HospitalInspections.org

Based on observation and staff interview, it was determined that 1 of 17 patient units on the first floor were not properly protected from fire. Findings include:

During a tour of the Emergency Department (ED) on 1/7/2014 at 3:12 PM, the following was observed:

1. outside of Room 1874
- missing ceiling tile
This finding was confirmed by Mechanical Engineering Manager A at 3:12 PM on 1/7/2014.

2. Super Fast Track area
- Two patient treatment areas were not physically separated from the corridor
This finding was confirmed by Mechanical Engineering Manager A at 3:14 PM on 1/7/2014. Further interview revealed that plans for the Super Fast Track were not submitted to the State Fire Marshal Office for review and approval. The area was immediately closed down and was prohibited from opening up until plans were submitted and approved by the State Fire Marshal Office.

Based on observation and staff interview, it was determined that 3 of 3 vaults were not properly protected from fire. Findings include:

During a tour of the Helen Graham Cancer Center on 1/10/2014 at 2:15 PM, missing ceiling tiles were observed in all 3 vaults. This finding was confirmed by Mechanical Engineering Manager A at time of discovery.

Based on observation and staff interview, it was determined that the hospital was not properly protected from fire. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. Room 3W91B - missing ceiling tile
This finding was confirmed by Mechanical Engineering Manager A at 2:10 PM on 1/13/2014.

2. Room 3W80 - missing ceiling tile
This finding was confirmed by Life Safety Officer A at 2:15 PM on 1/14/2014.

3. Information Technology (IT)/Telecom Room - missing ceiling tiles
This finding was confirmed by Mechanical Engineering Manager A at 2:16 PM on 1/14/2014.

4. IT closet by Stair 3 - missing/damaged ceiling tiles
This finding was confirmed by Mechanical Engineering Manager A at 2:20 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the facility failed to ensure that corridor doors had properly operating latching devices. Findings include:

During a tour of the facility with Mechanical Engineering Manager A on 1/7/2014 between 11:02 AM and 2:55 PM, the following was observed and acknowledged at the time of discovery:

1. 11:02 AM - Patient Room 2E08
- sliders were not latched properly in the frame

2. 2:55 PM - Patient Room 2460
- door was not latched properly in the frame

Based on observation and staff interview, it was determined that the hospital failed to ensure that corridor doors were properly maintained and free of any impediments to closing. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. Patient Room 6S12 - door was blocked by a cart placed near to the door jamb
This finding was confirmed by Life Safety Officer A at 11:29 AM on 1/13/2014.

2. Gift Shop - doors were chocked (wedged) open
This finding was confirmed by Mechanical Engineering Manager A at 12:45 PM on 1/14/2014.

3. Room 1S33 - doors had a gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 1:35 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the facility failed to ensure a smoke barrier was maintained for 1 of 20 smoke barriers observed during the survey. Findings include:

During a tour of the facility on 1/7/2014 at 1:15 PM, a ½ inch by ½ inch unsealed penetration was observed in the smoke barrier above the suspended ceiling by Room 2C17. This finding was confirmed by Life Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure smoke barrier doors were maintained for 2 of 20 smoke barrier doors observed during the survey. Findings include:

During a hospital tour on 1/7 and 1/9/2014, the following was observed:

1. 1/7/2014 at 9:45 AM
- double set doors leading to Rooms 4A32-44 had an undercut more than ¾ inch
This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

2. 1/9/2014 at 10:20 AM
- double set of doors leading to the Heart and Vascular Interventional Services Prep & Hold had a gapping more then 1/8 inch between the double doors
This finding was confirmed by Life Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the hospital failed to ensure that smoke barrier doors were maintained for 7 of 40 smoke barrier doors observed during the survey. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. doors by Room 3W91A - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 2:05 PM on 1/13/2014.

2. doors by Room 3S40 - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 2:17 PM on 1/13/2014.

3. doors by Room 3S60M - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 10:01 AM on 1/14/2014.

4. doors by Room 3S40S - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 10:13 AM on 1/14/2014.

5. doors by Room 3S41D - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 10:17 AM on 1/14/2014.

6. doors by Operating Room 3 - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 11:19 AM on 1/14/2014.

