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Based on observation and interview, it was determined the facility failed to maintain latching hardware for three corridor doors, on two of three floors of the building.

Findings include:

1. Observation on October 18, 2011, at 11:39 AM revealed the corridor door to Room 185PBX was held open with a wooden wedge.

Interview with Mechanic 3 on October 18, 2011, at 11:39 AM confirmed the use of an unapproved door hold-open device and the subsequent correction of the deficiency at the time of the survey.

2. Observation on October 18, 2011, at 11:43 AM revealed the dutch-door to Room ED161 lacked an astragal, rabbet or bevel, and required a latching adjustment to properly latch in the frame.

Interview with Mechanic 3 on October 18, 2011, at 11:43 AM confirmed the missing hardware and the need for a latching adjustment.

3. Observation on October 19, 2011, at 9:30 AM revealed the glass sliding-corridor door to ICU 11, Room 229, required an adjustment to close and latch in the frame.

Interview with the Director of Facilities Management (DFM) on October 19, 2011, at 9:30 AM confirmed the door did not latch in the frame.

Based on observation and interview, it was determined the facility failed to clearly identify access to exits by readily visible signs in one location, on one of three floors.

Findings include:

Observation on October 18, 2011, at 10:32 AM revealed an exit sign outside of Room RA123 lacked a lit chevron directing egress to one exit.

Interview with Mechanic 3 on October 18, 2011, at 10:32 AM confirmed the improperly lit exit sign 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 proper fire-resistance rating of smoke-barrier walls in eight locations, on three of three floors of the facility.

Findings include:

1. Observation on October 18, 2011, between 10:45 AM and 1:38 PM, revealed the following unsealed smoke-barrier penetrations:

a) 10:45 AM, around a silver conduit and an approximate one-inch hole, located above the suspended ceiling in 3rd Floor Med Room 374;
b) 11:15 AM, inside an approximate two-inch hole, located behind the white insulated chilled water supply lines, in 3rd Floor Mechanical Room 361;
c) 1:38 PM, inside an approximate two-inch hole, located behind the white insulated chilled water supply lines and the drywall capping the underside of the steel I-beam to the smoke-barrier wall, was not sealed tight to the wall, located in 2nd Floor Mechanical Room 261.

Interview with the DFM on October 18, 2011, at 1:38 PM confirmed the unsealed penetrations and the subsequent correction of items (a) and (b) at the time of the survey.

2. Observation on October 19, 2011, between 9:15 AM and 11:50 AM, revealed the following unsealed smoke-barrier penetrations:

a) 9:15 AM, inside an approximate one-inch cored hole, located in the 2nd Floor Corridor, between the Elevator and the Oxygen Storage Room;
b) 10:55 AM, around the bottom and right side of a steel I -beam to the deck, located above the single smoke-barrier door at the end of the 1st Floor Mammography Corridor;
c) 11:20 AM, inside a silver conduit with a white wire, located in the 1st Floor Women's Center Corridor, across from C-Section Suite WC151;
d) 11:50 AM, the facility must verify the 1st Floor Women's Center smoke-barrier wall is continuous at the corner of the Environmental Services Closet WC185 and the cross-corridor smoke-barrier doors. It appeared the corridor wall was continuos (intersecting) through the smoke-barrier wall, from the floor to the deck.

Interview with the DFM on October 19, 2011, at 11:50 AM confirmed the unsealed penetrations and the subsequent correction of items (a) and (c) at the time of the survey.

3. Observation on October 19, 2011, at 9:38 AM revealed an approximate two-inch cored hole, around a copper pipe, located in the First Floor Mechanical Room 126.

Interview with Mechanic 3 on October 19, 2011 at 9:38 AM confirmed the penetration of the smoke-barrier wall.

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barriers walls in two locations, on one of three floors of the facility.

Findings include:

1. Observation on October 18, 2011, between 11:18 AM and 11:30 AM, revealed the following double corridor smoke-barrier doors had a gap greater than 1/8 inch at the top meeting edge, when in the closed position:

a) 11:18 AM, 3rd Floor smoke-barrier doors, by Patient Room 338 and Traction Room RE319;
b) 11:30 AM, 3rd Floor smoke-barrier doors, by Patient Room 346 and Electrical Room 360.

Interview with the DFM on October 18, 2011, at 11:30 AM confirmed the doors were not smoke-tight at the meeting edge.

Based on observation and interview, it was determined the facility failed to maintain the one-hour fire-rated construction for hazardous areas in seven locations, on three of three floors of the facility.

