findings include:

1. Observation on December 20, 2010, at 10:30 am, revealed on the third floor, Patient Tower, west corridor soiled linen room sink wall was incomplete.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the wall was incomplete.

2. Observation on December 22, 2010, at 1:40 pm, on the ground floor revealed corridor wall into Integrated Support Services, to the left of the door there were unsealed penetrations created by wires and steam pipes.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unsealed corridor wall penetrations.

Based on observation and interview, it was determined the facility failed to ensure there are no impediments to the closing of the corridor doors and ensure the corridor doors positively latch into the door frame in order that the doors remain closed in its frame in one instance within the component.

Findings include:

Observation on December 20, 2010, at 2:12 pm, on first floor revealed the Cardiac Rehabilitation suite corridor door closure would not close the door with enough force to positively latch the door to the frame. The corridor door is located near the chapel.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the corridor door requires an adjustment and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain the fire rated construction of the vertical openings on one of three floors.

Findings include:

Observation on December 21, 2010, at 9:00 am, revealed the fire barrier doors of the atrium on the first floor failed to completely close and latch.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the vertical enclosure door did not close and latch.

Based upon observation and interview, it was determined that the facility failed to maintain the one half hour fire resistance rating of the smoke barrier walls in two instances within this component.

Findings include:

1. Observation on December 20, 2010, at 12:50 pm, revealed on the second floor, A wing west at room 263, and above the double cross corridor doors, unsealed penetration of wires in the smoke barrier wall..

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke wall penetrations.

2. Observation on December 21, 2010, at 11:30 am, revealed on the first floor smoke barrier wall at the old Emergency Department waiting area and above the cross corridor double doors there were unsealed wire penetrations in the wall..

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke wall penetrations.

Based upon observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of the smoke barrier walls in one instance within this component.

Findings include:

Observation on December 22, 2010, at 9:15 am, inside the second floor above the suspended ceiling in the consultation room revealed an unsealed hole in the smoke barrier wall.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke barrier penetration.

Based upon observation and interview, it was determined that the facility failed to ensure the doors in smoke barrier partitions maintain a twenty-minute fire resistance rating, are free of impediments to closing the door, and are maintained smoke tight in their frames in one instance within this component.

Findings include:

Observation on December 20, 2010, at 10:10 am, revealed on the third floor, west wing by room 321, the smoke barrier doors had a gap greater than one quarter inch width.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the gap width.

Based upon observation and interview, the facility failed to maintain the smoke barrier doors to provide at least twenty minutes fire resistance rating in two of eight smoke compartments, NFPA 101, 2000 edition, 8.3.4.

Findings include:

1. Observation on December 21, 2010, at 10:05 am, revealed the left leaf of the smoke barrier doors by Discharge Planning Office on the first floor of South Wing did not completely close into the frame, leaving a gap.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke barrier doors were not capable of resisting smoke.


2. Observation on December 21, 2010, at 10:40 am, revealed a gap greater than a quarter of an inch at the top of the leading edges of the smoke doors by Environmental Services Room E1216.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke barrier doors were not capable of resisting smoke.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas are self closing in one instance within this component.

Findings include:

Observation on December 20, 2010, at 2:05 pm, on the first floor, revealed the closure on the corridor door to Jazzman's snack bar storage room, would not close the door with enough force to positively latch the door to the frame. The storage room is greater than 50 square feet in area, and contained numerous cardboard boxes, papers, and other combustibles.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the hazardous area door requires adjustment and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain the one hour fire rating of the hazardous spaces, in conjunction with the sprinkler system, and the facility failed to ensure the doors to hazardous areas are self closing and remain closed within the door frame on two of five floors within this component.

Findings include:

1. Observation on December 21, 2010, at 1:50 pm, on the second floor B wing revealed the door closure was removed from the supply room door, which is located across from Operating Room 2. The room is approximately 128 square feet in area and contained numerous amounts of combustible storage.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the hazardous area door did not self close.