7. double doors in Emergency Department by Room 1S33 - were locked in the open position and the operation of the doors could not be tested
This finding was confirmed by Mechanical Engineering Manager A at 1:31 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the facility failed to maintain 2 of 5 hazardous areas in the surgical unit observed during the survey. Findings include:

During a hospital tour with Life Safety Officer A on 1/9/2014 between 9:42 AM and 10:35 AM, the following was observed and acknowledged at the time of discovery:

1. 9:42 AM - door to Room 2633 (soiled utility room) did not have a self-closing or automatic-closing device

2. 10:35 AM - door to Room 2864 (soiled utility room) did not latch properly

Based on observation and staff interview, it was determined that the hospital failed to maintain 1 of 3 electrical hazardous areas observed during the survey. Findings include:

During a hospital tour on 1/14/2014 at 3:10 PM, it was observed that the doors to General Supply Electric Gear Room had gapping more than 1/8 inch between the double doors. This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure that fire doors were properly maintained. Findings include:

During a hospital tour on 1/6/2014 at 1:05 PM, observation revealed that the fire door label was painted over on the fire doors by Room 5C18. This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure that rated doors were properly maintained. Findings include:

During a hospital tour on 1/14/2014 at 9:42 AM, the operating room doors were observed to have the door labels painted over. This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure the storage area within 1 of 4 stair enclosures observed during the survey was properly separated. Findings include:

During a tour of the Helen Graham Cancer Center with Mechanical Engineering Manager A on 1/10/2014 at 2:05 PM, the following was observed and acknowledged at the time of discovery:

1. Stairway 3
- wooden outdoor furniture was stored underneath the stairs without proper separation with the stair enclosure

Based on observation and staff interview, it was determined that the hospital failed to ensure that doors in the means of egress (exit access) on 2 of 8 floors were properly maintained. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/7/2014, the following was observed and acknowledged at the time of discovery:

1. 10:00 AM - the 3rd floor stairway door to Stair 19 delayed egress function was not working properly

2. 10:14 AM - the 3rd floor stairway door to Stair 2 had no delayed egress sign and the door did not function properly

3. 10:31 AM - the double doors by Room 3D44 delayed egress function was not working properly

4. 10:45 AM - the 3rd floor door to Stair 22 did not latch properly

5. 3:00 PM - the double doors by Room 2452 had no delayed egress sign and the door did not function properly

Based on observation and staff interview, it was determined that the hospital failed to ensure the means of egress (exit access) on 2 of 9 floors were properly maintained. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/14/2014, the following was observed and acknowledged at the time of discovery:

1. 10:12 AM - double doors by Room 3S40 did not have any delayed egress signage

2. 10:35 AM - double doors by Room 3S36 did not latch properly and delayed egress function was not working properly

3. 11:25 AM - elevator lobby by Operating Room 3 was being used for storage of beds

Based on observation and staff interview, it was determined that the facility failed to ensure that exit directional signs were displayed with continuous illumination. Findings include:

During a tour of the Comprehensive Center for Behavioral Health on 1/15/2014 at 11:40 AM, it was observed that 1 of 3 exit signs in the parking garage was not illuminated. This finding was confirmed by Life Safety Officer A at time of discovery.

Based on observation and staff interview, it was determined that the hospital failed to provide signs indicating "No Exit" within the exit stairwells for areas that lead back into the building on the level of exit discharge in 1 of 6 stairwells observed during the survey. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/14/2014 at 2:41 PM, the following was observed and acknowledged at the time of discovery:

1. Stairwell #3 - the ground floor was missing a "NO EXIT" sign

Based on observation and staff interview, it was determined that the hospital failed to properly maintain the fire alarm system. Findings include:

During a hospital tour on 1/7/2014 at 9:40 AM, observation above the suspended ceiling by Room 4B00, revealed a fire alarm junction box missing a cover plate. This finding was confirmed by Life Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the hospital failed to properly maintain the fire alarm system. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/14/2014 at 11:31 AM, the following was observed and acknowledged at the time of discovery:

1. Pharmacy in surgical suite had a roll down fire shutter but did not have two smoke detectors installed to operate it.

Based on observation and staff interview, it was determined that the facility failed to ensure proper installation, maintenance, and supervision of the sprinkler system. Findings include:

During a tour of Springside Plaza - Christiana Care Rehabilitation Services on 1/10/2014 at 11:30 AM, no sprinkler heads were observed in Room 1114. This finding was confirmed by Life Safety Officer A at time of discovery.