Findings include:

1. Observation on October 18, 2011, between 10:25 AM and 2:09 PM, revealed unsealed penetrations of hazardous area enclosures in the following locations:

a) 10:25 AM, around the right side of the steel I-beam, above door 387 inside 3rd Floor Clean Storage and around two green MC cables above door 387 in the corridor, across from Med Room 374;
b) 2:09 PM, the back wall and around the back column of 2nd Floor Soiled Utility Room 250, was not sealed to the deck and around a steel I-beam penetrating the back wall.

Interview with the DFM on October 18, 2011, at 2:09 PM confirmed the unsealed penetrations and the subsequent correction of item (a) at the time of the survey.

2. Observation on October 18, 2011, at 10:43 AM revealed an unsealed penetration inside a conduit containing two purple wires, outside Room RA130 above the medical-gas alarm panel.

Interview with Mechanic 3 on October 18, 2011, at 10:43 AM confirmed the unsealed penetration and the subsequent correction of the deficiency at the time of the survey.

3. Observation on October 18, 2011, at 2:39 PM revealed an unsealed penetration inside a conduit containing multiple wires outside Room 158.

Interview with Mechanic 3a on October 18, 2011, at 2:39 PM confirmed the unsealed penetration.

4. Observation on October 18, 2011, at 2:40 PM revealed an unsealed penetration inside a silver conduit across from Room 158, above the fire alarm strobe light.

Interview with Mechanic 3a on October 18, 2011, at 2:40 PM confirmed the unsealed penetration.

5. Observation on October 18, 2011, at 2:47 PM revealed two penetrations, each around a silver conduit across from Room LL111, above and to the left of the fire alarm strobe light.

Interview with Mechanic 3a on October 18, 2011, at 2:47 PM confirmed the unsealed penetrations.
6. Observation on October 19, 2011, at 11:26 AM revealed unsealed penetrations inside a conduit with blue wire and two wall corners, had approximate 1-2 inch sections damaged, above the suspended ceiling, within 1st Floor Women's Center Soiled Holding WC187.

Interview with the DFM on October 19, 2011, at 11:26 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain stairway openings and the proper fire-resistance rating of an exit component enclosures in eight locations, on one of three floors of the facility.

Findings include:

1. Observation on October 18, 2011, between 12:40 PM and 3:00 PM, revealed that positive latching hardware was removed from 6 stair-tower doors, at the end of A, B, and C Corridors, on the 2nd and 3rd Floors, when a Special Locking Arrangement (SLA) was installed. The doors would not latch in the frame.

Interview with the DFM on October 18, 2011, at 3:00 PM confirmed the 2nd and 3rd Floor stair tower doors lacked positive latching hardware.

2. Observation on October 19, 2011, at 9:20 AM revealed the 2nd Floor center stair-tower corridor door, across from the elevators, would not properly close and latch in the frame.

Interview with the DFM on October 19, 2011, at 9:20 AM confirmed the door would not properly close and latch in the frame and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on October 19, 2011, at 9:45 AM revealed an unsealed penetration of the 2nd Floor center stair-tower, inside an approximate one-inch hole, viewed from ICU Clean Utility Room CU219.

Interview with the DFM on October 19, 2011, at 9:45 AM confirmed the unsealed penetration 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 exit access readily accessible at all times, in three out of three exit stairtowers.

Findings include:

Observation on October 18, 2011, at 2:15 PM revealed that A, B and C-Wing Stair Towers were equipped with delayed-egress locks. The signage on the stair doors indicated "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 30 SECONDS." Pushing the door released the locking mechanism within 15 seconds.

Interview with the DFM on October 18, 2011, at 2:15 PM confirmed that the signage on the stair-tower doors was inaccurate.

Based on observation and interview, it was determined the facility failed to maintain horizontal exits by having an unsealed penetration of the two-hour firewall in one location, on one of three floors.

Findings include:

Observation on October 18, 2011, at 1:58 PM revealed an unsealed penetration inside a conduit, above the specimen refrigerator located in the Blood Bank on the First Floor.

Interview with Mechanic 3 on October 18, 2011, at 1:58 PM confirmed the unsealed penetration in the two-hour wall used as a horizontal exit.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system by having items supported by sprinkler piping, missing escutcheons on the sprinkler system and obstructing one sprinkler head in four locations, on two of three floors of the facility.

Findings include:

1. Observation on October 18, 2011, at 10:05 AM revealed a wire tied to the sprinkler piping, in the 1st Floor Corridor, outside Room ED118.

Interview with Mechanic 3 on October 18, 2011 at 10:05 AM confirmed a wire was tied to the sprinkler piping and the subsequent correction of the deficiency at the time of the survey.