2. Observation on December 22, 2010, between 10:00 am and 11:00 am, revealed penetrations in hazardous spaces in the following locations:

a. 10:00 am, ground floor, SPD Equipment storage room, there were holes in the wall by the light switch.
b. 11:00 am, ground floor, loading dock hall way by the Cafeteria, the Central Supply pass through fire window is not sealed at the ceiling level, between the window sill and the Central Supply ceiling.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed there were penetrations in the hazardous area enclosures.

Based on observation and interview, it was determined the facility failed to maintain the one hour fire rating of the hazardous spaces, in conjunction with the sprinkler system, in one of eight smoke compartments.

Findings include:

Observation on December 21, 2010, at 11:15 am, revealed an unsealed conduit inside the ground floor shell/storage space above the exit door approximately in the middle of the corridor, next to the medical gas lines.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed there was an unsealed conduit in the hazardous area enclosure.

Based on observation and interview, it was determined the facility failed to ensure doors in exit stairways close and positively latch to the door frame in order to maintain a continuous path of escape and provide protection against fire or smoke from other parts of the building in one instance within the component.

Findings include:

Observation on December 21, 2010, at 9:31 am, on the first floor east wing revealed the closure on the entrance door to stair tower 2 would not close the door with enough force to positively latch the door to the frame.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed exit stairway door failed to close properly and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined that the facility failed to ensure that exits are readily accessible and access to exits are not blocked in one instance within the component.

Findings include:

Observation on December 20, 2010, at 12:40 am, on the second floor revealed a computer on wheels in front of and partially blocking the exit door to exit stairway five.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the blocked exit door and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined that the facility failed to keep the corridors serving as exit access were readily accessible in one of eight smoke compartments.

Findings include:

Observation on December 21, 2010, between 10:20 am and 10:50 am, revealed Computers on Wheels were housed and being charged in the suite corridors, partially blocking egress, at the following locations:

a. 10:20 am, first floor South, by Soiled Linen Room E1223 outside of Triage.
b. 10:50 am, first floor South, lined up across the corridor, blocking access by Room E1101.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the exit access was used to charge equipment, partially obstructing egress.

Based on observation and interview, it was determined the facility failed to maintain the exit and directional signs to ensure the signs indicate the location of required exits in one instance within this component.

Findings include:

Observation on December 21, 2010, at 10:25 am, on first floor revealed the exit sign had been removed from above exit door to exit stairway three.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the exit sign was missing.

Based on observation and interview, it was determined that the facility failed to maintain the automatic sprinkler system piping free of non-system components, sprinkler heads smoke tight to the ceiling and free of debris on two of five floors within this component.

Findings include:

1. Observations made on December 20, 2010, between 9:05 am and 9:35 am, revealed sprinkler heads were not smoke tight to the ceiling possibly affecting activation of the sprinkler head at the following locations:

a. 9:05 am, fourth floor, Patient Tower, service elevator room was missing an escutcheon
b. 9:30 am, fourth floor, Patient Tower, west side soiled utility room was missing an escutcheon.
c. 9:35 am, fourth floor, Patient Tower, west side soiled utility room ceiling tile was cut too large around the sprinkler head.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the sprinkler heads were not smoke tight to the ceiling.

2. Observation on December 22, 2010, at 10:45 am, revealed a missing sprinkler escutcheon in the Soiled Linen Holding room, on the ground floor of the Soiled Linen/Morgue Suite.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the sprinkler escutcheon was missing.

Based on observation and interview, it was determined that the facility failed to maintain the sprinkler system in working order three of eight smoke compartments.

Findings include:

Observation on December 21, 2010, between 9:10 am and 11:00 am, revealed there were missing sprinkler escutcheons in the following locations:

a. 9:10 am, second floor South, Staff Restroom E2201.
b. 9:20 am, second floor South, Environmental Services E2214.
c. 9:30 am, second floor South, Medication Room E2206D.
d. 9:40 am, first floor South, Main Waiting Room by the TV.
e. 10:15 am, first floor North, Family Consultation Room.
f. 11:00 am, first floor South, Clean Utility Room E1222.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the sprinkler escutcheons were missing.

