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Based on observation and interview, it was determined that the facility failed to ensure that common walls are properly inspected and maintained and that doors in fire walls positively latch on one of four levels within this component.

Findings include:

Observation made on January 17, 2013, at 10:50 am, revealed that above the commonwall door from the Main building into the Pavilion building there as a unsealed penetration around a sprinkler pipe.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the above location had a unsealed penetration through the commonwall.

Based on observation, documentation review, and interview, it was determined that the facility failed to maintain the requirements for a fire resistance rating for structural members within this building component.

Findings Include:

1. Observation made and documentation reviewed on January 16-17, 2013, between 8:30 am and 2:25 pm, revealed that there were unprotected structural steel beams, bar joist and steel columns within this building. The story height exceeds the maximum allowance for an unprotected non-combustible construction.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 p.m., confirmed that the structural members were unprotected and identified that the facility has a acceptable Fire Safety Evaluation System reviewed on
January 17, 2013, addressing this issue.

Based on observation and interview, it was determined that the facility failed to ensure that the corridor walls are properly inspected and maintained to be smoke tight on one of four levels within this component.

Findings include:

1. Observation made on January 16, 2013, at 1:10 pm, revealed that in the basement the environmental supply room was not smoke tight due to a cinder block missing at the base of the wall next to the corridor door.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 p.m., confirmed that the above location there was a cinder block missing at the base of the wall next to the corridor door.

2. Observation made on January 17, 2013, at 9:45 am, revealed that in the basement inside the Morgue above the rolling stacked refrigeration units there is a open mechanical area in the rear of this area the was a unsealed penetration to the corridor.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 p.m., confirmed that the above location there was a unsealed penetration to the corridor.

Based on observation and interview, it was determined the facility failed to maintain corridor doors from being obstructed from closing on one of four levels within this facility component.

Findings include:

Observation made on January 16, 2013, at 11:45 am, revealed that the fourth floor Pavilion Building patient room 461, corridor door was impeded from closing by a chair.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the corridor door was blocked open.

Based on observation and interview, it was determined facility failed to maintain vertical openings between floors on one of four levels within this facility component.

Findings include:

Observation made on January 16, 2013, at 12:00 pm, revealed that inside four floor East wing Pavilion building utility room, there were two unsealed vertical penetrations through the floor assembly inside orange fiber optic conduit by electrical panel labeled RP-401-S1.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain smoke barriers partition walls on one of four levels within this facility component.

Findings include:

Observation made on January 16, 2013, at 1:15 pm, revealed that Main Building fourth floor, above the smoke barrier doors at maternity, their was a partially sealed penetration around HVAC piping.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the improperly sealed penetration.

Based on observation and interview, it was determined that the facility failed to maintain a fire-resistance rated smoke barrier door assembly on one of four levels within this Facility component.

Findings include:

Observation made on January 17, 2013, at 2:00 pm, revealed that the first floor Main building smoke barrier doors at mental health, had a gap of more than 1/8" between them.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed that the smoke barrier separation doors was not maintained properly.

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

Findings include:

Observation made on January 17, 2013, at 11:15 am, revealed that the first floor mechanical room/electric service room self-closing device, closer arm was detached.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the door was inoperable.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the stair towers, and/or maintain a continuous path of escape on one of four levels within this facility component.

Findings include

Observation made on January 17, 2013, at 2:10 pm, revealed that the first floor stair tower X corridor exit access door, handle had a key operated locking mechanism installed.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the door assembly component was not maintained properly.

Based on observation and interview, it was determined that the facility failed to ensure the stairways and smoke proof towers were free and clear of obstructions on two of two levels within this facility component.

Findings include:

1.Observation made January 17, 2013, between 10:55 am and 11:05 am, revealed that the following stair towers had storage in them.

a. 10:55 am, inside stair tower # 2, first floor landing had a janitorial chart stored under the stairs of the stair tower.
b. 11:05 am, inside stair tower # 1, second floor landing had a large 30 gallon trash bag filled with debris, and other discarded building materials.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed there were items stored in the stair tower.

Based on observation and interview it was determined that the facility failed to ensure that exit access was readily accessible at all times on one of four levels within this component.

Findings include:

1. Observation made on January 17, 2013, at 11:20 am, revealed that in the basement chiller room exit door (marked exit) was stuck would not open without the use of a excessive amount of force.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had a exit door that was not readily accessible.

2. Observation made on January 17, 2013, at 11:32 am, revealed that on the first floor direct exit from the CCU stairwell there were two trash cans in the path of exit egress.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had a exit egress path that was blocked.

Based on observation and interview, it was determined the facility failed to maintain smoke detectors to be operational condition on one of four levels within this facility component.

