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Based on observation and interview, the facility failed to maintain fire resistance rating for structural steel, on three of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, at 10:05 AM revealed unprotected structural steel, above the Visitor's Restroom sign, in the 7th floor Elevator Lobby.

Interview with Maintenance Representative 2 on February 8, 2017, at 10:05 AM confirmed the unprotected steel.


2. Observation on February 8, 2017, at 12:45 PM revealed unprotected structural steel above Chiller #2, in the 6th floor Mechanical Room.

Interview with Maintenance Representative 2 on February 8, 2017, at 12:45 PM confirmed the unprotected steel.


3. Observation on February 8, 2017, at 1:25 PM revealed unprotected structural steel, above the Conference Room door and by Patient Room #500, in the corridor on the 5th floor.

Interview with Maintenance Representative 2 on February 8, 2017, at 1:25 PM confirmed the unprotected steel.

Based on observation and interview, it was determined the facility failed to maintain exit access corridors to be clear and unobstructed, on two of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, between 1:00 PM and 1:30 PM, revealed computer stands and soiled linen carts were being stored in the corridor, throughout the 6th floor.

Interview with Maintenance Representative 2 on February 8, 2017, at 1:30 PM confirmed items were being stored in the corridor.


2. Observation on February 8, 2017, between 1:00 PM and 2:00 PM, revealed computer stands were being stored in the corridor, throughout the 5th floor.

Interview with Maintenance Representative 2 on February 8, 2017, at 2:00 PM confirmed items were being stored in the corridor.

Based on observation and interview, it was determined the facility failed to maintain corridor doors to be unobstructed, on one of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, at 1:45 PM revealed the Cafeteria Conference Room A and B door was equipped with a self-closure device, which was held open by a sign, keeping the door in the open position.

Interview with Maintenance Representative 1 on February 8, 2017, at 1:45 PM confirmed the door was obstructed from closing.


2. Observation on February 8, 2017, at 1:53 PM revealed the Cafeteria Kitchen Food Prep Room was held open, by a food cart.

Interview with Maintenance Representative 1 on February 8, 2017, at 1:53 PM confirmed the door was obstructed from closing.

Based on observation and interview, it was determined the facility failed to maintain the required fire rating of stairtowers, with doors, which are capable of self-closing and positively latching, on two of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, between 1:12 PM and 2:00 PM revealed the stairtower doors failed to latch into the frame, at the following locations:

a) 1:12 PM, basement double doors, in the South Wing, East Stairtower, did not latch in the frame.
b) 2:00 PM, the door at the top of the ramp, from the communicating stairtower to the protected passageway, did not latch in the frame.

Interview with the Director of Facilities Management on February 8, 2017, at 3:00 PM confirmed the doors failed to positively latch.


2. Observation on February 8, 2017, at 2:27 PM revealed an unsealed penetration of the South Wing East Stairwell, above the ceiling.

Interview with Maintenance Representative 1 on February 8, 2017, at 2:27 PM confirmed the penetration.


3. Observation on February 8, 2017, at 2:32 PM revealed the interstitial space above and below the ceiling/floor assembly, at the protected passageway from the basement, has various items passing through the space, which are not part of the passageway, such as data and communication wiring, flexible dispenser piping for units in the 1st floor Dining Area and ductwork for the Pharmacy.

Interview with the Director of Facilities Management on February 8, 2017, at 2:32 PM confirmed the items penetrated the rated envelope of the protected passage way.

Based on observation and interview, it was determined the facility failed to provide two exits, remote from one another, on one of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, at 1:10 PM revealed the Mechanical Sub-basement area lacked two separate and remote exits.

Interview with Maintenance Representative 3 on February 8, 2017, at 1:10 PM confirmed there is only one exit from this sub-basement area.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas to be fire rated or smoke resistant construction, with self-closing and positive latching doors, on one of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, between 1:35 PM to 1:45 PM revealed hazardous area doors failed to close and latch, in the following locations:

a. 1:35 PM, 2nd floor Mechanical Room #2NWB, corridor doors failed to latch and close;
b. 1:45 PM, 2nd floor Mechanical Room #2NWA, corridor doors failed to latch and close.

