HospitalInspections.org

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 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 Pavilion building into the Main 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 and interview it was determined that the facility failed to ensure that common fire walls and doors are properly inspected to maintain a fire resistive rating and that doors have approved glass in one of one floor within this component.

Findings include:

1. Observation made on January 17, 2013, at 1:10 pm, revealed that on the first floor building separation common wall to the MRI Cassette building, the fire doors had normal glass instead of approved rated fire glass installed.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unapproved glass in the common wall doors.

2. Observation made on January 17, 2013, at 1:35 pm, revealed that at the first floor common wall MRI Cassette to the Pavilion Building above the ceiling there was a unsealed penetration of the common wall by data wiring.

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

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 the facility failed to maintain that the doors protecting corridor openings in other than hazardous areas to be, with no impediments and positive latching, on two of four levels within this facility component.

Findings:

1. Observation made on January 17, 2013, at 2:05 pm, revealed that mental health patient room 110, corridor door sticks on the door frame assembly, when place in the open position.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the corridor door requires and adjustment.

2. Observation made on January 17, 2013, at 10:25 am, revealed that in the basement the corridor door to Mechanical room D-3 there was a small wooden pallet in the swing of the door.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the corridor door had a small wooden pallet in the swing of the door.

3. Observation made on January 17, 2013, at 2:43 pm, revealed that in the Kitchen the locker room door was held open by a kick-down device and had a bag on the handle that would prevent the door from closing and latching.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the corridor door had a bag on the handle and a kick-down device that would prevent the door from closing and latching.

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 facility failed to maintain vertical openings between floors on one of two levels within this facility component.

Findings include:

Observation made on January 17, 2013, at 11:00 pm, revealed that within second floor IT closet, had two unsealed vertical penetrations through the floor assembly inside orange plastic fiber optic conduit.

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 facility failed to maintain vertical openings between floors on one of four levels within this facility component.

Findings include:

Observation made on January 17, 2013, at 9:25 am, inside basement corridor closet marked 040 there were two four inch core drilled unsealed penetrations through the ceiling to the first floor.

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

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 the smoke barrier walls are properly inspected to maintain a fire resistive rating on one of four levels within this component.

Findings include:

Observation made on January 17, 2013, at 1:35 pm, revealed that at the first floor common wall MRI Cassette to the Pavilion Building above the ceiling there was a unsealed penetration of the smoke wall by data wiring.

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

Based on observation and interview it was determined that the facility failed to maintain the smoke barrier walls are properly inspected to maintain a fire resistive rating on one of one floor within this component.

Findings include:

Observation made on January 17, 2013, at 1:35 pm, revealed that at the first floor common wall MRI Cassette to the Pavilion Building above the ceiling there was a unsealed penetration of the smoke wall by data wiring.

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

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 maintain smoke barrier doors are properly inspected to maintain a fire resistive rating and that doors have approved glass in one of four levels within this component.

Findings include:

1. Observation made on January 17, 2013, at 1:10 pm, revealed that on the first floor smoke wall to the MRI Cassette building, the fire doors had normal glass instead of approved rated fire glass installed.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unapproved glass in the smoke wall doors.

Based on observation and interview it was determined that the facility failed to maintain smoke barrier doors are properly inspected to maintain a fire resistive rating and that doors have approved glass in one of one floor within this component.

Findings include:

1. Observation made on January 17, 2013, at 1:10 pm, revealed that on the first floor smoke wall to the MRI Cassette building, the fire doors had normal glass instead of approved rated fire glass installed.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unapproved glass in the smoke wall doors.

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 ensure the doors to hazardous areas doors are self-closing without impediments on one of four levels within this component.

Findings include:

1. Observation made on January 17, 2013, at 2:15 pm, revealed that inside the kitchen area, the door (near the exhaust hoods) to the kitchen dry storage room was held open by a rice bin in the swing of the door.

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 hazardous area door held open by a unapproved device.

2. Observation made on January 17, 2013, at 2:15 pm, revealed that inside the kitchen area the dry storage room door near the walk-in refrigerator failed to latch.

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 hazardous area door failed to latch.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas doors are self-closing without impediments on one of four levels within this component.

Findings include:

Observation made on January 17, 2013, at 11:15 am, revealed that in the basement the boiler room door failed to positively latch into its frame.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location the hazardous area door failed to latch.

