HospitalInspections.org

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in one location on one of ten floors.

Findings include:

Observation of the sixth floor I.C.U. Waiting Room at 09:24 a.m. on March 13, 2012, revealed horizontal structural steel within to lack spray fireproofing in one location

Interview with facilities manager at 09:25 a.m. on March 13, 2012, confirmed the structural steel to lack spray fireproofing in one location.

Based upon observation and interview, it was determined the facility failed to maintain two corridor openings in two locations on one of ten floors.

Findings include:

1. Observation of various corridor openings between 09:15 a.m. and 09:22 a.m. on March 13, 2012, revealed the below deficiencies:

a. The sixth floor Family Room corridor entrance door lacks smoke-tight integrity when coupled with the corresponding door frame assembly. 09:15 a.m.
b. The sixth floor I.C.U. Waiting Room corridor entrance door lacks smoke-tight integrity when coupled with the corresponding door frame assembly. 09:22 a.m.

Interview with facilities manager at 09:23 a.m. on March 13, 2012, confirmed the above corridor entrance doors to lack smoke-tight integrity.

Based upon observation and interview, it was determined the facility failed to maintain one vertical opening in one location on one of five floors.

Findings include:

Observation of the basement-level portion of the conduit shaft enclosure at 08:22 a.m. on March 14, 2012, revealed the shaft to require a fire resistive seal around the annular spaces of miscellaneous electrical conduit.

Interview with facilities manager two at 08:23 a.m. on March 14, 2012, confirmed the vertical opening deficiency.

Based upon observation and interview, it was determined the facility failed to maintain one vertical opening in one location on one of nine floors.

Findings include:

Observation of the fourth floor electrical room located closest to Patient Room 425 at 09:54 a.m. on March 13, 2012, revealed a conduit penetration at the floor slab assembly.

Interview with facilities manager at 09:55 a.m. on March 13, 2012, confirmed the vertical opening deficiency.

Based upon observation and interview, it was determined the facility failed to maintain one vertical opening in one location on one of ten floors.

Findings include:

Observation of the sixth floor I.C.U. Waiting Room at 09:26 a.m. on March 13, 2012, revealed two large conduit penetrations located at the floor slab assembly (beyond the suspended ceiling assembly.)

Interview with facilities manager at 09:27 a.m. on March 13, 2012, confirmed the vertical penetrations.

Based upon observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall in one location on one of nine floors.

Findings include:

Observation of the area beyond the ground floor smoke barrier separation doors (S.D.G05) at 11:12 a.m. on March 13, 2012, revealed a penetration of the smoke barrier separation wall.

Interview with facilities manager at 11:13 a.m. on March 13, 2012, confirmed the smoke barrier separation wall deficiency.

Based upon observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall in two locations on one of ten floors.

Findings include:

Observation of the portion of the sixth floor smoke barrier separation wall located beyond SD 603 at 09:08 a.m. on March 13, 2012, revealed several penetrations of the smoke barrier wall in this location.

Interview with facilities manager at 09:09 a.m. on March 13, 2012, confirmed the penetrations of the smoke barrier wall.

Based upon observation and interview, it was determined the facility failed to maintain one hazardous area enclosure in one location on one of five floors.

Findings include:

Observation of the basement-level mechanical room entrance door at 08:06 a.m. on March 14, 2012, revealed the door to be held open by unapproved means.

Interview with facilities manager two at 08:07 a.m. on March 14, 2012, confirmed the door to be held open by means of a chock device.

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

Findings include:

1. Observation of various exit access corridor systems between 10:06 a.m. and 10:22 a.m. on March 13, 2012, revealed the below deficiencies:

a. Illuminated exit signage is lacking at the 200 smoke barrier separation doors. 10:06 a.m.
b. Illuminated exit signage is required within the ground floor S.P.D. corridor (west end.) 10:22 a.m.

Interview with facilities manager at 10:25 a.m. on March 13, 2012, confirmed the absence of illuminated exit signage in the above locations.

Based upon observation and interview, it was determined the facility failed to maintain electrical systems (and associated apparatus) in one location on one of nine floors.

Findings include:

Observation of the first floor Gift Shop at 10:09 a.m. on March 13, 2012, revealed a surge protector being used to power an electrical lamp.

Interview with facilities manager at 10:10 a.m. on March 13, 2012, confirmed the electrical deficiency stated above.

Based upon observation and interview, it was determined the facility failed to properly install alcohol-based hand rub dispensers in one location on one of ten floors.