Interview with Maintenance Representative 2 on February 8, 2017, at 1:45 PM confirmed the hazardous area doors did not close and positively latch.


2. Observation on February 8, 2017, between 1:35 PM and 2:00 PM revealed penetrations through the hazardous areas, in the following locations:

a. 1:35 PM, 2nd floor Mechanical Room #2NWB, a 3-inch penetration over the double corridor doors;
b. 1:37 PM, 2nd floor Mechanical Room #2NWB, two open 4-inch conduits, over the fire extinguisher;
c. 1:38 PM, 2nd floor Mechanical Room #2NWB, none of the conduits, leading through the rated wall, were sealed;
d. 1:39 PM, 2nd floor Mechanical Room #2NWB, unsealed penetration of an open conduit with purple data wire, over Exhaust Duct #317;
e. 1:40 PM, 2nd floor Mechanical Room #2NWB, unsealed around two 4-inch conduits, over Electrical Panel #EQDPD;
f. 2:00 PM, #2NWA Mechanical Room, in the 2nd floor Waiting Room, open 2-inch conduit.

Interview with Maintenance Representative 2 on February 8, 2017, at 2:00 PM confirmed the penetrations.

Based on observation and interview, it was determined the facility failed to maintain the flame-spread rating for interior wall finishes, on one of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, at 11:20 AM revealed a peg board, with a class C rating, was installed on the South Wall of the Ortho Room, in the basement.

Interview with Maintenance Representative 3 on February 8, 2017, at 11:20 AM confirmed the peg board has a class C rating.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system to be clear of extraneous weight, on one of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, at 1:00 PM revealed two large gray cable bundles were being supported by a sprinkler branch line, in the corridor outside of Mechanical Room #3-S, in the basement.

Interview with the Director of Facilities Management on February 8, 2017, at 3:00 PM confirmed the cables were supported by the sprinkler pipe.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers to be installed not less than three inches from the ground, and readily accessible at all times, on two of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, at 1:10 PM revealed a chair was blocking access to the fire extinguisher, in the 6th floor corridor by Patient Room #616.

Interview with Maintenance Representative 2 on February 8, 2017, at 1:10 PM confirmed the blocked extinguisher access.


2. Observation on February 8, 2017, at 2:50 PM revealed a fire extinguisher sitting on the floor, in the 3rd floor Mechanical Room.

Interview with the Director of Facilities Management on February 8, 2017, at 2:50 PM confirmed the fire extinguisher was installed at least 3 inches from the floor.

Based on observation and interview, it was determined the facility failed to maintain corridor walls to be smoke tight, on three of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, between 9:58 AM and 2:30 PM revealed corridor walls did not extend to the deck above, on both sides of the wall, at the following locations:

a) 9:58 AM, various basement level corridor walls;
b) 10:15 AM, 1st floor.

Interview with the Director of Facilities Management on February 8, 2017, at 3:00 PM confirmed the corridor walls are not all complete, to the deck.


2. Observation on February 8, 2017, at 10:01 AM revealed a group of unsealed data wires were passing through the corridor wall above the ceiling, to the right of the Green Elevator in the basement.

Interview with Maintenance Representative 3 on February 8, 2017, at 10:01 AM confirmed the area around there were penetrations.


3. Observation on February 8, 2017, at 2:50 PM revealed a 2-inch round hole, in the Janitor's Closet ceiling, of the 1st floor South Wing.

Interview with Maintenance Representative 1 on February 8, 2017, at 2:50 PM confirmed the ceiling was not smoke tight.


4. Observation on February 9, 2017, at 11:05 AM revealed there was an unsealed penetration, of the 1st floor Radiology entrance, above the ceiling.

Interview with the Director of Facility Maintenance on February 9, 2017, at 11:05 AM confirmed the penetration.