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 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:

Observation made on January 17, 2013, between 9:00 am and 2:45 pm, revealed the following locations that there were exit egress doors that had impediments that would not allow access to the corridor means of egress:

a. 9:00 am, basement 5000 Volt High Voltage Transformer vault had a hasp and padlock on the corridor side of the door that was not defeatable from the egress side of the door.
b. 10:08 am, basement CSR Storage area had three doors to exit this space two are slide bolted from the outside of the doors and one with no handle and no way to open the door.
c. 2:05 pm, first floor exit door from the freight elevator to the outside loading dock (marked exit) the double doors are slide doors that cannot be opened without power to the push pad switch.
d. 2:43 pm, first floor kitchen locker/break room has a slide bolt on the outer side of the door.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the above locations had impediments that were not defeatable from the egress side of the doors.

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 that the facility failed to maintain complete sprinkler coverage one of four levels within this facility component.

Findings Include:

Observation made on January 17, 2013, at 9:55 am, revealed that inside the Pavilion Building stair tower N, first floor exit passageway lacks complete automatic sprinkler protection leading to discharge door and the public way.

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 facility failed to maintain automatic sprinkler systems components, free of non sprinkler components attached or supported by sprinkler components on one of four levels within this component.

Findings include:

1. Observation made on January 17, 2013, at 10:55 am, revealed that the length of the corridor connector in the basement pavilion to the boiler room had data wires ziptied to the sprinkler supports.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had non sprinkler components attached or supported by sprinkler components.

2. Observation made on January 17, 2013, at 11:31 am, revealed that in the boiler room in front of the high voltage vault there was a roller chain wrapped around the sprinkler piping.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had non sprinkler components attached or supported by sprinkler components.

3. Observation made on January 17, 2013, at 1:45 pm, revealed that on the first floor outside the smoke barrier wall into the MRI Cassette there was fiberoptic conduit zip-tied to the sprinkler piping above the ceiling.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had non sprinkler components attached or supported by sprinkler components.

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 upon observation and interview, it was determined that facility failed to maintain medical gas cylinder storage in a secure manner on one of four levels within this component.

Findings include:

Observation made on January 17, 2013, at 10:10 am, inside the basement oxygen storage room there were two unsecured Carbon dioxide H-tanks on the floor standing.

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

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.

Based on observation and interview it was determined that the facility failed to ensure that electrical wiring and equipment is properly inspected and maintained that the unauthorized use of powerstrips, and extension cords is prohibited in one of one floors within this component.

Findings include:

Observations made on January 17, 2013, between 1:15 pm and 1:30 pm, revealed the unauthorized use of powerstrips in the following locations:

a. 1:15 pm, MRI Cassette reception area, portable heater being powered by a powerstrip.
b. 1:30 pm, MRI Cassette reception area, refrigerator being 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 unauthorized use of powerstrips in the above named locations.

Based on observation and interview it was determined that the facility failed to ensure that electrical wiring and equipment is properly inspected and maintained, that the unauthorized use of powerstrips, extension cords and outlet multipliers is prohibited, junction boxes and circuit breakers and exposed wires are protected and that electrical vault locations maintain a fire resistive rating on one of four levels within this component.

Findings include:

1. Observations made on January 16, 2013, between 10:50 am and 11:30 am, revealed the unauthorized use of powerstrips, extension cords and outlet multipliers in the following locations:

a. 10:50 am, Basement general mechanical shop, hoist being powered by a yellow extension cord.
b. 10:51 am, Basement general mechanical shop, extension cord in use to power a radio.
c. 11:15 am, Emergency room security office, microwave oven, coffee machine and hot and cold water cooler being powered by a powerstrip.
d. 11:30 am, Basement environmental services office, fax machine being powered by a extension cord.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unauthorized use of extension cords and powerstrips in the above named locations.

2. Observation made on January 16, 2013, at 10:00 am, revealed that in the basement level stairtower " F ", there were two mechanical electrical switches that were missing there protective covers.

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

3. Observations made on January 17, 2013, between 10:30 am and 10:40 am, revealed the unauthorized use of powerstrips, extension cords and outlet multipliers in the following locations:

a. 10:30 am, Basement level mechanical room D-3, extension cord powering a sump pump next to the medical air pump.
b. 10:40 am, Basement level plumbers shop, computer being powered by a UPS that was powered by a extension cord.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unauthorized use of extension cords and powerstrips in the above named locations.

4. Observation made on January 17, 2013 at 10:20 am, in the basement mechanical room D3 there was a two inch electrical conduit that had pulled out of the coupling near AC unit 29 exposing the inner wiring.

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

5. Observation made on January 17, 2013 at 10:45 am, in the basement plumbers shop there was a light back by the workbench that was powered by a SJ cord that had the insulation removed about two inches from the plug end that exposed the inner wiring.