Based on observation and interview, it was determined the facility failed to ensure the fire dampers are installed inside duct work as required in one instance within the component.

Findings include:

Observation on December 22, 2010, at 9:55 am, revealed on the second floor above the fire doors separating the corridor to the elevator atrium, there were two duct work penetrations of the one hour fire resistive rated partition. The supply duct penetration had a fire/smoke damper installed and the return duct penetration had no fire damper. A review of the facility supplied architectural drawings dated October 16, 2009, indicate (page M2.2a) installation of a fire damper on only the supply duct work. On the facility supplied architectural drawings dated May 27, 2009, the drawings indicate (page M2.2b) installation of a fire damper on both the supply and return duct work. The facility shall verify with the architect and construction company where the fire dampers are required to be installed.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed incomplete duct protection per facility mechanical drawings.

Based on observation and interview, it was determined the facility failed to ensure free standing medical gas cylinders are properly chained or supported in a proper cylinder stand or cart in one instance within this component.

Findings include:

Observation on December 20, 2010, at 1:05 pm, on the second floor revealed at the entrance from the corridor to the O.R. nurse station there were two E type oxygen cylinders laying unsecured on top of two stretchers.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unsecured cylinders and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined the facility failed to ensure electrical fixtures located in the manifold room containing stored medical gas cylinders, are installed at the proper height above the floor as a precaution against their physical damage in one instance within the component.

Findings include:

Observation on December 21, 2010, at 2:05 am, revealed on the second floor OR area in the manifold gas room the electrical light switches were not installed at greater then 5 ft above the floor in order to avoid physical damage.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the medical gas storage room light switch installed at less than five feet.

Based upon document review and interview, it was determined that the facility failed to monitor and maintain equipment in anesthetizing locations at the approved levels in nine of nine operating rooms.

Findings include:

Observation on December 22, 2010, at 2:00 pm, revealed the equipment used to record the monitoring of the operating room humidity levels was not modified into Y2K compliance, resulting in the incorrect year being displayed on the humidity level reports

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the equipment monitoring humidity levels does not reflect the current year.

Based upon observation and interview, it was determined that the facility failed to maintain the proper use of and protection of electrical equipment and failed to to ensure electrical panel boxes are labeled accurately on four of five floors within this component.

Findings include:

1. Observation on December 20, 2010, at 11:10 am, revealed on the second floor north in labor and delivery area at the nurse station located across from room 212 there was an extension cords powering a microwave.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed extension cord in use.

2. Observation on December 21, 2010, at 10:55 am, revealed on the first floor, B wing transformer room, panel LPRR has no circuit breaker schedule.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the missing schedule.

3. Observation on December 21, 2010, at 10:56 am, revealed inside the first floor B-wing transformer room, panel LPRR cover is unsecured and missing screws.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unsecured panel box cover.

4. Observations on December 21, 2010, between 9:55 am and 2:10 pm, revealed a unauthorized use of surge protectors and extension cords in the following areas:

a. 9:55 am, first floor, Library, multiple daisy chained power strips powering computers at the computer table.
b. 10:05 am, first floor, Infection Control Office, appliances powered through a surge protector.
c. 11:20 am first floor, Laboratory, chemistry room, freezer plugged into an extension cord.
d. 2:10 pm refrigerator and microwave wave powered from a surge protector on the third floor, Patient Tower, IV Team.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unauthorized use of electrical powered supply equipment and the subsequent correction of item "a" at the time of the survey.

5. Observation on December 21, 2010, at 10:30 am, revealed on the first floor above the ceiling in the corridor outside the MRI Suite double doors located near exit stairway three there were unsecured junction boxes.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unsecured junction boxes.

6. Observation on December 22, 2010, at 11:10 am, revealed a surge protector was being powered by another surge protector in the cubicle by the window in the Integrated Support Services Office on the ground floor, by the Boiler Room.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the surge protector was being used in an unauthorized method.

Based upon observation and interview, it was determined the facility failed to ensure that temporary wiring was not used in place of permanent wiring in one instance within this component.

