HospitalInspections.org

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations within this component.

Findings include:

Observation of various aspects of building construction requirements between 10:13 a.m. and 10:55 a.m. on January 10, 2011, revealed this component to exceed maximum story height requirements by one story.

Interview with facilities manager during the exit interview process conducted between 12:00 p.m. and 12:15 p.m. on January 10, 2012, confirmed the building story height/construction deficiency and identified the facility as possessing an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on January 10, 2012, addressing this issue.

Based upon observation and interview, it was determined the facility failed to construct and maintain various vertical openings in various locations within this component.

Findings include:

Observation of various vertical openings within this component between 10:00 a.m. and 10:25 a.m. on January 11, 2012, revealed shaft enclosures to lack required one and two-hour fire resistive integrity due to metal lathe plaster construction.

Interview with facilities manager during the exit interview process conducted between 10:25 a.m. and 10:30 a.m. on January 11, 2012, confirmed the vertical opening deficiency and identified the facility as possessing an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on January 11, 2012, addressing this issue.

Based upon observation and interview, it was determined the facility failed to maintain one hazardous area enclosure in one location on one of four total floors.

Findings include:

Observation of the fourth floor Psychology Storage Room entrance door at 11:18 a.m. on January 10, 2012, revealed the corridor entrance door to lack a self-closing device.

Interview with facilities manager at 11:17 a.m. on January 10, 2012, confirmed the corridor door to lack a self-closing device.

Based upon observation and interview, it was determined the facility failed to provide two exits, remote from one another, within one fire section of this component.

Findings include:

Observation of the sub-basement-level mechanical spaces at 10:17 a.m. on January 11, 2012, revealed less than two acceptable means of egress from this level.

Interview with facilities manager during the exit interview process conducted between 10:15 a.m. and 10:30 a.m. on January 11, 2012, confirmed the exiting deficiency from the sub-basement-level mechanical spaces and identified the facility as possessing an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on January 11, 2012, addressing this issue.

Based upon observation and interview, it was determined the facility failed to properly construct and maintain one exit stair tower location within this component.

Findings include:

Observation of the basement and first floor levels of the number ten stair tower enclosure between 10:14 a.m. and 10:16 a.m. on January 11, 2012, revealed headroom to be less than the required six feet, eight inches due to overhead protrusion.

Interview with facilities manager at 10:17 a.m. on January 11, 2012, confirmed the stair tower enclosure deficiency and identified the facility as possessing an acceptable Fire safety Evaluation System (F.S.E.S.) reviewed on January 11, 2012, addressing this issue.

Based upon observation and interview, it was determined the facility failed to maintain exit access in two locations on two of five floors.

Findings include:

1. Observation of various exit access corridor systems within this component between 09:55 a.m. and 11:02 a.m. on January 10, 2012, revealed the below deficiencies:

a. Copy paper and a shredder bin is located within the second floor exit access corridor system closest to the elevator enclosure. 09:55 a.m.
b. A shredder is located within the fifth floor exit access corridor system closest to the elevator enclosure. 11:02 a.m.

Interview with facilities manager at 09:56 a.m. and 11:05 a.m. on January 10, 2012, confirmed the items located within the exit access corridor systems specified above.

Based upon observation and interview, it was determined the facility failed to maintain the automatic sprinkler systems in two instance on one of four total floors.

Findings include:

1. Observation of the second floor PT Gym closet at 11:40 a.m. on January 10, 2012, revealed the below deficiencies:

a. Storage items are located within eighteen inches of a sprinkler head assembly. 11:40 a.m.
b. An escutcheon plate is lacking from a sprinkler head assembly 11:40 a.m.

Interview with facilities manager at 11:41 a.m. on January 10, 2012, confirmed the storage items located in close proximity to the sprinkler head assembly and the missing escutcheon plate.