5. Observation on February 9, 2017, between 12:02 PM and 1:48 PM revealed unsealed penetrations, in the following areas:

a) 12:02 PM, at the corridor wall and the decking, in the 1st floor, North Wing CAT Scan hall;
b) 1:48 PM, at Bay #15 above the ceiling, there is a horizontal penetration, at the fire wall, around the duct work.

Interview with the Director of Facilities Management on February 9, 2017, at 1:48 PM confirmed the penetrations.

Based on observation and interview, it was determined the facility failed to maintain corridor doors to close and resist the passage of smoke, on four of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, between 12:52 PM and 1:35 PM revealed corridor doors would not positively latch, at the following locations:

a. 12:52 PM, 6th floor, Patient Room #606 would not close and latch, due to an isolation rack hanging over the door;
b. 1:03 PM, 6th floor, Patient Room #624 failed to latch and close;
d. 1:05 PM, 6th floor, Patient Room #623 would not close and latch, due to a four-wheeled cart blocking the door;
e. 1:03 PM, 6th floor, Patient Room #620 failed to latch and close;
f. 1:20 PM, 6th floor, Patient Room #610 failed to latch and close;
g. 12:58 PM, 5th floor, Resident Room #508 failed to latch in its frame;
h. 1:30 PM, 5th floor, Pyxis Room would not close and latch, due to a blood pressure machine blocking the door;
i. 1:35 PM, 5th floor, Patient Room #52 would not close and latch, due to an isolation rack hanging over the door.

Interview with Maintenance Representative 2 on February 8, 2017, at 1:35 PM confirmed the doors failed to positively latch.


2. Observation on February 8, 2017, at 1:00 PM revealed the door, to Patient Room #625, had a gap greater than one quarter of an inch.

Interview with Maintenance Representative 2 on February 8, 2017, at 1:00 PM confirmed the door was not smoke tight.


3. Observation on February 9, 2017, between 11:00 AM and 11:58 AM revealed corridor doors failed to positively latch, at the following locations:

j. 11:00 AM, 3rd floor, Cancer Center Office double doors failed to close and latch;
k. 11:50 AM, 2nd floor, double doors to the Surgical Services Office failed to latch and close;
l. 11:58 AM, 2nd floor, double doors to the Huddle Room failed to latch and close.

Interview with Maintenance Representative 2 on February 9, 2017, at 11:58 PM confirmed the doors failed to positively latch.

Based on observation and interview, it was determined the facility failed to provide smoke compartments not greater than 22,500 square feet, on three of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, between 9:55 AM and 11:50 AM, revealed the following smoke compartments are greater than 22,500 square feet in area:

a) 9:55 AM, basement level;
b) 10:30 AM, 2nd floor;
c) 10:35 AM, 1st floor.

Interview with Maintenance Representative 2 on February 8, 2017, at 10:35 AM confirmed the smoke compartments were larger than the maximum size allowed.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls, affecting five of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, at 10:00 AM revealed an unsealed penetration around an M/C cable and grey data wire, over the time clock in the Elevator Lobby smoke barrier wall, on the 7th floor.

Interview with the Maintenance Representative 2 on February 8, 2017, at 10:00 AM confirmed there was an unsealed penetration.


2. Observation on February 8, 2017, at 12:55 PM revealed open conduits in the smoke barrier wall, from the Waiting Room to the Mechanical Room on the 6th floor, inside a 4" and a 1" conduit.

Interview with the Maintenance Representative 2 on February 8, 2017, at 12:55 PM confirmed the open conduits.


3. Observation on February 8, 2017, at 1:00 PM revealed an unsealed penetration around a red data wire, on the right smoke wall in the Unit Nursing Office, on the 6th floor.

Interview with the Maintenance Representative 2 on February 8, 2017, at 1:00 PM confirmed there was unsealed penetration.