Findings include:

Observation on December 20, 2010, at 2:05 pm, on the first floor revealed inside the mechanical electrical closet there was a flexible yellow colored wire supplying power to an electrical receptacle. The receptacle was powering a low voltage electrical transformer.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the electrical flexible wire was in use in place of permanent wiring.

Based upon observation and interview, it was determined the facility failed to maintain the electrical elements in working order in one of eight smoke compartments, Department of Health message board, message dated October 30, 2009, and NFPA 70.

Findings include:

Observation on December 21, 2010, between 9:45 am and 10:00 am, revealed there were unapproved power tap devices being used at the following locations:

a. 9:45 am, first floor South, Main Lobby, an extension cord was powering the Christmas Tree.
b. 9:50 am, first floor South, Security Office, an extension cord supplying power under a desk against the outside wall.
c. 10:00 am, first floor South, Discharge Planning Office, an extension cord was powering the floor lamp.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed there were unapproved power tap devices being used.

Based on observation and interview, it was determined the facility failed to maintain Alcohol Based Hand Rub (ABHR) dispensers away from ignition sources in one of eight smoke compartments.

Findings include:

Observation on December 21, 2010, at 10:30 am, revealed an ABHR was installed directly above an electrical outlet in the North Wing of the first floor between ER Rooms 32 and 33.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the ABHR was installed above an ignition source.

Based upon observation and interview, it was determined that the facility failed to maintain the fire resistive rated doors located in Communicating openings of the fire rated walls in two instances within this component.

Findings include:

1. Observation on December 20, 2010, at 1:10 am, revealed Second floor, near PACU in the building separation common/fire wall with the ACC building, the fire rated double doors would not positively latch into the door frame.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the doors failed to positively.

2. Observation on December 21, 2010, at 9:25 am, revealed at the common wall to the Pavilion bridge on the first floor the fire rated double doors would not close properly into the door frame because of leafs was dragging on the carpet.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the carpet impediment to closing the door.

Based on observation and interview, it was determined the facility failed to maintain the two hour fire resistance rating of the building in three instances within this component.

Findings include:

Observations on December 20, 2010, between 9:00 am and 1:35 pm, revealed fire proofing material used to maintain the fire resistance rating on structural steel members was incomplete in the following locations:

a. 9:00 am, fourth floor, next to exit stairway three.
b. 9:15 am, fourth floor, above PTOT door, three structural beams above the suspended ceiling in the corridor.
c. 1:35 pm, B-wing penthouse, far corner column located near A/C 5, missing fire proofing where steel plates are attached.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the structural steel missing fire proofing.

Based upon observation and interview, it was determined the facility failed to maintain the corridor walls to meet the required one half hour fire resistance rating to the deck above in partially sprinklered buildings on two of five floors within this component.

Findings include:

1. Observation on December 20, 2010, at 10:30 am, revealed on the third floor, Patient Tower, west corridor soiled linen room sink wall was incomplete.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the wall was incomplete.

2. Observation on December 22, 2010, at 1:40 pm, on the ground floor revealed corridor wall into Integrated Support Services, to the left of the door there were unsealed penetrations created by wires and steam pipes.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unsealed corridor wall penetrations.

Based on observation and interview, it was determined the facility failed to ensure there are no impediments to the closing of the corridor doors and ensure the corridor doors positively latch into the door frame in order that the doors remain closed in its frame in one instance within the component.

Findings include:

Observation on December 20, 2010, at 2:12 pm, on first floor revealed the Cardiac Rehabilitation suite corridor door closure would not close the door with enough force to positively latch the door to the frame. The corridor door is located near the chapel.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the corridor door requires an adjustment and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain the fire rated construction of the vertical openings on one of three floors.

Findings include:

Observation on December 21, 2010, at 9:00 am, revealed the fire barrier doors of the atrium on the first floor failed to completely close and latch.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the vertical enclosure door did not close and latch.

Based upon observation and interview, it was determined that the facility failed to maintain the one half hour fire resistance rating of the smoke barrier walls in two instances within this component.