Findings include:

Observation made on January 16, 2013, at 10:15 am, revealed that located in the Main Building (Penthouse IT mechanical space), over the emergency room, the smoke detector device was missing off its base.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed that the device was not properly maintain.

Based on observation and interview, it was determined that the facility failed to ensure that buildings that are classified as fully sprinklered have sprinkler protection in all required areas on one of four levels within this facility component.

Findings Include:

Observation made on January 17, 2013, at 2:08 pm, revealed that Main Building first floor Old Wound Care lobby entrance lacks automatic sprinkler protection.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the area lacks sprinkler protection.

Based on observation and interview, it was determined facility failed to maintain automatic sprinkler systems components, escutcheon plates, pressure gauges and protective covers, protective caps on the fire department connections were not maintained as required on three of four levels within this facility component.

Findings include:

1. Observation made on January 16, 2013, at 11:20 am, revealed that located on fourth floor East wing Stair tower X fire department connections, had a sprinkler gauge that was dated 2002.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the sprinkler system component was not maintained properly.

2. Observation made on January 16, 2013, between 1:10 pm and 2:00 pm, revealed that the following fire department hose connection protective caps were missing.

a. 1:10 pm, fourth floor laboratory stair tower B fire department connection labeled 4B2.
b. 1:15 pm, fourth floor laboratory stair tower A fire department connection labeled 4A3.
c. 2:00 pm, second floor stair tower X fire department connection labeled 2X1.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm,confirmed the sprinkler system components were missing protective covers.

3. Observation made on January 16, 2013, between 11:16 am and 11:23 am, revealed in the following areas the suspended drop ceiling assembly was missing which may delay sprinkler operation:

a. 11:16 am, fourth floor F Wing Main Building rooms 480 thru 482.
b. 11:23 am, fourth floor F Wing Main Building rooms, soiled utility and oncology protocol.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed missing ceiling tiles.

4. Observation made on January 17, 2013, between 10:00 am and 0:15 am, revealed the following areas were missing sprinkler escutcheon plates.

a. 10:00 am, second floor back hall of OR # 4.
b. 10:15 am, second floor OR suite nurses station.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed escutcheons were missing.

5. Observation made on January 17, 2013, at 9:40 am, revealed in the basement inside the Morgue there was a drop ceiling tile missing that would affect the response of the sprinkler heads within this room.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the above ceiling tile was missing that would affect the response of the sprinkler heads within this room.

6. Observation made on January 17, 2013, at 9:45 am, revealed in the basement inside the Morgue above the stacked slide in refrigerators there was a open grate to the void space above the unit that lacks sprinkler coverage and would also affect the response of the sprinkler heads within this room.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the space above this unit lacks sprinkler coverage.

7. Observation made on January 17, 2013, at 2:30 pm, revealed in the first floor Kitchen walk-in freezer there was icicles on the sprinkler head and storage within eighteen inches of the sprinkler head (four inches).

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed there was icicles on the sprinkler head and storage within eighteen inches of the sprinkler head.

Based on observation and interview it was determined that the facility failed to ensure that portable heating devices are properly inspected and documented and used on in approved areas in one of one floors within this component.

Findings include:

Observation made on January 17, 2013, at 1:15 pm, revealed that in the first floor reception area, there was a portable heater that was plugged into a powerstrip. The facility could not produce documentation that the heater element does not exceed 212 degrees.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the lack of documentation for the portable heater.

Based on observation and interview, it was determined the facility failed to ensure free standing medical gas cylinders are properly secured on one of four levels within this component.

Findings include:

Observation made on January 17, 2013, at 11:35 am, revealed that inside the first floor Pavilion Cath lab in the nitrogen manifold closet there were three unrestrained H-tanks (two attached and one spare).

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had medical gas compressed cylinders that were unsecured.

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were stored properly on one of two levels within this facility component.

Findings include:

Observation made on January 17, 2013, at 11:25 am, revealed that the outside piped in medical gas manifold tank storage area, had eleven " H " size oxygen medical gas cylinders that were unsecured and not chained.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the cylinders were not secured.

Based on observation and interview it was determined that the facility failed to maintain electrical wiring and equipment is properly inspected, and prevent the unauthorized use of powerstrips, extension cords, junction boxes and circuit breakers and exposed wires are protected on two of four levels within this component.

Findings include:

1. Observation made on January 17, 2013, at 11:30 am, inside the transformer vault in the boiler room there was a electrical outlet by the vault door that was unsecured.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had a unsecured electrical device.

2. Observation made on January 17, 2013, at 11:40 am, inside the Cath lab by the nurses station there was a defibrillator powered by a powerstrip.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location was using a powerstrip to power medical equipment.