4. Observation on February 9, 2017, between 11:05 AM and 1:05 PM, revealed smoke barrier walls had unsealed penetrations, at the following locations:

a. 11:05 AM, 2nd floor, Soiled Handling Room had an untaped seam, various penetrations and not sealed to the deck.
b. 11:10 AM, 2nd floor, Men's Locker Room, North Wall had an untaped seam, various penetrations and not sealed to the deck.
c. 11:20 AM, 2nd floor, Sterile Corridor above the double doors, outside Center Core, was not sealed around conduits and data wires and not sealed at the deck.
d. 11:30 AM, 2nd floor, Center Core was not sealed to the bottom of the I-Beam and the wallboard does not continue behind the ceiling grid C-Channel.
e. 11:30 AM, third floor, outside Lab Entrance, above the ceiling, 3/4 hole around an MC Cable and Data Wires
f. 11:40 AM, 2nd floor, Sterile Corridor outside OR #3, around a conduit and data wires.
g. 12:35 PM, first floor, across from the two Bank Elevators, around three 3/4 inch conduits.
h. 12:36 PM, first floor, across from the two Bank Elevators, inside a 3/4 inch conduit.
i. 12:45 PM, first floor, Men's Room sinks had gaps around 4 supply lines and 2 drain lines.
j. 1:05 PM, first floor, Triage Room #3 had a penetration inside 2 gray flex tubes, above the ceiling.

Interview with the Maintenance Representative 2 and the Director of Facilities on February 9, 2017, at 1:05 PM confirmed there were penetrations.

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barriers to close and resist the passage of smoke, affecting one of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, at 1:18 PM revealed the 4th floor double smoke barrier doors (AD4NWO22), leading into the ICU, were equipped with latching hardware, and did not close and latch.

Interview with the Director of Facilities Management on February 8, 2017, at 1:18 PM confirmed the doors failed to latch.

Based on observation and interview, it was determined the facility failed to store soiled linen and trash receptacles that are greater than 32-gallon capacity when left unattended, on four of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, between 10:15 AM and 1:37 PM, revealed soiled-linen hampers and trash containers, with combined or single capacities exceeding 32 gallons, were stored outside of a protected hazardous storage area, in the following areas:

a. 10:15 AM, 7th floor, Clean Utility Room, one soiled linen hamper.
b. 10:20 AM, 7th floor, outside Patient Rooms 715, 710, and 711, one soiled-linen hamper at each.
c. 10:30 AM, 7th floor, Nurses' Station, a shred-it container, a 23-gallon paper container, and two waste baskets.
d. 11:20 AM, 7th floor, outside Patient Rooms 703 and 702, one soiled-linen hamper at each.
e. 12:00 PM, 6th floor, Patient Room 606, one soiled-linen hamper.
f. 1:05 PM, 6th floor, outside Conference Room by Resident Room 605, one soiled-linen hamper.
g. 1:07 PM, 6th floor, in corridor outside Patient Rooms 603, 602, and 601, one soiled-linen hamper at each.
h. 1:10 PM, 6th floor, in corridor outside Patient Rooms 618, 617, 616, 612, and 609, one soiled-linen hamper at each.
i. 1:25 PM, 6th floor, Nurses' Station, a shredder container and waste basket.
j. 1:20 PM, 5th floor, inside Patient Room 527, one soiled-linen hamper.
k. 1:35 PM, 5th floor, inside Patient Rooms 512, 508, and 503, one soiled-linen hamper at each.
l. 1:37 PM, 5th floor, in corridor outside Patient Rooms 501 and 500, one soiled-linen hamper at each.

Interview with the Maintenance Representative 2 on February 8, 2017, at 1:37 PM confirmed the soiled-linen, shredder and trash containers were stored outside of a protected hazardous storage area.


2. Observation on February 8, 2017, between 12:52 AM and 2:30 PM, revealed recycling containers, with a capacity of approximately 64 gallons, were being stored in a non-rated room, in the following locations:

a. 12:52 AM, 1st floor HIM Room.
b. 12:54 AM, 1st floor Staff Room.

Interview with Maintenance Representative 1 on February 8, 2017, at 12:54 AM confirmed the recycle receptacles were stored outside of a protected rated storage area.