Findings include:

1. Observation on December 20, 2010, at 12:50 pm, revealed on the second floor, A wing west at room 263, and above the double cross corridor doors, unsealed penetration of wires in the smoke barrier wall..

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke wall penetrations.

2. Observation on December 21, 2010, at 11:30 am, revealed on the first floor smoke barrier wall at the old Emergency Department waiting area and above the cross corridor double doors there were unsealed wire penetrations in the wall..

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke wall penetrations.

Based upon observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of the smoke barrier walls in one instance within this component.

Findings include:

Observation on December 22, 2010, at 9:15 am, inside the second floor above the suspended ceiling in the consultation room revealed an unsealed hole in the smoke barrier wall.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke barrier penetration.

Based upon observation and interview, it was determined that the facility failed to ensure the doors in smoke barrier partitions maintain a twenty-minute fire resistance rating, are free of impediments to closing the door, and are maintained smoke tight in their frames in one instance within this component.

Findings include:

Observation on December 20, 2010, at 10:10 am, revealed on the third floor, west wing by room 321, the smoke barrier doors had a gap greater than one quarter inch width.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the gap width.

Based upon observation and interview, the facility failed to maintain the smoke barrier doors to provide at least twenty minutes fire resistance rating in two of eight smoke compartments, NFPA 101, 2000 edition, 8.3.4.

Findings include:

1. Observation on December 21, 2010, at 10:05 am, revealed the left leaf of the smoke barrier doors by Discharge Planning Office on the first floor of South Wing did not completely close into the frame, leaving a gap.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke barrier doors were not capable of resisting smoke.


2. Observation on December 21, 2010, at 10:40 am, revealed a gap greater than a quarter of an inch at the top of the leading edges of the smoke doors by Environmental Services Room E1216.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the smoke barrier doors were not capable of resisting smoke.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas are self closing in one instance within this component.

Findings include:

Observation on December 20, 2010, at 2:05 pm, on the first floor, revealed the closure on the corridor door to Jazzman's snack bar storage room, would not close the door with enough force to positively latch the door to the frame. The storage room is greater than 50 square feet in area, and contained numerous cardboard boxes, papers, and other combustibles.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the hazardous area door requires adjustment and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain the one hour fire rating of the hazardous spaces, in conjunction with the sprinkler system, and the facility failed to ensure the doors to hazardous areas are self closing and remain closed within the door frame on two of five floors within this component.

Findings include:

1. Observation on December 21, 2010, at 1:50 pm, on the second floor B wing revealed the door closure was removed from the supply room door, which is located across from Operating Room 2. The room is approximately 128 square feet in area and contained numerous amounts of combustible storage.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the hazardous area door did not self close.

2. Observation on December 22, 2010, between 10:00 am and 11:00 am, revealed penetrations in hazardous spaces in the following locations:

a. 10:00 am, ground floor, SPD Equipment storage room, there were holes in the wall by the light switch.
b. 11:00 am, ground floor, loading dock hall way by the Cafeteria, the Central Supply pass through fire window is not sealed at the ceiling level, between the window sill and the Central Supply ceiling.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed there were penetrations in the hazardous area enclosures.

Based on observation and interview, it was determined the facility failed to maintain the one hour fire rating of the hazardous spaces, in conjunction with the sprinkler system, in one of eight smoke compartments.

Findings include:

Observation on December 21, 2010, at 11:15 am, revealed an unsealed conduit inside the ground floor shell/storage space above the exit door approximately in the middle of the corridor, next to the medical gas lines.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed there was an unsealed conduit in the hazardous area enclosure.

Based on observation and interview, it was determined the facility failed to ensure doors in exit stairways close and positively latch to the door frame in order to maintain a continuous path of escape and provide protection against fire or smoke from other parts of the building in one instance within the component.

Findings include:

Observation on December 21, 2010, at 9:31 am, on the first floor east wing revealed the closure on the entrance door to stair tower 2 would not close the door with enough force to positively latch the door to the frame.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed exit stairway door failed to close properly and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined that the facility failed to ensure that exits are readily accessible and access to exits are not blocked in one instance within the component.