2. Observation on October 18, 2011, at 11:20 AM revealed the suspended ceiling grid was supported by the sprinkler piping, in the 3rd Floor Corridor, outside Traction Room RE319.

Interview with the DFM on October 18, 2011, at 11:20 AM confirmed the ceiling grid was supported by the sprinkler piping and the subsequent correction of the deficiency at the time of the survey.

3. Observation on October 19, 2011, at 1:18 PM revealed the sprinkler head closest to the door in Room OR137 was missing an escutcheon.

Interview with Mechanic 3 on October 19, 2011, at 1:18 PM confirmed the missing escutcheon.

4. Observation on October 19, 2011, at 1:30 PM revealed a sprinkler head was within 12 inches of, and obstructed by, a light fixture in Room OR132.

Interview with Mechanic 3 on October 19, 2011, at 1:30 PM confirmed the obstructed sprinkler head.

Based on observation and interview, it was determined the facility failed to maintain medical- gas storage areas in one location, on one of three floors.

Findings include:

Observation on October 18, 2011, at 11:23 AM revealed an unsecured oxygen cylinder in Room ED154.

Interview with Mechanic 3 on October 18, 2011, at 11:23 AM confirmed the unsecured cylinder 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 electrical wiring system in nine locations, on two of three floors of the facility.

Findings include:

1. Observation on October 18, 2011, at 11:19 AM revealed a refrigerator plugged into a surge suppressor in Room ED103.

Interview with Mechanic 3 on October 18, 2011, at 11:19 AM confirmed the improper use of a surge suppressor and the subsequent correction of the deficiency at the time of the survey.

2. Observation on October 18, 2011, at 11:35 AM revealed a relocatable power tap in use behind the middle desk in Room 179.

Interview with Mechanic 3 on October 18, 2011, at 11:35 AM confirmed the use of a power tap and the subsequent correction of the deficiency at the time of the survey.

3. Observation on October 18, 2011, at 2:47 PM revealed a junction box without a cover, located above the light outside of Room CL111.

Interview with Mechanic 3 on October 18, 2011, at 2:47 PM confirmed the junction box was missing a cover.

4. Observation on October 19, 2011, between 9:04 AM and 9:08 AM, revealed that temporary wiring was used inappropriately in the following locations:

a) 9:04 AM, a power strip was used for a phone charging station, behind the 2nd Floor Nursing Station;
b) 9:08 AM, a relocatable power tap was used for computer equipment, in 2nd Floor EM Care Hospitalist Site Coordinator's Office.

Interview with the DFM on October 19, 2011, at 9:08 AM confirmed the wiring was not used properly and the subsequent correction of the deficiency at the time of the survey.

5. Observation on October 19, 2011, at 9:26 AM revealed a relocatable power tap in use and hanging from a cord in the office of the Director of Human Resources.

Interview with Mechanic 3 on October 19, 2011, at 9:26 AM confirmed the use of a power tap and the subsequent correction of the deficiency at the time of the survey.

6. Observation on October 19, 2011, at 10:58 AM revealed a junction box without a cover located above the suspended ceiling outside of Room HK102.

Interview with Mechanic 3 on October 19, 2011, at 10:58 AM confirmed the junction box was missing a cover and the subsequent correction of the deficiency at the time of the survey.

7. Observation on October 19, 2011, at 1:18 PM revealed a relocatable power tap in use in the First Floor Anesthesia On-Call Room.

Interview with Mechanic 3 on October 19, 2011, at 1:18 PM confirmed the use of a power tap and the subsequent correction of the deficiency at the time of the survey.

8. Observation on October 19, 2011, at 1:39 PM revealed two piggy-backed surge suppressors in use in the First Floor Anesthesia Work Room.

Interview with Mechanic 3 on October 19, 2011, at 1:39 PM confirmed the improper use of surge suppressors 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 properly install Alcohol Based Hand Rub (ABHR) dispensers in three locations, on one of three floors.

Findings include:

1. Observation on October 18, 2011, revealed the following:

a. 10:50 AM, one ABHR dispenser was located above a light switch in Room RA131;
b. 11:06 AM, one ABHR dispenser was located above a light switch in Room RA137.

Interview with Mechanic 3 on October 18, 2011, at 11:06 AM confirmed the improperly installed ABHR dispensers.

2. Observation on October 19, 2011, at 11:28 AM revealed an ABHR dispenser was located above a light switch in the Bathroom of Room GS107.

Interview with Mechanic 3 on October, 19, 2011, at 11:28 AM confirmed the improperly installed ABHR dispenser.