Based on observation and staff interview, it was determined that the automatic sprinkler system was not maintained in compliance with NFPA 13 and NFPA 25. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/13/2014, the following was observed and acknowledged at the time of discovery:

1. 9:40 AM - 8th floor in Stair 5
- a plastic cap was placed over the sprinkler head

2. 9:50 AM - 8th and 9th floor shell spaces
- numerous wiring was lying across/attached to the sprinkler pipes

3. 2:02 PM - hallway by Room 3W91A
- sprinkler was missing an escutcheon plate

Based on observation and staff interview, it was determined that the automatic sprinkler system was not maintained in compliance with NFPA 25. Findings include:

During a tour of Roxana Cannon Arsht Surgicenter on 1/15/2014 between 9:33 AM and 9:38 AM, the following was observed:

1. Sprinkler was missing an escutcheon plate:
- by Post Anesthesia Care Unit A/B
- by Room 163A
- in Room 182

These findings were confirmed at time of discovery by Life Safety Officer A.

Based on observation and staff interview, it was determined that the hospital failed to ensure that exit corridors were maintained free of impediments which would interfere with the safe usage of the corridors during a fire or other emergency. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. beds, not in use, were lined up in corridor by Room 3S97E
This finding was confirmed by Mechanical Engineering Manager A at 2:45 PM on 1/13/2014.

2. chairs, not in use, were lined up in corridor and a storage cabinet was next to an exit door by Room 2W93C
This finding was confirmed by Mechanical Engineering Manager A at 12:52 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the hospital failed to ensure that exit corridors were maintained free of impediments which would interfere with the safe usage of the corridors during a fire or other emergency. Findings include:

During a tour with Mechanical Engineering Manager A on 1/7/2014, the following was observed and acknowledged at the time of discovery:

1. 1:17 PM - wheelchairs, not in use, were lined up in the corridor by Room 2C27

2. 3:15 PM - beds and linen carts, not in use, were lined up in the corridor by Room 1874

Based on observation and staff interview, it was determined that for 8 of 12 fire walls observed during the survey, the hospital failed to ensure the fire resistance rating was maintained. Findings include:

During hospital tours on 1/7, 1/8 and 1/9/2014, the following was observed:

1. fire doors by Room 4C35 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 9:25 AM on 1/7/2014.

2. fire doors by Room 3A44 - did not unlock with 15 pounds of pressure
This finding was confirmed by Mechanical Engineering Manager A at 10:06 AM on 1/7/2014.

3. fire doors by MER#12 3215 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 10:26 AM on 1/7/2014.

4. fire doors by Room 2C35 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 1:09 PM on 1/7/2014.

5. fire wall above the suspended ceiling between Rooms 2A12 and 2A23 - approximately a 2 inch round unsealed penetration around a pipe sleeve
This finding was confirmed by Life Safety Officer A at 1:35 PM on 1/7/2014.

6. double set of fire doors leading to the Triangle Restaurant - had a gapping more than 1/8 inch between the double doors
This finding was confirmed by Life Safety Officer A at 2:45 PM on 1/7/2014.

7. fire doors next to Room 1597B - had a gapping more than 1/8 inch between the double doors and the undercut was more than ¾ inch
This finding was confirmed by Life Safety Officer A at 2:47 PM on 1/8/2014.

8. Post Anesthesia Care Unit separation fire doors - latching mechanism did not function properly
This finding was confirmed by Life Safety Officer A at 10:00 AM on 1/9/2014.

Based on observation and staff interview, it was determined that the hospital failed to ensure fire resistance rating was maintained for 8 of 12 fire walls observed during the survey. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. fire wall above the suspended ceiling in Room 7S49 revealed approximately a 1 inch square unsealed penetration
This finding was confirmed by Life Safety Officer A at 10:27 AM on 1/13/2014.

2. fire wall above the suspended ceiling next to Room 6S12 revealed an unsealed penetration around a 1 inch data tube
This finding was confirmed by Life Safety Officer A at 10:50 AM on 1/13/2014.

3. two hour rated wall with a 45 minute rated door to Operating Room (OR) 3E01
This finding was confirmed by Mechanical Engineering Manager A at 9:41 AM on 1/14/2014.

4. fire doors to the gateway to the ORs - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 9:56 AM on 1/14/2014.

5. fire doors to gateway Room 3S40 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 10:10 AM on 1/14/2014.