Findings include:

Observation on December 20, 2010, at 12:40 am, on the second floor revealed a computer on wheels in front of and partially blocking the exit door to exit stairway five.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the blocked exit door and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined that the facility failed to keep the corridors serving as exit access were readily accessible in one of eight smoke compartments.

Findings include:

Observation on December 21, 2010, between 10:20 am and 10:50 am, revealed Computers on Wheels were housed and being charged in the suite corridors, partially blocking egress, at the following locations:

a. 10:20 am, first floor South, by Soiled Linen Room E1223 outside of Triage.
b. 10:50 am, first floor South, lined up across the corridor, blocking access by Room E1101.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the exit access was used to charge equipment, partially obstructing egress.

Based on observation and interview, it was determined the facility failed to maintain the exit and directional signs to ensure the signs indicate the location of required exits in one instance within this component.

Findings include:

Observation on December 21, 2010, at 10:25 am, on first floor revealed the exit sign had been removed from above exit door to exit stairway three.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the exit sign was missing.

Based on observation and interview, it was determined that the facility failed to maintain the automatic sprinkler system piping free of non-system components, sprinkler heads smoke tight to the ceiling and free of debris on two of five floors within this component.

Findings include:

1. Observations made on December 20, 2010, between 9:05 am and 9:35 am, revealed sprinkler heads were not smoke tight to the ceiling possibly affecting activation of the sprinkler head at the following locations:

a. 9:05 am, fourth floor, Patient Tower, service elevator room was missing an escutcheon
b. 9:30 am, fourth floor, Patient Tower, west side soiled utility room was missing an escutcheon.
c. 9:35 am, fourth floor, Patient Tower, west side soiled utility room ceiling tile was cut too large around the sprinkler head.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the sprinkler heads were not smoke tight to the ceiling.

2. Observation on December 22, 2010, at 10:45 am, revealed a missing sprinkler escutcheon in the Soiled Linen Holding room, on the ground floor of the Soiled Linen/Morgue Suite.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the sprinkler escutcheon was missing.

Based on observation and interview, it was determined that the facility failed to maintain the sprinkler system in working order three of eight smoke compartments.

Findings include:

Observation on December 21, 2010, between 9:10 am and 11:00 am, revealed there were missing sprinkler escutcheons in the following locations:

a. 9:10 am, second floor South, Staff Restroom E2201.
b. 9:20 am, second floor South, Environmental Services E2214.
c. 9:30 am, second floor South, Medication Room E2206D.
d. 9:40 am, first floor South, Main Waiting Room by the TV.
e. 10:15 am, first floor North, Family Consultation Room.
f. 11:00 am, first floor South, Clean Utility Room E1222.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the sprinkler escutcheons were missing.

Based on observation and interview, it was determined the facility failed to ensure the fire dampers are installed inside duct work as required in one instance within the component.

Findings include:

Observation on December 22, 2010, at 9:55 am, revealed on the second floor above the fire doors separating the corridor to the elevator atrium, there were two duct work penetrations of the one hour fire resistive rated partition. The supply duct penetration had a fire/smoke damper installed and the return duct penetration had no fire damper. A review of the facility supplied architectural drawings dated October 16, 2009, indicate (page M2.2a) installation of a fire damper on only the supply duct work. On the facility supplied architectural drawings dated May 27, 2009, the drawings indicate (page M2.2b) installation of a fire damper on both the supply and return duct work. The facility shall verify with the architect and construction company where the fire dampers are required to be installed.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed incomplete duct protection per facility mechanical drawings.

Based on observation and interview, it was determined the facility failed to ensure free standing medical gas cylinders are properly chained or supported in a proper cylinder stand or cart in one instance within this component.

Findings include:

Observation on December 20, 2010, at 1:05 pm, on the second floor revealed at the entrance from the corridor to the O.R. nurse station there were two E type oxygen cylinders laying unsecured on top of two stretchers.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unsecured cylinders and the subsequent correction of the deficiency at the time of the survey.

