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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.
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Observation made during an onsite Revisit conducted on April 15, 2013, determined that the following item remained deficient:

The first floor mechanical room/electric service room self-closing device was still detached.

Interview at the exit conference with the Director of Facilities Management on April 15, 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.
(COMPLETED)


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Observation made during onsite Revisit conducted on April 15, 2013, determined that the following item remained deficient:

Item 1. Inside the kitchen area, the door near the exhaust hoods to the kitchen dry storage room was still held open by a rice bin.

Interview at the exit conference with the Director of Facilities Management on April 15, 2013, at 12: 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.

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Observation made during an onsite Revisit conducted on April 15, 2013, determined that the following item remained deficient:

The basement boiler room door stilll failed to positively latch into its frame.

Interview at the exit conference with the Director of Facilities Management on April 15, 2013, at 12:45 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 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 cart 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.
(COMPLETED)

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.
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Observation made during an onsite Revisit conducted on April 15, 2013, determined that the following item remained deficient:

Item 1. a. Inside stair tower # 2, first floor landing, a janitorial cart was still stored under the stair tower.

Interview at the exit conference with the Director of Facilities Management on April 15, 2013, at 1:00 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.
(COMPLETED)

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Observation made during an onsite Revisit conducted on April 15, 2013, determined that the following item remained deficient:

Item 1. The basement chiller room exit door marked exit was still stuck and would not open without the use of an excessive amount of force and now is also equipped with a slide bolt.

Interview at the exit conference with the Director of Facilities Management on April 15, 2013, at 12:45 pm, confirmed the above location had a exit door that was not readily accessible.

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.
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Observation made during onsite Revisit conducted on April 15, 2013, determined that the following item remained deficient:


The Main Building, first floor Old Wound Care lobby entrance still lacks automatic sprinkler protection.

Interview at the exit conference with the Director of Facilities Management on April 15, 2013, at 1:00 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.
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Observation made during an onsite Revisit conducted on April 15, 2013, determined that the following item remained deficient:

Inside the Pavilion Building stair tower N, first floor exit passageway still 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 April 15, 2013, at 1:00 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.
(COMPLETED)


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.
(COMPLETED)


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.
(COMPLETED)


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.
(COMPLETED)


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.
(COMPLETED)


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.
(COMPLETED)

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Observation made during onsite Revisit conducted on April 15, 2013, determined that the following item remained deficient:

Item 6. In the basement inside the Morgue above the stacked slide in refrigerators there was an open grate to the void space above the unit that still 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 April 15, 2013, at 12:45 pm, confirmed the space above this unit lacks sprinkler coverage.

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.
(COMPLETED)

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Observation made during an onsite Revisit conducted on April 15, 2013, determined that the following item remained deficient:

Item 1. Inside the transformer vault in the boiler room there was still an electrical outlet by the vault door that was unsecured.

Interview at the exit conference with the Director of Facilities Management on April 15, 2013, at 12:45 pm, confirmed the above location had a unsecured electrical device.

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.
(COMPLETED)


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.
(COMPLETED)


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.
(COMPLETED)


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.
(COMPLETED)

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Observation made during an onsite Revisit conducted on April 15, 2013, determined that the following items remained deficient:

Item 3. a. Basement level mechanical room D-3, extension cord was still powering a sump pump next to the medical air pump.

Item 3. b. Basement level plumbers shop, computer was still powered by a UPS that was powered by an extension cord.

Interview at the exit conference with the Director of Facilities Management on April 15, 2013, at 12:45 pm, confirmed the unauthorized use of extension cords and powerstrips in the above named locations.