HospitalInspections.org

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013 between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed unsealed penetrations in the corridor wall at the "Blood Bank".

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed a sprinkler head in the 2nd floor trash room dust loaded.

2. Observed that the latch to room 46 is broken.

3. Observed that the door to room 444 has a significant gap and is not reasonably smoke tight.

4. Observed that the door to room 446 has a significant gap and is not reasonably smoke tight.

5. Observed that the door to room 346 did not fully close and latch when tested.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed an unsealed penetration around sprinkler line, above the door to Stairwell 4F.

2. Observed rated door assembly for the shafts located in Stairwell 4D was not anchored correctly.

3. Observed an unsealed penetration around sprinkler line, above the door to Stairwell 2J.

4. Observed that the door to Stairwell F, 5th floor, did not fully close and self-latch when tested.

5. Observed an unapproved TV cable that was ran through Stairwell D, first floor. (Facility to relocate cable.)

6. Observed an unsealed wall penetration in the "Small Vestibule" in 1st floor Stairwell C.

7. Observed that the rated door from Stairwell C to the Chapel was held open.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed an unsealed wall penetration above the cross-corridor smoke barrier doors at room 385.

2. Observed an unsealed conduit penetration above the cross-corridor smoke barrier doors to the Graduate Medical Education wing.

3. Observed an unsealed wall penetration above the cross-corridor smoke barrier doors adjacent to the Central Store Room.

4. Observed unsealed cable penetrations above the cross-corridor smoke barrier doors at the 2nd floor electrical room.

5. Observed multiple unsealed wall penetrations above the cross-corridor smoke barrier doors to Non-Invasive Cardiology 2108.

6. Observed an unsealed wall penetration, around the duct work angle iron, above the cross-corridor smoke barrier at Stairwell door 2K.

7. Observed an unapproved sliding window within a rated wall in Patient Accounts office 2117.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed a gap exceeding 1/8" between the astragal and bottom of the cross-corridor smoke barrier door at Cisto Lab.

2. Observed a gap exceeding 1/8" between the astragal and bottom of the cross-corridor smoke barrier door to P.A.T.

3. Observed that the cross-corridor smoke barrier doors at classroom 4 did not fully close when tested.

4. Observed that the coordinator on the cross-corridor smoke barrier doors did not function when tested.

5. Observed that the fire door to the 1st floor doctors' lounge has been removed. This door is part of a rated wall.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed the Hilti sleeve penetrations in room 63175-T were not completely closed.

2. Observed that the door to the trash chute in the Emergency Department west corridor did not fully close and latch when tested.

3. Observed unsealed penetrations, around conduit, in room 60145.

4. Observed an unsealed wall penetration around the sprinkler line in I.S. storage room.

5. Observed improperly fire stopped yellow cables penetrating the corridor wall inside of I.S. storage room.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed that the door to environmental services did not fully close and self-latch when tested.

2. Observed that the "small" access doors to the rated shaft did not self-close and latch when tested.

3. Observed that the door to the "Isolation Caddies" is not self-closing.

4. Observed that the door to storage room B121 does not self-close.

5. Observed combustible storage under the stairs at radiation oncology.

6. Observed combustibles being stored in the 2nd floor "Market" corridor.

7. Observed a large unsealed wall penetration in the kitchens rated wall, adjacent to the freezer.

8. Observed an excessive amount of combustibles that have the ability to overwhelm the sprinkler system in the dietary storage room.

9. Observed unsealed wall penetrations in the fire alarm panel room WB25A.

10. Observed unsealed wall penetrations in the main boiler room around the red pipe and at city water feed.

11. Observed unsealed wall penetrations above the door to the lab.

12. Observed unsealed wall penetrations above the door to electrical room 2206.

13. Observed an unsealed penetration around the sprinkler line in room 420.

14. Observed an unsealed floor conduit in the electrical closet at the 4E nurses' station.

15. Observed that patient room 447 is being used for storage and that the door is not self-closing and latching.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed wheelchairs being stored in the corridor at room 328.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed that the battery operated emergency light in the boiler room, at the men's room, did not function when tested.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed that the smoke detector at the 6th floor elevator was not properly attached to the junction box.

2. Observed that the fire alarm pull station at the 4-East nurses' station was obstructed by papers.

3. Observed spliced fire alarm wires not in a junction box above the door to Stairwell 2K.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed that a sprinkler escutcheon was missing in Bio-hazard room 60139.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed a sprinkler head in the 2nd floor trash room dust loaded.

2. Observed the new duct work in the 3rd floor large mechanical room has insufficient sprinkler coverage underneath.

3. Observed equipment being hung from the sprinkler systems inspectors test valve in the janitor's closet at room 400F.

4. Observed during renovation of the Women's Center waiting room the sprinkler head was not relocated and is obstructed by the ceiling tile.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation and/or review of records the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed that the fire extinguishers in the lab were obstructed by equipment. (Facility to install signs.)

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed that grease filters above the "Fresh Grill" were not installed correctly.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed an electrical junction box above the ceiling at room 60145 missing a cover plate.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed an open electrical junction box above the door to the 1st floor administration offices.

2. Observed an open electrical junction box above the 2-hour fire rated doors at the 2nd floor building separation.

3. Observed combustibles stacked against the electrical panel in the basement environmental storage room.

4. Observed combustibles stacked against the electrical panel in the building 4 basement electrical room.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013 between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed unsealed penetrations in the corridor wall at the "Blood Bank".

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed a sprinkler head in the 2nd floor trash room dust loaded.