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

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 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 Pavilion building into the Main 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 and interview it was determined that the facility failed to ensure that common fire walls and doors are properly inspected to maintain a fire resistive rating and that doors have approved glass in one of one floor within this component.

Findings include:

1. Observation made on January 17, 2013, at 1:10 pm, revealed that on the first floor building separation common wall to the MRI Cassette building, the fire doors had normal glass instead of approved rated fire glass installed.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unapproved glass in the common wall doors.

2. Observation made on January 17, 2013, at 1:35 pm, revealed that at the first floor common wall MRI Cassette to the Pavilion Building above the ceiling there was a unsealed penetration of the common wall by data wiring.

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

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 the facility failed to maintain that the doors protecting corridor openings in other than hazardous areas to be, with no impediments and positive latching, on two of four levels within this facility component.

Findings:

1. Observation made on January 17, 2013, at 2:05 pm, revealed that mental health patient room 110, corridor door sticks on the door frame assembly, when place in the open position.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the corridor door requires and adjustment.

2. Observation made on January 17, 2013, at 10:25 am, revealed that in the basement the corridor door to Mechanical room D-3 there was a small wooden pallet in the swing of the door.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the corridor door had a small wooden pallet in the swing of the door.

3. Observation made on January 17, 2013, at 2:43 pm, revealed that in the Kitchen the locker room door was held open by a kick-down device and had a bag on the handle that would prevent the door from closing and latching.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the corridor door had a bag on the handle and a kick-down device that would prevent the door from closing and latching.

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 facility failed to maintain vertical openings between floors on one of two levels within this facility component.

Findings include:

Observation made on January 17, 2013, at 11:00 pm, revealed that within second floor IT closet, had two unsealed vertical penetrations through the floor assembly inside orange plastic fiber optic conduit.

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 facility failed to maintain vertical openings between floors on one of four levels within this facility component.

Findings include:

Observation made on January 17, 2013, at 9:25 am, inside basement corridor closet marked 040 there were two four inch core drilled unsealed penetrations through the ceiling to the first floor.

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

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 the smoke barrier walls are properly inspected to maintain a fire resistive rating on one of four levels within this component.

Findings include:

Observation made on January 17, 2013, at 1:35 pm, revealed that at the first floor common wall MRI Cassette to the Pavilion Building above the ceiling there was a unsealed penetration of the smoke wall by data wiring.

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

Based on observation and interview it was determined that the facility failed to maintain the smoke barrier walls are properly inspected to maintain a fire resistive rating on one of one floor within this component.

Findings include:

Observation made on January 17, 2013, at 1:35 pm, revealed that at the first floor common wall MRI Cassette to the Pavilion Building above the ceiling there was a unsealed penetration of the smoke wall by data wiring.

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

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 maintain smoke barrier doors are properly inspected to maintain a fire resistive rating and that doors have approved glass in one of four levels within this component.

Findings include:

1. Observation made on January 17, 2013, at 1:10 pm, revealed that on the first floor smoke wall to the MRI Cassette building, the fire doors had normal glass instead of approved rated fire glass installed.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unapproved glass in the smoke wall doors.

Based on observation and interview it was determined that the facility failed to maintain smoke barrier doors are properly inspected to maintain a fire resistive rating and that doors have approved glass in one of one floor within this component.

Findings include:

1. Observation made on January 17, 2013, at 1:10 pm, revealed that on the first floor smoke wall to the MRI Cassette building, the fire doors had normal glass instead of approved rated fire glass installed.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unapproved glass in the smoke wall doors.

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 ensure the doors to hazardous areas doors are self-closing without impediments on one of four levels within this component.

Findings include:

1. Observation made on January 17, 2013, at 2:15 pm, revealed that inside the kitchen area, the door (near the exhaust hoods) to the kitchen dry storage room was held open by a rice bin in the swing of the door.

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 hazardous area door held open by a unapproved device.

2. Observation made on January 17, 2013, at 2:15 pm, revealed that inside the kitchen area the dry storage room door near the walk-in refrigerator failed to latch.

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 hazardous area door failed to latch.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas doors are self-closing without impediments on one of four levels within this component.

Findings include:

Observation made on January 17, 2013, at 11:15 am, revealed that in the basement the boiler room door failed to positively latch into its frame.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location the hazardous area door failed to latch.