6. fire wall above the suspended ceiling next to Room 3S24 revealed unsealed penetration around a 1 inch data tube
This finding was confirmed by Life Safety Officer A at 10:11 AM on 1/14/2014.

7. fire doors to gateway to Post Anesthesia Care Unit - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 10:12 AM on 1/14/2014.

8. fire wall above the suspended ceiling next to Stair 2 revealed unsealed penetration around 2 steam pipes that were removed
This finding was confirmed by Life Safety Officer A at 2:00 PM on 1/14/2014.

9. fire doors next to Room GN89 had a gapping more than 1/8 inch between the double doors
This finding was confirmed by Life Safety Officer A at 2:35 PM on 1/14/2014.

10. fire wall in the Fire Pump Room revealed unsealed penetration around a 2 inch pipe
This finding was confirmed by Life Safety Officer A at 3:00 PM on 1/14/2014.

11. fire doors to Fire Pump Room had a gapping more than 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 3:15 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the hospital failed to properly maintain electrical panels, equipment and junction boxes in accordance with NFPA 70, National Electric Code. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. Stair 5 - an open electrical junction box
This finding was confirmed by Mechanical Engineering Manager A at 9:42 AM on 1/13/2014.

2. Room 5W97 - an air conditioner plugged into an extension cord
This finding was confirmed by Mechanical Engineering Manager A at 1:10 PM on 1/13/2014.

3. Room 3M65 - storage in front of the electrical panels
This finding was confirmed by Life Safety Officer A at 2:03 PM on 1/13/2014.

4. Fire Pump Room, ceiling level - there was an open electrical junction box
This finding was confirmed by Life Safety Officer A at 3:15 PM on 1/13/2014.

5. Materials Distribution Room - an extension cord with a multi-plug adapter in use
This finding was confirmed by Mechanical Engineering Manager A at 2:23 PM on 1/14/2014.

6. Mail Room - a multi-plug adapter in use
This finding was confirmed by Mechanical Engineering Manager A at 2:25 PM on 1/14/2014.

Based on observation and staff interview, it was determined that Alcohol Based Hand Rub (ABHR) dispensers were installed directly over or adjacent to an ignition source on 1 of 8 floors. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/14/2014 at 10:39 AM, the following was observed and acknowledged at the time of discovery:

1. Room 3S30 - an ABHR dispenser was installed directly above an electrical outlet

Based on observation and staff interview, it was determined that 1 of 17 patient units on the first floor were not properly protected from fire. Findings include:

During a tour of the Emergency Department (ED) on 1/7/2014 at 3:12 PM, the following was observed:

1. outside of Room 1874
- missing ceiling tile
This finding was confirmed by Mechanical Engineering Manager A at 3:12 PM on 1/7/2014.

2. Super Fast Track area
- Two patient treatment areas were not physically separated from the corridor
This finding was confirmed by Mechanical Engineering Manager A at 3:14 PM on 1/7/2014. Further interview revealed that plans for the Super Fast Track were not submitted to the State Fire Marshal Office for review and approval. The area was immediately closed down and was prohibited from opening up until plans were submitted and approved by the State Fire Marshal Office.

Based on observation and staff interview, it was determined that 3 of 3 vaults were not properly protected from fire. Findings include:

During a tour of the Helen Graham Cancer Center on 1/10/2014 at 2:15 PM, missing ceiling tiles were observed in all 3 vaults. This finding was confirmed by Mechanical Engineering Manager A at time of discovery.

Based on observation and staff interview, it was determined that the hospital was not properly protected from fire. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. Room 3W91B - missing ceiling tile
This finding was confirmed by Mechanical Engineering Manager A at 2:10 PM on 1/13/2014.

2. Room 3W80 - missing ceiling tile
This finding was confirmed by Life Safety Officer A at 2:15 PM on 1/14/2014.

3. Information Technology (IT)/Telecom Room - missing ceiling tiles
This finding was confirmed by Mechanical Engineering Manager A at 2:16 PM on 1/14/2014.

4. IT closet by Stair 3 - missing/damaged ceiling tiles
This finding was confirmed by Mechanical Engineering Manager A at 2:20 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the facility failed to ensure that corridor doors had properly operating latching devices. Findings include:

During a tour of the facility with Mechanical Engineering Manager A on 1/7/2014 between 11:02 AM and 2:55 PM, the following was observed and acknowledged at the time of discovery:

1. 11:02 AM - Patient Room 2E08
- sliders were not latched properly in the frame

2. 2:55 PM - Patient Room 2460
- door was not latched properly in the frame

Based on observation and staff interview, it was determined that the hospital failed to ensure that corridor doors were properly maintained and free of any impediments to closing. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. Patient Room 6S12 - door was blocked by a cart placed near to the door jamb
This finding was confirmed by Life Safety Officer A at 11:29 AM on 1/13/2014.

