HospitalInspections.org

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/ or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 10:55 a.m., observation revealed and confirmed by the facility maintenance director, the "CEO Office" door was held open with a wood wedge.

- On April 27, 2010 at 11:38 a.m., observation revealed and confirmed by the facility maintenance director, the rear door to the "Basement Conference Room" did not self-close to provide a positive latch.

- On April 27, 2010 at 12:50 p.m., observation revealed and confirmed by the facility maintenance director, "Patient Room #118" door did not close to provide a positive latch.

- On April 27, 2010 at 12:55 p.m., observation revealed and confirmed by the facility maintenance director, "Patient Room #114" door did not close to provide a positive latch.

- On April 27, 2010 at 12:58 p.m., observation revealed and confirmed by the facility maintenance director, "Patient Room #102" door did not close to provide a positive latch.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 11:04 a.m., observation revealed and confirmed by the facility maintenance director, two holes and a pipe penetration above the smoke barrier doors adjacent to the "Facilities Management Office".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 11:17 a.m., observation revealed and confirmed by the facility maintenance director, a network blue cable penetrations not sealed and an insulated pipe and the pipe sleeve not sealed above the smoke barrier doors adjacent to the "Basement Server Room".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 11:46 a.m., observation revealed and confirmed by the facility maintenance director, an insulated pipe penetration not sealed above the smoke barrier doors by the "New Elevator".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 12:15 p.m., observation revealed and confirmed by the facility maintenance director, a drywall patch not sealed and a pipe penetration not sealed completely above the smoke barrier doors adjacent to "Patient Room #102".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 12:44 p.m., observation revealed and confirmed by the facility maintenance director, a hole in the wall and a pipe penetration sealed with an unknown grey material above the smoke barrier wall adjacent to "Patient Room #113".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 12:52 p.m., observation revealed and confirmed by the facility maintenance director, a wire penetration and a penetration in the mortar above the smoke barrier doors adjacent to "Patient Room #116".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

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 potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 11:34 a.m., observation and confirmed by the facility maintenance director, revealed a gap larger than 1/8" between the smoke barrier doors adjacent to the "Maintenance Room" rear door.

- On April 27, 2010 at 11:44 a.m., observation revealed and confirmed by the facility maintenance director, the smoke barrier doors by the "New Elevator" did not self-close to provide a positive latch.

- On April 27, 2010 at 12:09 p.m., observation revealed and confirmed by the facility maintenance director, the smoke barrier doors adjacent to the "Kitchen Storage Room" did not self-close to provide a positive latch.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 11:17 a.m., observation revealed and confirmed by the facility maintenance director, a group of seven pipes with a hole in the wall below two of the pipes in the "Material Management Rear Store Room".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 11:31 a.m., observation revealed and confirmed by the facility maintenance director, the "Soiled Linen Room" door across from the "O.R. Storage Room" not self-closing to provide a positive latch. (fixed at the time of inspection)

- On April 27, 2010 at 12:12 p.m., observation and confirmed by the facility maintenance director, revealed the "Storage Room" door to the "Kitchen" did not self-close to provide a positive latch.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1.
This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 10:58 a.m., observation revealed and confirmed by the facility maintenance director, the emergency light in the "Lower Level Meeting Room" did not work when tested.

- On April 27, 2010 at 11:40 a.m., observation revealed and confirmed by the facility maintenance director, the emergency light in the "Lower Level Storage Room West End" did not work when tested.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 12:34 p.m., observation revealed and confirmed by the facility maintenance director, a smoke detector cover with a cloth and a dust cover in the "Gift of Life Janitor Closet". (fixed at the time of inspection)

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 10:45 a.m., observation revealed and confirmed by the facility maintenance director, several ceiling tiles broken or had holes in them in the basement corridors. (fixed at the time of inspection). With the ceiling tiles being broken or out of place, this has the potential to affect the proper operation and height placement of the sprinkler heads.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 11:49 a.m., observation revealed and confirmed by the facility maintenance director, a missing circuit cover in the "Basement New Electrical Room"; panel #ELP-LS1.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/ or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 10:55 a.m., observation revealed and confirmed by the facility maintenance director, the "CEO Office" door was held open with a wood wedge.

