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Based on observation and interview, the Type I (332) facility failed to maintain the protective foam coatings applied to vertical and horizontal steel beams that served as main structural elements that support the nine floor hospital in three of three shell space areas and two of two floors used for mechanical space. Without the protective foam coating or Class A interior protection, the steel beams, connecting plates, bolts and cross-members (part of steel beam connecting other structural steel beams together) are vulnerable to heat and could fail and result in a catastrophic collapse of the entire structure, affecting all patients, staff and visitors.

The facility census was 131.

Findings included:

1. Observation on 07/07/15 at 3:00 PM showed holes and penetrations in the fire resistant foam covering structural steel beams, connecting plates and cross-members as follows:
- Random corners, crevices and mounting points on steel columns, connecting plates and cross-members in the 9th floor Penthouse mechanical rooms.
- Random corners, crevices and mounting points on steel columns, connecting plates and cross-members in the 8th floor shell space.
- Random corners, crevices and mounting points on steel columns, connecting plates and cross-members in the 6th floor shell space.
- Random corners, crevices and mounting points on steel columns, connecting plates and cross-members in the 1st floor shell space.
- Random corners, crevices and mounting points on steel columns, connecting plates and cross-members in the Lower Level mechanical rooms.

2. The heat-protective foam coatings in these areas was vulnerable and had been struck or gouged by other equipment such as forklifts, pallets and mechanical cabinets, or scraped off to provide secure mounting points for electrical conduits, water pipes and bracing.

3. During an interview on 07/07/15 at 4:30 PM, Staff A, Plant Manager, acknowledged the findings.

Based on observation and interview, the facility failed to ensure four of seven occupied patient floors the fire and smoke doors closed to separate extended corridors and prevent the spread of smoke or fire to unaffected patient rooms. Failure to maintain separate fire spaces prevents staff from being able to isolate a fire to a limited area and prevent the spread of smoke, which potentially affects all staff, visitors and all patients in the nine story structure.

The facility census was 131.

that had fire and smoke doors closed, to separate extended corridors and prevent the spread of smoke or fire to unaffected patient rooms.

Findings included:

1. Observation on 07/07/15 at 3:30 PM showed one or both of the following pairs of doors a pair of doors failed to close together when released:
- A pair of doors in a 7 South corridor fire wall.
- A pair of doors in a 7 North corridor fire wall.
- A pair of doors in a 6 North corridor fire wall did not have an astragal to cover the gap between doors.
- A pair of doors in the 2nd floor Cancer Center fire wall.
- A pair of doors in the 2nd floor elevator (#11) lobby.
- A pair of doors in the lower level main corridor (outside of Central Sterile).

2. During an interview on 07/06/15 at 4:30 PM, Staff A, Plant Manager, acknowledged the findings and stated that the last Preventive Maintenance and Fire Evaluation rounds had been completed about two months ago.