2. Gift Shop - doors were chocked (wedged) open
This finding was confirmed by Mechanical Engineering Manager A at 12:45 PM on 1/14/2014.

3. Room 1S33 - doors had a gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 1:35 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the facility failed to ensure a smoke barrier was maintained for 1 of 20 smoke barriers observed during the survey. Findings include:

During a tour of the facility on 1/7/2014 at 1:15 PM, a ½ inch by ½ inch unsealed penetration was observed in the smoke barrier above the suspended ceiling by Room 2C17. This finding was confirmed by Life Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure smoke barrier doors were maintained for 2 of 20 smoke barrier doors observed during the survey. Findings include:

During a hospital tour on 1/7 and 1/9/2014, the following was observed:

1. 1/7/2014 at 9:45 AM
- double set doors leading to Rooms 4A32-44 had an undercut more than ¾ inch
This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

2. 1/9/2014 at 10:20 AM
- double set of doors leading to the Heart and Vascular Interventional Services Prep & Hold had a gapping more then 1/8 inch between the double doors
This finding was confirmed by Life Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the hospital failed to ensure that smoke barrier doors were maintained for 7 of 40 smoke barrier doors observed during the survey. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. doors by Room 3W91A - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 2:05 PM on 1/13/2014.

2. doors by Room 3S40 - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 2:17 PM on 1/13/2014.

3. doors by Room 3S60M - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 10:01 AM on 1/14/2014.

4. doors by Room 3S40S - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 10:13 AM on 1/14/2014.

5. doors by Room 3S41D - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 10:17 AM on 1/14/2014.

6. doors by Operating Room 3 - had gapping more then 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 11:19 AM on 1/14/2014.

7. double doors in Emergency Department by Room 1S33 - were locked in the open position and the operation of the doors could not be tested
This finding was confirmed by Mechanical Engineering Manager A at 1:31 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the facility failed to maintain 2 of 5 hazardous areas in the surgical unit observed during the survey. Findings include:

During a hospital tour with Life Safety Officer A on 1/9/2014 between 9:42 AM and 10:35 AM, the following was observed and acknowledged at the time of discovery:

1. 9:42 AM - door to Room 2633 (soiled utility room) did not have a self-closing or automatic-closing device

2. 10:35 AM - door to Room 2864 (soiled utility room) did not latch properly

Based on observation and staff interview, it was determined that the hospital failed to maintain 1 of 3 electrical hazardous areas observed during the survey. Findings include:

During a hospital tour on 1/14/2014 at 3:10 PM, it was observed that the doors to General Supply Electric Gear Room had gapping more than 1/8 inch between the double doors. This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure that fire doors were properly maintained. Findings include:

During a hospital tour on 1/6/2014 at 1:05 PM, observation revealed that the fire door label was painted over on the fire doors by Room 5C18. This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure that rated doors were properly maintained. Findings include:

During a hospital tour on 1/14/2014 at 9:42 AM, the operating room doors were observed to have the door labels painted over. This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure the storage area within 1 of 4 stair enclosures observed during the survey was properly separated. Findings include:

During a tour of the Helen Graham Cancer Center with Mechanical Engineering Manager A on 1/10/2014 at 2:05 PM, the following was observed and acknowledged at the time of discovery:

1. Stairway 3
- wooden outdoor furniture was stored underneath the stairs without proper separation with the stair enclosure

Based on observation and staff interview, it was determined that the hospital failed to ensure that doors in the means of egress (exit access) on 2 of 8 floors were properly maintained. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/7/2014, the following was observed and acknowledged at the time of discovery:

1. 10:00 AM - the 3rd floor stairway door to Stair 19 delayed egress function was not working properly

2. 10:14 AM - the 3rd floor stairway door to Stair 2 had no delayed egress sign and the door did not function properly

3. 10:31 AM - the double doors by Room 3D44 delayed egress function was not working properly

4. 10:45 AM - the 3rd floor door to Stair 22 did not latch properly

5. 3:00 PM - the double doors by Room 2452 had no delayed egress sign and the door did not function properly

