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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 affect all occupants in the facility in the event of a fire where the products of combustion are allowed to transmit throughout from the adjacent non-conforming building due to improperly maintained separation.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 08:40 AM observed that the 2nd floor Conference Hall #2300 south leaf of the south 2 hr rated doors did not close to a positive latch.
- At approximately 09:40 AM observed that on the 1st floor above the 2 hr rated doors near the Janitor's Closet #1027 there was a 4" conduit that had created a penetration through the wall that was not sealed with a fire rated material.
- At approximately 10:25 AM observed that on the 1st floor there were 2 hr rated doors at the Lab/Xray Entrance that were equipped with a power-assist mechanism that did not cease to function upon activation of a smoke detection system.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 18.3.6.3.6. This deficient practice could affect all occupants of the smoke compartment in the event of a fire in one of the rooms with improperly installed or maintained corridor doors.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 9:20 AM observed that the 2nd floor Medical Records File Processing Room door was held in the open position with a wedge.

FS011

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could affect all occupants of the smoke compartment in the event of a fire in one of the rooms with improperly installed or maintained corridor doors.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 11:47 AM observed that the Doctors Office corridor door was held in the open position with a rubber wedge.

FS011

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 19.2.2.2.6. This deficient practice could affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly maintained doors.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 11:43 AM observed that the smoke barrier door west leaf did not come to a complete close when released from the door hold open device.

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 affect an undetermined number of occupants in the event of a fire within the hazardous area enclosure where the products of combustion are allowed to spread to the means of egress due to improperly installed or maintained hazardous room doors.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 9:05 AM observed that the 2nd floor Equipment Storage Room #2143 door was held in the open position with a wedge.

FS011

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 2:35 PM observed that quarterly fire drill records for the 2011 3rd and 4th quarters, and the 2012 1st quarter were not available for review at the time of inspection.

Based on observation the facility failed to provide signs where oxygen is used or stored in accordance with NFPA 99. This deficient practice could affect all occupants of the smoke compartment in the event of a fire where improperly signed oxygen storage rooms contribute to a delay in control of a fire in that area.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 9:10 AM observed that the 2nd floor Clean Supply Room #2114 was being used for oxygen storage and was not equipped with a sign indicating oxygen storage.
- At approximately 10:00 AM observed that the 1st floor Equipment Storage Room #1329 was being used for oxygen storage and was not equipped with a sign indicating oxygen storage.

FS011

Based on observation the facility failed to provide signs where oxygen is used or stored in accordance with NFPA 99. This deficient practice could affect all occupants of the smoke compartment in the event of a fire where improperly signed oxygen storage rooms contribute to a delay in control of a fire in that area.


Findings include:

On 05/10/12, the following observations were made:

- At approximately 11:40 AM observed that the Oxygen Storage Room was not equipped with a sign indicating oxygen storage.

Based on observation and/or review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could affect all occupants of the facility in the event that the generator did not function as designed.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 2:40 PM observed that the emergency generator battery weekly electrolyte level recordings were not available for review at the time of inspection.
- At approximately 2:40 PM observed that the emergency generator battery specific gravity recordings were not available for review at the time of inspection.

FS011

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could affect all occupants of the facility in the event of a failure of the electrical equipment, or the exposure to hazardous electrical currents due to improper protection.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 11:35 AM observed that in the corridor near the entrance to the Ambulance Bay there was a wall mounted Time Clock device with its power cord fed through the corridor wall into a Janitor's Closet, and then connected to an extension cord.

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 affect all occupants in the facility in the event of a fire where the products of combustion are allowed to transmit throughout from the adjacent non-conforming building due to improperly maintained separation.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 08:40 AM observed that the 2nd floor Conference Hall #2300 south leaf of the south 2 hr rated doors did not close to a positive latch.
- At approximately 09:40 AM observed that on the 1st floor above the 2 hr rated doors near the Janitor's Closet #1027 there was a 4" conduit that had created a penetration through the wall that was not sealed with a fire rated material.
- At approximately 10:25 AM observed that on the 1st floor there were 2 hr rated doors at the Lab/Xray Entrance that were equipped with a power-assist mechanism that did not cease to function upon activation of a smoke detection system.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 18.3.6.3.6. This deficient practice could affect all occupants of the smoke compartment in the event of a fire in one of the rooms with improperly installed or maintained corridor doors.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 9:20 AM observed that the 2nd floor Medical Records File Processing Room door was held in the open position with a wedge.

FS011

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could affect all occupants of the smoke compartment in the event of a fire in one of the rooms with improperly installed or maintained corridor doors.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 11:47 AM observed that the Doctors Office corridor door was held in the open position with a rubber wedge.

FS011

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 19.2.2.2.6. This deficient practice could affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly maintained doors.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 11:43 AM observed that the smoke barrier door west leaf did not come to a complete close when released from the door hold open device.

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 affect an undetermined number of occupants in the event of a fire within the hazardous area enclosure where the products of combustion are allowed to spread to the means of egress due to improperly installed or maintained hazardous room doors.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 9:05 AM observed that the 2nd floor Equipment Storage Room #2143 door was held in the open position with a wedge.

FS011

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 2:35 PM observed that quarterly fire drill records for the 2011 3rd and 4th quarters, and the 2012 1st quarter were not available for review at the time of inspection.

Based on observation the facility failed to provide signs where oxygen is used or stored in accordance with NFPA 99. This deficient practice could affect all occupants of the smoke compartment in the event of a fire where improperly signed oxygen storage rooms contribute to a delay in control of a fire in that area.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 9:10 AM observed that the 2nd floor Clean Supply Room #2114 was being used for oxygen storage and was not equipped with a sign indicating oxygen storage.
- At approximately 10:00 AM observed that the 1st floor Equipment Storage Room #1329 was being used for oxygen storage and was not equipped with a sign indicating oxygen storage.

FS011

Based on observation the facility failed to provide signs where oxygen is used or stored in accordance with NFPA 99. This deficient practice could affect all occupants of the smoke compartment in the event of a fire where improperly signed oxygen storage rooms contribute to a delay in control of a fire in that area.


Findings include:

On 05/10/12, the following observations were made:

- At approximately 11:40 AM observed that the Oxygen Storage Room was not equipped with a sign indicating oxygen storage.

Based on observation and/or review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could affect all occupants of the facility in the event that the generator did not function as designed.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 2:40 PM observed that the emergency generator battery weekly electrolyte level recordings were not available for review at the time of inspection.
- At approximately 2:40 PM observed that the emergency generator battery specific gravity recordings were not available for review at the time of inspection.

FS011

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could affect all occupants of the facility in the event of a failure of the electrical equipment, or the exposure to hazardous electrical currents due to improper protection.

Findings include:

On 05/10/12, the following observations were made:

- At approximately 11:35 AM observed that in the corridor near the entrance to the Ambulance Bay there was a wall mounted Time Clock device with its power cord fed through the corridor wall into a Janitor's Closet, and then connected to an extension cord.