Findings include:

Observation of the sixth floor Rehab Gym at 08:55 a.m. on March 13, 2012, revealed an adjacent electrical outlet in close proximity to the alcohol-based hand rub station.

Interview with facilities manager at 08:56 a.m. on March 13, 2012, confirmed the improper installation of the A.B.H.R. dispenser.

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in one location on one of ten floors.

Findings include:

Observation of the sixth floor I.C.U. Waiting Room at 09:24 a.m. on March 13, 2012, revealed horizontal structural steel within to lack spray fireproofing in one location

Interview with facilities manager at 09:25 a.m. on March 13, 2012, confirmed the structural steel to lack spray fireproofing in one location.

Based upon observation and interview, it was determined the facility failed to maintain two corridor openings in two locations on one of ten floors.

Findings include:

1. Observation of various corridor openings between 09:15 a.m. and 09:22 a.m. on March 13, 2012, revealed the below deficiencies:

a. The sixth floor Family Room corridor entrance door lacks smoke-tight integrity when coupled with the corresponding door frame assembly. 09:15 a.m.
b. The sixth floor I.C.U. Waiting Room corridor entrance door lacks smoke-tight integrity when coupled with the corresponding door frame assembly. 09:22 a.m.

Interview with facilities manager at 09:23 a.m. on March 13, 2012, confirmed the above corridor entrance doors to lack smoke-tight integrity.

Based upon observation and interview, it was determined the facility failed to maintain one vertical opening in one location on one of five floors.

Findings include:

Observation of the basement-level portion of the conduit shaft enclosure at 08:22 a.m. on March 14, 2012, revealed the shaft to require a fire resistive seal around the annular spaces of miscellaneous electrical conduit.

Interview with facilities manager two at 08:23 a.m. on March 14, 2012, confirmed the vertical opening deficiency.

Based upon observation and interview, it was determined the facility failed to maintain one vertical opening in one location on one of nine floors.

Findings include:

Observation of the fourth floor electrical room located closest to Patient Room 425 at 09:54 a.m. on March 13, 2012, revealed a conduit penetration at the floor slab assembly.

Interview with facilities manager at 09:55 a.m. on March 13, 2012, confirmed the vertical opening deficiency.

Based upon observation and interview, it was determined the facility failed to maintain one vertical opening in one location on one of ten floors.

Findings include:

Observation of the sixth floor I.C.U. Waiting Room at 09:26 a.m. on March 13, 2012, revealed two large conduit penetrations located at the floor slab assembly (beyond the suspended ceiling assembly.)

Interview with facilities manager at 09:27 a.m. on March 13, 2012, confirmed the vertical penetrations.

Based upon observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall in one location on one of nine floors.

Findings include:

Observation of the area beyond the ground floor smoke barrier separation doors (S.D.G05) at 11:12 a.m. on March 13, 2012, revealed a penetration of the smoke barrier separation wall.

Interview with facilities manager at 11:13 a.m. on March 13, 2012, confirmed the smoke barrier separation wall deficiency.

Based upon observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall in two locations on one of ten floors.

Findings include:

Observation of the portion of the sixth floor smoke barrier separation wall located beyond SD 603 at 09:08 a.m. on March 13, 2012, revealed several penetrations of the smoke barrier wall in this location.

Interview with facilities manager at 09:09 a.m. on March 13, 2012, confirmed the penetrations of the smoke barrier wall.

Based upon observation and interview, it was determined the facility failed to maintain one hazardous area enclosure in one location on one of five floors.

Findings include:

Observation of the basement-level mechanical room entrance door at 08:06 a.m. on March 14, 2012, revealed the door to be held open by unapproved means.

Interview with facilities manager two at 08:07 a.m. on March 14, 2012, confirmed the door to be held open by means of a chock device.

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

Findings include:

1. Observation of various exit access corridor systems between 10:06 a.m. and 10:22 a.m. on March 13, 2012, revealed the below deficiencies:

a. Illuminated exit signage is lacking at the 200 smoke barrier separation doors. 10:06 a.m.
b. Illuminated exit signage is required within the ground floor S.P.D. corridor (west end.) 10:22 a.m.

Interview with facilities manager at 10:25 a.m. on March 13, 2012, confirmed the absence of illuminated exit signage in the above locations.

Based upon observation and interview, it was determined the facility failed to maintain electrical systems (and associated apparatus) in one location on one of nine floors.

Findings include:

Observation of the first floor Gift Shop at 10:09 a.m. on March 13, 2012, revealed a surge protector being used to power an electrical lamp.

Interview with facilities manager at 10:10 a.m. on March 13, 2012, confirmed the electrical deficiency stated above.