Based on observation and interview, it was determined the facility failed to ensure electrical fixtures located in the manifold room containing stored medical gas cylinders, are installed at the proper height above the floor as a precaution against their physical damage in one instance within the component.

Findings include:

Observation on December 21, 2010, at 2:05 am, revealed on the second floor OR area in the manifold gas room the electrical light switches were not installed at greater then 5 ft above the floor in order to avoid physical damage.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the medical gas storage room light switch installed at less than five feet.

Based upon document review and interview, it was determined that the facility failed to monitor and maintain equipment in anesthetizing locations at the approved levels in nine of nine operating rooms.

Findings include:

Observation on December 22, 2010, at 2:00 pm, revealed the equipment used to record the monitoring of the operating room humidity levels was not modified into Y2K compliance, resulting in the incorrect year being displayed on the humidity level reports

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the equipment monitoring humidity levels does not reflect the current year.

Based upon observation and interview, it was determined that the facility failed to maintain the proper use of and protection of electrical equipment and failed to to ensure electrical panel boxes are labeled accurately on four of five floors within this component.

Findings include:

1. Observation on December 20, 2010, at 11:10 am, revealed on the second floor north in labor and delivery area at the nurse station located across from room 212 there was an extension cords powering a microwave.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed extension cord in use.

2. Observation on December 21, 2010, at 10:55 am, revealed on the first floor, B wing transformer room, panel LPRR has no circuit breaker schedule.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the missing schedule.

3. Observation on December 21, 2010, at 10:56 am, revealed inside the first floor B-wing transformer room, panel LPRR cover is unsecured and missing screws.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unsecured panel box cover.

4. Observations on December 21, 2010, between 9:55 am and 2:10 pm, revealed a unauthorized use of surge protectors and extension cords in the following areas:

a. 9:55 am, first floor, Library, multiple daisy chained power strips powering computers at the computer table.
b. 10:05 am, first floor, Infection Control Office, appliances powered through a surge protector.
c. 11:20 am first floor, Laboratory, chemistry room, freezer plugged into an extension cord.
d. 2:10 pm refrigerator and microwave wave powered from a surge protector on the third floor, Patient Tower, IV Team.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unauthorized use of electrical powered supply equipment and the subsequent correction of item "a" at the time of the survey.

5. Observation on December 21, 2010, at 10:30 am, revealed on the first floor above the ceiling in the corridor outside the MRI Suite double doors located near exit stairway three there were unsecured junction boxes.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the unsecured junction boxes.

6. Observation on December 22, 2010, at 11:10 am, revealed a surge protector was being powered by another surge protector in the cubicle by the window in the Integrated Support Services Office on the ground floor, by the Boiler Room.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the surge protector was being used in an unauthorized method.

Based upon observation and interview, it was determined the facility failed to ensure that temporary wiring was not used in place of permanent wiring in one instance within this component.

Findings include:

Observation on December 20, 2010, at 2:05 pm, on the first floor revealed inside the mechanical electrical closet there was a flexible yellow colored wire supplying power to an electrical receptacle. The receptacle was powering a low voltage electrical transformer.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed the electrical flexible wire was in use in place of permanent wiring.

Based upon observation and interview, it was determined the facility failed to maintain the electrical elements in working order in one of eight smoke compartments, Department of Health message board, message dated October 30, 2009, and NFPA 70.

Findings include:

Observation on December 21, 2010, between 9:45 am and 10:00 am, revealed there were unapproved power tap devices being used at the following locations:

a. 9:45 am, first floor South, Main Lobby, an extension cord was powering the Christmas Tree.
b. 9:50 am, first floor South, Security Office, an extension cord supplying power under a desk against the outside wall.
c. 10:00 am, first floor South, Discharge Planning Office, an extension cord was powering the floor lamp.

Interview at the exit conference with the Director of Plant Operations on December 22, 2010, at 2:20 pm, confirmed there were unapproved power tap devices being used.