Based on observation and staff interview, it was determined that the hospital failed to ensure the means of egress (exit access) on 2 of 9 floors were properly maintained. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/14/2014, the following was observed and acknowledged at the time of discovery:

1. 10:12 AM - double doors by Room 3S40 did not have any delayed egress signage

2. 10:35 AM - double doors by Room 3S36 did not latch properly and delayed egress function was not working properly

3. 11:25 AM - elevator lobby by Operating Room 3 was being used for storage of beds

Based on observation and staff interview, it was determined that the facility failed to ensure that exit directional signs were displayed with continuous illumination. Findings include:

During a tour of the Comprehensive Center for Behavioral Health on 1/15/2014 at 11:40 AM, it was observed that 1 of 3 exit signs in the parking garage was not illuminated. This finding was confirmed by Life Safety Officer A at time of discovery.

Based on observation and staff interview, it was determined that the hospital failed to provide signs indicating "No Exit" within the exit stairwells for areas that lead back into the building on the level of exit discharge in 1 of 6 stairwells observed during the survey. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/14/2014 at 2:41 PM, the following was observed and acknowledged at the time of discovery:

1. Stairwell #3 - the ground floor was missing a "NO EXIT" sign

Based on observation and staff interview, it was determined that the hospital failed to properly maintain the fire alarm system. Findings include:

During a hospital tour on 1/7/2014 at 9:40 AM, observation above the suspended ceiling by Room 4B00, revealed a fire alarm junction box missing a cover plate. This finding was confirmed by Life Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the hospital failed to properly maintain the fire alarm system. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/14/2014 at 11:31 AM, the following was observed and acknowledged at the time of discovery:

1. Pharmacy in surgical suite had a roll down fire shutter but did not have two smoke detectors installed to operate it.

Based on observation and staff interview, it was determined that the facility failed to ensure proper installation, maintenance, and supervision of the sprinkler system. Findings include:

During a tour of Springside Plaza - Christiana Care Rehabilitation Services on 1/10/2014 at 11:30 AM, no sprinkler heads were observed in Room 1114. This finding was confirmed by Life Safety Officer A at time of discovery.

Based on observation and staff interview, it was determined that the automatic sprinkler system was not maintained in compliance with NFPA 13 and NFPA 25. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/13/2014, the following was observed and acknowledged at the time of discovery:

1. 9:40 AM - 8th floor in Stair 5
- a plastic cap was placed over the sprinkler head

2. 9:50 AM - 8th and 9th floor shell spaces
- numerous wiring was lying across/attached to the sprinkler pipes

3. 2:02 PM - hallway by Room 3W91A
- sprinkler was missing an escutcheon plate

Based on observation and staff interview, it was determined that the automatic sprinkler system was not maintained in compliance with NFPA 25. Findings include:

During a tour of Roxana Cannon Arsht Surgicenter on 1/15/2014 between 9:33 AM and 9:38 AM, the following was observed:

1. Sprinkler was missing an escutcheon plate:
- by Post Anesthesia Care Unit A/B
- by Room 163A
- in Room 182

These findings were confirmed at time of discovery by Life Safety Officer A.

Based on observation and staff interview, it was determined that the hospital failed to ensure that exit corridors were maintained free of impediments which would interfere with the safe usage of the corridors during a fire or other emergency. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. beds, not in use, were lined up in corridor by Room 3S97E
This finding was confirmed by Mechanical Engineering Manager A at 2:45 PM on 1/13/2014.

2. chairs, not in use, were lined up in corridor and a storage cabinet was next to an exit door by Room 2W93C
This finding was confirmed by Mechanical Engineering Manager A at 12:52 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the hospital failed to ensure that exit corridors were maintained free of impediments which would interfere with the safe usage of the corridors during a fire or other emergency. Findings include:

During a tour with Mechanical Engineering Manager A on 1/7/2014, the following was observed and acknowledged at the time of discovery:

1. 1:17 PM - wheelchairs, not in use, were lined up in the corridor by Room 2C27

2. 3:15 PM - beds and linen carts, not in use, were lined up in the corridor by Room 1874

Based on observation and staff interview, it was determined that for 8 of 12 fire walls observed during the survey, the hospital failed to ensure the fire resistance rating was maintained. Findings include:

During hospital tours on 1/7, 1/8 and 1/9/2014, the following was observed:

1. fire doors by Room 4C35 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 9:25 AM on 1/7/2014.

