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Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 18.1.1.4.1, 18.1.1.4.2. This deficient practice could potentially affect occupants in 1 of 8 smoke compartments in the event of a fire not being properly contained by rated construction.

Findings include:

On 8/30/10 at approximately 1:02pm, a conduit sleeve in the separation wall of the hospital and medical office building was observed to not be properly firestopped. The unfilled space of the conduit had the intumescent caulk removed. This condition was noted with the Maintenance Supervisor present.

Based on observation the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could potentially affect all occupants in 2 of 8 smoke compartments in the event of fire and smoke not being contained to the smoke compartment.

Findings include:

On 8/30/10 at approximately 12:57pm, a conduit was observed above the ceiling at the ACU Reception Desk that was not properly firestopped around the penetration or the unfilled space of the conduit. This condition was noted with the Maintenance Supervisor present.

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 18.3.7.5, 18.3.7.6, 18.3.7.8. This deficient practice could potentially affect all occupants in 4 of 8 smoke compartments in the event of fire and smoke not being contained.

Findings include:

1. On 8/30/10 at approximately 11:13am, the smoke barrier doors by the Anesthesia Office did not close properly upon testing. The doors are equipped with latching hardware. This condition was noted with the Maintenance Supervisor present.

2. On 8/30/10 at approximately 11:26am, both sets of smoke barrier doors by the X-Ray/Lab Waiting Area did not close properly upon testing. The doors are equipped with latching hardware. This condition was noted with the Maintenance Supervisor present.

3. On 8/30/10 at approximately 11:43am, the smoke barrier doors by the ED in the main corridor did not close properly upon testing. The doors are equipped with latching hardware. This condition was noted with the Maintenance Supervisor present.

4. On 8/30/10 at approximately 11:46am, the smoke barrier doors by the ACU Reception Desk did not close properly upon testing. The doors are equipped with latching hardware. This condition was noted with the Maintenance Supervisor present.

5. On 8/30/10 at approximately 11:47am, the rolling shutter completing the smoke barrier at the ACU Reception Desk was prevented from closing due to items being stored on the counter. This condition was noted with the Maintenance Supervisor present.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect staff in 1 of 8 smoke compartments in the event of a fire not being properly contained to the hazardous area.

Findings include:

On 8/30/10 at approximately 11:02am, the door to the File Storage Room in the Records Office was being held open by a wooden wedge. This condition was noted with the Maintenance Supervisor present.

Based on records review the facility failed to maintain emergency lighting in accordance with the LSC section 18.2.9.1. This deficient practice could potentially affect the occupants of the operating rooms in the event of a power failure.

Findings include:

On 8/30/10 between 9:15am and 11:00am during records review, the facility did not have documentation of the 90 minute annual testing of the battery operated emergency lighting as required by Section 7.9.3. This condition was noted with the Maintenance Supervisor present.

Based on review of records the facility failed to provide written documentation regarding fire drills or ensure that drills are conducted at unexpected times under varying circumstances in accordance with the LSC section 18.7.1.2. This deficient practice could potentially affect all occupants of the facility in the event of staff not being properly trained in fire emergency procedures.

Findings include:

1. On 8/30/10 between 9:15am and 11:00am during records review, the facility did not have documentation of the fire drills conducted for the 2nd and 3rd shifts during the 3rd quarter of 2009 or for the 2nd shift during the 4th quarter of 2009. This condition was noted with the Maintenance Supervisor present.

2. On 8/30/10 between 9:15am and 11:am during records review, the facility fire drill documentation showed that 2 of the 1st shift drills were conducted within the same hour, 2 of the 2nd shift drills were conducted within the same hour, and 3 of the 3rd shift drills were conducted within the same hour. The drills throughout the year did not occur at unexpected times or were not varied through the shift. This condition was noted with the Maintenance Supervisor present.

Based on review of records the facility failed to provide an fire watch plan in the event of the sprinkler system being out of service for more than 4 hours in a 24-hour period in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility in the event of a sprinkler system failure.

Findings include:

On 8/30/10 between 9:15am and 11:00am during records review, the facility did not have a policy for conducting a fire watch in the event of the sprinkler system being out of service. This condition was noted with the Maintenance Supervisor present.

Based on review of records the facility failed to provide an fire watch plan in the event of the fire alarm system being out of service for more than 4 hours in a 24-hour period in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility in the event of a fire alarm system failure.

Findings include:

On 8/30/10 between 9:15am and 11:00am during records review, the facility did not have a policy for conducting a fire watch in the event of the fire alarm system being out of service. This condition was noted with the Maintenance Supervisor present.

Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 18.1.1.4.1, 18.1.1.4.2. This deficient practice could potentially affect occupants in 1 of 8 smoke compartments in the event of a fire not being properly contained by rated construction.

Findings include:

On 8/30/10 at approximately 1:02pm, a conduit sleeve in the separation wall of the hospital and medical office building was observed to not be properly firestopped. The unfilled space of the conduit had the intumescent caulk removed. This condition was noted with the Maintenance Supervisor present.

Based on observation the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could potentially affect all occupants in 2 of 8 smoke compartments in the event of fire and smoke not being contained to the smoke compartment.

Findings include:

On 8/30/10 at approximately 12:57pm, a conduit was observed above the ceiling at the ACU Reception Desk that was not properly firestopped around the penetration or the unfilled space of the conduit. This condition was noted with the Maintenance Supervisor present.

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 18.3.7.5, 18.3.7.6, 18.3.7.8. This deficient practice could potentially affect all occupants in 4 of 8 smoke compartments in the event of fire and smoke not being contained.

Findings include:

1. On 8/30/10 at approximately 11:13am, the smoke barrier doors by the Anesthesia Office did not close properly upon testing. The doors are equipped with latching hardware. This condition was noted with the Maintenance Supervisor present.

2. On 8/30/10 at approximately 11:26am, both sets of smoke barrier doors by the X-Ray/Lab Waiting Area did not close properly upon testing. The doors are equipped with latching hardware. This condition was noted with the Maintenance Supervisor present.

3. On 8/30/10 at approximately 11:43am, the smoke barrier doors by the ED in the main corridor did not close properly upon testing. The doors are equipped with latching hardware. This condition was noted with the Maintenance Supervisor present.

4. On 8/30/10 at approximately 11:46am, the smoke barrier doors by the ACU Reception Desk did not close properly upon testing. The doors are equipped with latching hardware. This condition was noted with the Maintenance Supervisor present.

5. On 8/30/10 at approximately 11:47am, the rolling shutter completing the smoke barrier at the ACU Reception Desk was prevented from closing due to items being stored on the counter. This condition was noted with the Maintenance Supervisor present.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect staff in 1 of 8 smoke compartments in the event of a fire not being properly contained to the hazardous area.

Findings include:

On 8/30/10 at approximately 11:02am, the door to the File Storage Room in the Records Office was being held open by a wooden wedge. This condition was noted with the Maintenance Supervisor present.

Based on records review the facility failed to maintain emergency lighting in accordance with the LSC section 18.2.9.1. This deficient practice could potentially affect the occupants of the operating rooms in the event of a power failure.

Findings include:

On 8/30/10 between 9:15am and 11:00am during records review, the facility did not have documentation of the 90 minute annual testing of the battery operated emergency lighting as required by Section 7.9.3. This condition was noted with the Maintenance Supervisor present.

Based on review of records the facility failed to provide written documentation regarding fire drills or ensure that drills are conducted at unexpected times under varying circumstances in accordance with the LSC section 18.7.1.2. This deficient practice could potentially affect all occupants of the facility in the event of staff not being properly trained in fire emergency procedures.

Findings include:

1. On 8/30/10 between 9:15am and 11:00am during records review, the facility did not have documentation of the fire drills conducted for the 2nd and 3rd shifts during the 3rd quarter of 2009 or for the 2nd shift during the 4th quarter of 2009. This condition was noted with the Maintenance Supervisor present.

2. On 8/30/10 between 9:15am and 11:am during records review, the facility fire drill documentation showed that 2 of the 1st shift drills were conducted within the same hour, 2 of the 2nd shift drills were conducted within the same hour, and 3 of the 3rd shift drills were conducted within the same hour. The drills throughout the year did not occur at unexpected times or were not varied through the shift. This condition was noted with the Maintenance Supervisor present.

Based on review of records the facility failed to provide an fire watch plan in the event of the sprinkler system being out of service for more than 4 hours in a 24-hour period in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility in the event of a sprinkler system failure.

Findings include:

On 8/30/10 between 9:15am and 11:00am during records review, the facility did not have a policy for conducting a fire watch in the event of the sprinkler system being out of service. This condition was noted with the Maintenance Supervisor present.

Based on review of records the facility failed to provide an fire watch plan in the event of the fire alarm system being out of service for more than 4 hours in a 24-hour period in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility in the event of a fire alarm system failure.

Findings include:

On 8/30/10 between 9:15am and 11:00am during records review, the facility did not have a policy for conducting a fire watch in the event of the fire alarm system being out of service. This condition was noted with the Maintenance Supervisor present.