Based on observation and interview it was determined the facility failed to maintain electrical wiring and electrical protective coverings, on six of nine floors within the facility.

Findings include:

1. Observation on February 8, 2017, at 11:10 AM revealed an unterminated M/C cable on an I-Beam above the ceiling, in the 7th floor Conference Room.

Interview with Maintenance Representative 2 on February 8, 2017, at 11:10 AM confirmed this unterminated wire.


2. Observation on February 8, 2017, between 1:11 PM and 1:18 PM, revealed the temporary wiring was still in place, at the following locations:

a. 1:11 PM, temporary construction lighting fixtures and open-ended temporary lighting wiring was located in Mechanical Room 8S, in the South Wing of the 1st floor.
b. 1:18 PM, temporary lighting fixtures and open-ended temporary lighting wiring was located above the ceiling, in the North Wing of the basement.

Interview with Maintenance Representative 1 on February 8, 2017, at 1:18 PM confirmed the temporary lighting.


2. Observation on February 8, 2017, at 1:20 PM revealed an electrical junction box, which lacked a cover plate, on the 5th floor above Electrical Panel PE, across from Patient Room 526.

Interview with Maintenance Representative 2 on February 8, 2017, at 11:10 AM confirmed the box lacked a cover plate.


3. Observation on February 8, 2017, at 1:30 PM revealed Romex-style temporary wiring above the ceiling over the Pyxis Machine, on the 5th floor.

Interview with Maintenance Representative 2 on February 8, 2017, at 1:30 PM confirmed there was temporary wiring still in place.


4. Observation on February 8, 2017, between 1:11 PM and 2:30 PM revealed temporary wiring was still in place, at the following locations:

a) 1:11 PM, temporary construction lighting fixtures and open-ended temporary lighting wiring was located in Mechanical Room 8S, in the South Wing of the 1st floor;
b) 1:18 PM, temporary lighting fixtures and open-ended temporary lighting wiring was located above the ceiling, in the North Wing of the basement;

Interview with Maintenance Representative 1 on February 8, 2017, at 2:30 PM confirmed there was temporary wiring still in place. Refer to the 2011 edition of NFPA 70, National Electrical Code, Article 314.


5. Observation on February 8, 2017, between 1:55 PM and 2:30 PM revealed open junction boxes, at the following locations:

a. 1:55 PM, 1st floor, an open junction box above the exit sign ceiling, at the South Wing East Stairwell;
b. 2:30 PM, loading dock, an open junction box above the ceiling at the exit door, from the protected passage way.

Interview with Maintenance Representative 1 on February 8, 2017, at 2:30 PM confirmed the open junction boxes.


6. Observation on February 8, 2017, at 3:00 PM revealed Romex-style temporary wiring above the ceiling, at the following locations:

a. 3:00 PM, in the 2nd floor Waiting Room.
b. 3:00 PM, above the ceiling in the Sterile Corridor, outside the 2nd floor Center Core.

Interview with Maintenance Representative 2 on February 8, 2017, at 3:00 PM confirmed the temporary wiring.

Based on observation and interview, it was determined the facility failed to monitor for the unauthorized use of temporary power taps, on one of nine floors within the facility.

1. Observation on February 8, 2017, between 10:50 AM and 10:55 AM revealed the following electrical issues:

a. 10:50 AM, a coffee pot and microwave were being powered by a temporary power tap in the Receiving Office, in the basement.
b. 10:55 AM, two daisy-chained power taps were powering computer equipment in the Storeroom Office area, in the basement.

Interview with Maintenance Representative 3 on February 8, 2017, at 10:55 AM confirmed the appliances and power tap were being powered by power taps.

Based on observation and interview, it was determined the facility failed to secure medical gas cylinders, in one of nine floors within the facility.

Findings include:

1. Observation on February 9, 2017, at 12:45 PM revealed there were two unsecured oxygen "D" cylinders, in 1st floor ED Supply Room.

Interview with the Maintenance Representative 2 on February 9, 2017, at 12:45 PM confirmed the unsecured oxygen "D" cylinders.