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Based upon observation and interview, it was determined the facility failed to ensure the doors in the communicating openings of the fire resistive rated common wall, cannot be immobilized prohibiting their use as a means egress on one of four floors.

Findings include:

Observation on January 12, 2010, at approximately 10:05 am, revealed on the third floor at the common wall shared with the Pavilion building, there were fire/thermal pins installed in the cross corridor double fire doors protecting the communicating opening in the wall.

Door locks are required to be operable without the use of a key, tool or special knowledge while the building is occupied. Fire/thermal pins render the door inoperable after the pins activation. Reference the 2000 edition NFPA 101 Life Safety Code, Chapter 7.2.1.5.

Interview with the Vice President Hospital Administration, the Director of Facilities, and the Assistant Safety Officer on January 13, 2010, at 10:30 am, at the time of the exit conference confirmed the fire pins installed in the fire doors.

Based on observation and interview, it was determined the facility failed to ensure the corridors are separated from use areas by walls constructed to resist the passage of smoke on one of four floors.

Findings include:

Observation on January 12, 2010, at approximately 11:10 am, revealed on the second floor, above the electrical room H2-140 there was a horizontal sprinkler pipe penetration of the corridor wall. The electrical room does not have a suspended ceiling.

Interview with the Vice President Hospital Administration, the Director of Facilities, and the Assistant Safety Officer on January 13, 2010, at 10:30 am, at the time of the exit conference confirmed the penetration.

Based on observation and interview, it was determined the facility failed to ensure there are no impediments to the closing of the corridor doors, and ensure the corridor doors positively latch into the door frame in order that the doors remain closed in the frame on one of four floors.

Findings include:

Observation on January 12, 2010, at approximately 9:00 am, revealed on the third floor north, the clean linen storage room was prevented from closing by a metal storage rack that was hung over the door.

Interview with the Vice President Hospital Administration, the Director of Facilities, and the Assistant Safety Officer on January 13, 2010, at 10:30 am, at the time of the exit conference confirmed the storage rack on the corridor door and the subsequent removal of the rack during the time of the survey.

Based upon observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of the smoke barrier walls on two of four floors.

Findings include:

Observation on January 12, 2010, between approximately 10:15 am and 11:25 am, revealed the following unsealed the smoke barrier wall horizontal penetrations:

a. 10:15 am, third floor, smoke wall separating 3 North and 3 South near room H3-102, penetration created by electrical conduit. The conduit was open on the ends.
b. 11:25 am, second floor, smoke wall separating 2 North and 2 South, penetration created by orange data cable, conduit, and HVAC duct work.

Interview with the Vice President Hospital Administration, the Director of Facilities, and the Assistant Safety Officer on January 13, 2010, at 10:30 am, at the time of the exit conference confirmed the smoke barrier penetrations.

Based on observation and interview, it was determined that the facility failed to maintain the separation between other spaces and hazardous areas with smoke resistant partitions and the facility failed ensure the doors to hazardous areas are self closing and remain closed within the door frame on two of four floors.

Findings include:

1. Observation on January 12, 2010, at approximately 11:30 am, revealed on the second floor the automatic closure for the corridor door to room 214, would not close the door with enough force to positively latch the door. The room was greater than 50 square feet in area and contained numerous cardboard boxes containing medical supplies.

Interview with the Vice President Hospital Administration, the Director of Facilities, and the Assistant Safety Officer on January 13, 2010, at 10:30 am, at the time of the exit conference confirmed the door closure requires adjustment.

2. Observation on January 12, 2010, at approximately 11:50 am, on the second floor in the operating room service corridor revealed the surgery storage room had an unsealed steam pipe penetration above the corridor door.

Interview with the Vice President Hospital Administration, the Director of Facilities, and the Assistant Safety Officer on January 13, 2010, at 10:30 am, at the time of the exit conference confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders are secured and located to prevent falling on one of four floors.

Findings include:

Observation on January 12, 2010, at approximately 11:12 am, revealed on the second floor in the ICU, there was one unsecured "E" type oxygen cylinder setting on the floor.

Interview with the Vice President Hospital Administration, the Director of Facilities, and the Assistant Safety Officer on January 13, 2010, at 10:30 am, at the time of the exit conference confirmed the unsecured oxygen cylinder and the subsequent correction of the deficiency during the time of the survey.

Based on documentation review and interview, it was determined the facility failed to ensure the medical gas alarms and delivery systems are maintained as required in one instance within the facility.

Findings include:

Documentation review and interview conducted on January 13, 2010, at approximately 10:00 am, revealed in September 2009 an outside vender conducted an inspection of the facility's medical gas delivery system. A report of the vender's findings dated October 14, 2009 was reviewed and the following deficiencies were noted:

a. Five oxygen outlets, 14 vacuum outlets, and one nitrous oxide outlet that presented leaks or low flow conditions.
b. Four alarm panels that had inoperable alarm/control modules.
c. One zone valve box had inaccurate labeling.

At the time of this survey, there was no work started on correction of the noted deficiencies.

Interview with the Vice President Hospital Administration, the Director of Facilities, and the Assistant Safety Officer on January 13, 2010, at 10:30 am, at the time of the exit conference confirmed the medical gas deficiencies.

Based upon observation and interview, it was determined the facility failed to inspect and maintain electrical wiring and/or components in a workmanlike manner on two of four floors.

Findings include:

Observations on January 12, 2010, between approximately 11:10 am and 1:40 pm, revealed open electrical junction boxes exposing the electrical connections in the following locations:

a. 11:10 am, second floor, room H2-140 electrical room, junction box above the Simplex signal extender box.
b. 11:50 am, second floor operating rooms service corridor, inside the medical gas storage room.
c. 1:00 pm, first floor mechanical room for air handler nine, above the entrance door, two open junction boxes.
d. 1:40 pm, basement mechanical room, three junction boxes located on the ceiling.

Interview with the Vice President Hospital Administration, the Director of Facilities, and the Assistant Safety Officer on January 13, 2010, at 10:30 am, at the time of the exit conference confirmed the open junction boxes.