2. Observed that the latch to room 46 is broken.

3. Observed that the door to room 444 has a significant gap and is not reasonably smoke tight.

4. Observed that the door to room 446 has a significant gap and is not reasonably smoke tight.

5. Observed that the door to room 346 did not fully close and latch when tested.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed an unsealed penetration around sprinkler line, above the door to Stairwell 4F.

2. Observed rated door assembly for the shafts located in Stairwell 4D was not anchored correctly.

3. Observed an unsealed penetration around sprinkler line, above the door to Stairwell 2J.

4. Observed that the door to Stairwell F, 5th floor, did not fully close and self-latch when tested.

5. Observed an unapproved TV cable that was ran through Stairwell D, first floor. (Facility to relocate cable.)

6. Observed an unsealed wall penetration in the "Small Vestibule" in 1st floor Stairwell C.

7. Observed that the rated door from Stairwell C to the Chapel was held open.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed an unsealed wall penetration above the cross-corridor smoke barrier doors at room 385.

2. Observed an unsealed conduit penetration above the cross-corridor smoke barrier doors to the Graduate Medical Education wing.

3. Observed an unsealed wall penetration above the cross-corridor smoke barrier doors adjacent to the Central Store Room.

4. Observed unsealed cable penetrations above the cross-corridor smoke barrier doors at the 2nd floor electrical room.

5. Observed multiple unsealed wall penetrations above the cross-corridor smoke barrier doors to Non-Invasive Cardiology 2108.

6. Observed an unsealed wall penetration, around the duct work angle iron, above the cross-corridor smoke barrier at Stairwell door 2K.

7. Observed an unapproved sliding window within a rated wall in Patient Accounts office 2117.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed a gap exceeding 1/8" between the astragal and bottom of the cross-corridor smoke barrier door at Cisto Lab.

2. Observed a gap exceeding 1/8" between the astragal and bottom of the cross-corridor smoke barrier door to P.A.T.

3. Observed that the cross-corridor smoke barrier doors at classroom 4 did not fully close when tested.

4. Observed that the coordinator on the cross-corridor smoke barrier doors did not function when tested.

5. Observed that the fire door to the 1st floor doctors' lounge has been removed. This door is part of a rated wall.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed the Hilti sleeve penetrations in room 63175-T were not completely closed.

2. Observed that the door to the trash chute in the Emergency Department west corridor did not fully close and latch when tested.

3. Observed unsealed penetrations, around conduit, in room 60145.

4. Observed an unsealed wall penetration around the sprinkler line in I.S. storage room.

5. Observed improperly fire stopped yellow cables penetrating the corridor wall inside of I.S. storage room.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed that the door to environmental services did not fully close and self-latch when tested.

2. Observed that the "small" access doors to the rated shaft did not self-close and latch when tested.

3. Observed that the door to the "Isolation Caddies" is not self-closing.

4. Observed that the door to storage room B121 does not self-close.

5. Observed combustible storage under the stairs at radiation oncology.

6. Observed combustibles being stored in the 2nd floor "Market" corridor.

7. Observed a large unsealed wall penetration in the kitchens rated wall, adjacent to the freezer.

8. Observed an excessive amount of combustibles that have the ability to overwhelm the sprinkler system in the dietary storage room.

9. Observed unsealed wall penetrations in the fire alarm panel room WB25A.

10. Observed unsealed wall penetrations in the main boiler room around the red pipe and at city water feed.

11. Observed unsealed wall penetrations above the door to the lab.

12. Observed unsealed wall penetrations above the door to electrical room 2206.

13. Observed an unsealed penetration around the sprinkler line in room 420.

14. Observed an unsealed floor conduit in the electrical closet at the 4E nurses' station.

15. Observed that patient room 447 is being used for storage and that the door is not self-closing and latching.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed wheelchairs being stored in the corridor at room 328.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed that the battery operated emergency light in the boiler room, at the men's room, did not function when tested.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed that the smoke detector at the 6th floor elevator was not properly attached to the junction box.

2. Observed that the fire alarm pull station at the 4-East nurses' station was obstructed by papers.

3. Observed spliced fire alarm wires not in a junction box above the door to Stairwell 2K.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed that a sprinkler escutcheon was missing in Bio-hazard room 60139.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed a sprinkler head in the 2nd floor trash room dust loaded.

2. Observed the new duct work in the 3rd floor large mechanical room has insufficient sprinkler coverage underneath.

3. Observed equipment being hung from the sprinkler systems inspectors test valve in the janitor's closet at room 400F.

4. Observed during renovation of the Women's Center waiting room the sprinkler head was not relocated and is obstructed by the ceiling tile.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation and/or review of records the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed that the fire extinguishers in the lab were obstructed by equipment. (Facility to install signs.)

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed that grease filters above the "Fresh Grill" were not installed correctly.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observation was made:

1. Observed an electrical junction box above the ceiling at room 60145 missing a cover plate.

This finding was observed and confirmed by the facility maintenance director at the time of inspection.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 304 occupants of the facility. Findings include:

During an inspection conducted May 14-15, 2013, between the hours of 9:00 AM and 4:00 PM, the following observations were made:

1. Observed an open electrical junction box above the door to the 1st floor administration offices.

2. Observed an open electrical junction box above the 2-hour fire rated doors at the 2nd floor building separation.

3. Observed combustibles stacked against the electrical panel in the basement environmental storage room.

4. Observed combustibles stacked against the electrical panel in the building 4 basement electrical room.

These findings were observed and confirmed by the facility maintenance director at the time of inspection.