- On April 27, 2010 at 11:38 a.m., observation revealed and confirmed by the facility maintenance director, the rear door to the "Basement Conference Room" did not self-close to provide a positive latch.

- On April 27, 2010 at 12:50 p.m., observation revealed and confirmed by the facility maintenance director, "Patient Room #118" door did not close to provide a positive latch.

- On April 27, 2010 at 12:55 p.m., observation revealed and confirmed by the facility maintenance director, "Patient Room #114" door did not close to provide a positive latch.

- On April 27, 2010 at 12:58 p.m., observation revealed and confirmed by the facility maintenance director, "Patient Room #102" door did not close to provide a positive latch.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 11:04 a.m., observation revealed and confirmed by the facility maintenance director, two holes and a pipe penetration above the smoke barrier doors adjacent to the "Facilities Management Office".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 11:17 a.m., observation revealed and confirmed by the facility maintenance director, a network blue cable penetrations not sealed and an insulated pipe and the pipe sleeve not sealed above the smoke barrier doors adjacent to the "Basement Server Room".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 11:46 a.m., observation revealed and confirmed by the facility maintenance director, an insulated pipe penetration not sealed above the smoke barrier doors by the "New Elevator".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 12:15 p.m., observation revealed and confirmed by the facility maintenance director, a drywall patch not sealed and a pipe penetration not sealed completely above the smoke barrier doors adjacent to "Patient Room #102".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 12:44 p.m., observation revealed and confirmed by the facility maintenance director, a hole in the wall and a pipe penetration sealed with an unknown grey material above the smoke barrier wall adjacent to "Patient Room #113".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 12:52 p.m., observation revealed and confirmed by the facility maintenance director, a wire penetration and a penetration in the mortar above the smoke barrier doors adjacent to "Patient Room #116".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

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 potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 11:34 a.m., observation and confirmed by the facility maintenance director, revealed a gap larger than 1/8" between the smoke barrier doors adjacent to the "Maintenance Room" rear door.

- On April 27, 2010 at 11:44 a.m., observation revealed and confirmed by the facility maintenance director, the smoke barrier doors by the "New Elevator" did not self-close to provide a positive latch.

- On April 27, 2010 at 12:09 p.m., observation revealed and confirmed by the facility maintenance director, the smoke barrier doors adjacent to the "Kitchen Storage Room" did not self-close to provide a positive latch.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 11:17 a.m., observation revealed and confirmed by the facility maintenance director, a group of seven pipes with a hole in the wall below two of the pipes in the "Material Management Rear Store Room".
Note: Refer to the U.L. Building Materials Directory for specific material and design criteria.

- On April 27, 2010 at 11:31 a.m., observation revealed and confirmed by the facility maintenance director, the "Soiled Linen Room" door across from the "O.R. Storage Room" not self-closing to provide a positive latch. (fixed at the time of inspection)

- On April 27, 2010 at 12:12 p.m., observation and confirmed by the facility maintenance director, revealed the "Storage Room" door to the "Kitchen" did not self-close to provide a positive latch.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1.
This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 10:58 a.m., observation revealed and confirmed by the facility maintenance director, the emergency light in the "Lower Level Meeting Room" did not work when tested.

- On April 27, 2010 at 11:40 a.m., observation revealed and confirmed by the facility maintenance director, the emergency light in the "Lower Level Storage Room West End" did not work when tested.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 12:34 p.m., observation revealed and confirmed by the facility maintenance director, a smoke detector cover with a cloth and a dust cover in the "Gift of Life Janitor Closet". (fixed at the time of inspection)

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 10:45 a.m., observation revealed and confirmed by the facility maintenance director, several ceiling tiles broken or had holes in them in the basement corridors. (fixed at the time of inspection). With the ceiling tiles being broken or out of place, this has the potential to affect the proper operation and height placement of the sprinkler heads.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 27, 2010 at 11:49 a.m., observation revealed and confirmed by the facility maintenance director, a missing circuit cover in the "Basement New Electrical Room"; panel #ELP-LS1.