2. fire doors by Room 3A44 - did not unlock with 15 pounds of pressure
This finding was confirmed by Mechanical Engineering Manager A at 10:06 AM on 1/7/2014.

3. fire doors by MER#12 3215 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 10:26 AM on 1/7/2014.

4. fire doors by Room 2C35 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 1:09 PM on 1/7/2014.

5. fire wall above the suspended ceiling between Rooms 2A12 and 2A23 - approximately a 2 inch round unsealed penetration around a pipe sleeve
This finding was confirmed by Life Safety Officer A at 1:35 PM on 1/7/2014.

6. double set of fire doors leading to the Triangle Restaurant - had a gapping more than 1/8 inch between the double doors
This finding was confirmed by Life Safety Officer A at 2:45 PM on 1/7/2014.

7. fire doors next to Room 1597B - had a gapping more than 1/8 inch between the double doors and the undercut was more than ¾ inch
This finding was confirmed by Life Safety Officer A at 2:47 PM on 1/8/2014.

8. Post Anesthesia Care Unit separation fire doors - latching mechanism did not function properly
This finding was confirmed by Life Safety Officer A at 10:00 AM on 1/9/2014.

Based on observation and staff interview, it was determined that the hospital failed to ensure fire resistance rating was maintained for 8 of 12 fire walls observed during the survey. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. fire wall above the suspended ceiling in Room 7S49 revealed approximately a 1 inch square unsealed penetration
This finding was confirmed by Life Safety Officer A at 10:27 AM on 1/13/2014.

2. fire wall above the suspended ceiling next to Room 6S12 revealed an unsealed penetration around a 1 inch data tube
This finding was confirmed by Life Safety Officer A at 10:50 AM on 1/13/2014.

3. two hour rated wall with a 45 minute rated door to Operating Room (OR) 3E01
This finding was confirmed by Mechanical Engineering Manager A at 9:41 AM on 1/14/2014.

4. fire doors to the gateway to the ORs - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 9:56 AM on 1/14/2014.

5. fire doors to gateway Room 3S40 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 10:10 AM on 1/14/2014.

6. fire wall above the suspended ceiling next to Room 3S24 revealed unsealed penetration around a 1 inch data tube
This finding was confirmed by Life Safety Officer A at 10:11 AM on 1/14/2014.

7. fire doors to gateway to Post Anesthesia Care Unit - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 10:12 AM on 1/14/2014.

8. fire wall above the suspended ceiling next to Stair 2 revealed unsealed penetration around 2 steam pipes that were removed
This finding was confirmed by Life Safety Officer A at 2:00 PM on 1/14/2014.

9. fire doors next to Room GN89 had a gapping more than 1/8 inch between the double doors
This finding was confirmed by Life Safety Officer A at 2:35 PM on 1/14/2014.

10. fire wall in the Fire Pump Room revealed unsealed penetration around a 2 inch pipe
This finding was confirmed by Life Safety Officer A at 3:00 PM on 1/14/2014.

11. fire doors to Fire Pump Room had a gapping more than 1/8 inch between the double doors
This finding was confirmed by Mechanical Engineering Manager A at 3:15 PM on 1/14/2014.

Based on observation and staff interview, it was determined that the hospital failed to properly maintain electrical panels, equipment and junction boxes in accordance with NFPA 70, National Electric Code. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. Stair 5 - an open electrical junction box
This finding was confirmed by Mechanical Engineering Manager A at 9:42 AM on 1/13/2014.

2. Room 5W97 - an air conditioner plugged into an extension cord
This finding was confirmed by Mechanical Engineering Manager A at 1:10 PM on 1/13/2014.

3. Room 3M65 - storage in front of the electrical panels
This finding was confirmed by Life Safety Officer A at 2:03 PM on 1/13/2014.

4. Fire Pump Room, ceiling level - there was an open electrical junction box
This finding was confirmed by Life Safety Officer A at 3:15 PM on 1/13/2014.

5. Materials Distribution Room - an extension cord with a multi-plug adapter in use
This finding was confirmed by Mechanical Engineering Manager A at 2:23 PM on 1/14/2014.

6. Mail Room - a multi-plug adapter in use
This finding was confirmed by Mechanical Engineering Manager A at 2:25 PM on 1/14/2014.