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 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:

Observation made on January 17, 2013, between 9:00 am and 2:45 pm, revealed the following locations that there were exit egress doors that had impediments that would not allow access to the corridor means of egress:

a. 9:00 am, basement 5000 Volt High Voltage Transformer vault had a hasp and padlock on the corridor side of the door that was not defeatable from the egress side of the door.
b. 10:08 am, basement CSR Storage area had three doors to exit this space two are slide bolted from the outside of the doors and one with no handle and no way to open the door.
c. 2:05 pm, first floor exit door from the freight elevator to the outside loading dock (marked exit) the double doors are slide doors that cannot be opened without power to the push pad switch.
d. 2:43 pm, first floor kitchen locker/break room has a slide bolt on the outer side of the door.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2: 45 pm, confirmed the above locations had impediments that were not defeatable from the egress side of the doors.

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 that the facility failed to maintain complete sprinkler coverage one of four levels within this facility component.

Findings Include:

Observation made on January 17, 2013, at 9:55 am, revealed that inside the Pavilion Building stair tower N, first floor exit passageway lacks complete automatic sprinkler protection leading to discharge door and the public way.

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 facility failed to maintain automatic sprinkler systems components, free of non sprinkler components attached or supported by sprinkler components on one of four levels within this component.

Findings include:

1. Observation made on January 17, 2013, at 10:55 am, revealed that the length of the corridor connector in the basement pavilion to the boiler room had data wires ziptied to the sprinkler supports.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had non sprinkler components attached or supported by sprinkler components.

2. Observation made on January 17, 2013, at 11:31 am, revealed that in the boiler room in front of the high voltage vault there was a roller chain wrapped around the sprinkler piping.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had non sprinkler components attached or supported by sprinkler components.

3. Observation made on January 17, 2013, at 1:45 pm, revealed that on the first floor outside the smoke barrier wall into the MRI Cassette there was fiberoptic conduit zip-tied to the sprinkler piping above the ceiling.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the above location had non sprinkler components attached or supported by sprinkler components.

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 upon observation and interview, it was determined that facility failed to maintain medical gas cylinder storage in a secure manner on one of four levels within this component.

Findings include:

Observation made on January 17, 2013, at 10:10 am, inside the basement oxygen storage room there were two unsecured Carbon dioxide H-tanks on the floor standing.

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

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.

Based on observation and interview it was determined that the facility failed to ensure that electrical wiring and equipment is properly inspected and maintained that the unauthorized use of powerstrips, and extension cords is prohibited in one of one floors within this component.

Findings include:

Observations made on January 17, 2013, between 1:15 pm and 1:30 pm, revealed the unauthorized use of powerstrips in the following locations:

a. 1:15 pm, MRI Cassette reception area, portable heater being powered by a powerstrip.
b. 1:30 pm, MRI Cassette reception area, refrigerator being 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 unauthorized use of powerstrips in the above named locations.

Based on observation and interview it was determined that the facility failed to ensure that electrical wiring and equipment is properly inspected and maintained, that the unauthorized use of powerstrips, extension cords and outlet multipliers is prohibited, junction boxes and circuit breakers and exposed wires are protected and that electrical vault locations maintain a fire resistive rating on one of four levels within this component.

Findings include:

1. Observations made on January 16, 2013, between 10:50 am and 11:30 am, revealed the unauthorized use of powerstrips, extension cords and outlet multipliers in the following locations:

a. 10:50 am, Basement general mechanical shop, hoist being powered by a yellow extension cord.
b. 10:51 am, Basement general mechanical shop, extension cord in use to power a radio.
c. 11:15 am, Emergency room security office, microwave oven, coffee machine and hot and cold water cooler being powered by a powerstrip.
d. 11:30 am, Basement environmental services office, fax machine being powered by a extension cord.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unauthorized use of extension cords and powerstrips in the above named locations.

2. Observation made on January 16, 2013, at 10:00 am, revealed that in the basement level stairtower " F ", there were two mechanical electrical switches that were missing there protective covers.

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

3. Observations made on January 17, 2013, between 10:30 am and 10:40 am, revealed the unauthorized use of powerstrips, extension cords and outlet multipliers in the following locations:

a. 10:30 am, Basement level mechanical room D-3, extension cord powering a sump pump next to the medical air pump.
b. 10:40 am, Basement level plumbers shop, computer being powered by a UPS that was powered by a extension cord.

Interview at the exit conference with the Director of Facilities Management on January 17, 2013, at 2:45 pm, confirmed the unauthorized use of extension cords and powerstrips in the above named locations.

4. Observation made on January 17, 2013 at 10:20 am, in the basement mechanical room D3 there was a two inch electrical conduit that had pulled out of the coupling near AC unit 29 exposing the inner wiring.

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

5. Observation made on January 17, 2013 at 10:45 am, in the basement plumbers shop there was a light back by the workbench that was powered by a SJ cord that had the insulation removed about two inches from the plug end that exposed the inner wiring.

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