HospitalInspections.org

The facility did not ensure that corridors were separated from use areas by walls constructed with at least a 30 minutes rating as required by the referenced LSC.

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that the corridor wall on the fifth (5th) floor next to the cafeteria entrance had HVAC ductwork installed within the barrier that was not protected as required by LSC section(s) 19.3.6.1, 19.3.6.2.1, and/or 19.3.6.5.

The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors.

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that the Clean Linen storage room door on the eighth (8) floor, West wing was split and damaged to the core, which does not meet the requirement of LSC section 19.3.6.3.6.

The facility did not ensure that smoke barriers were provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients or as required by the referenced LSC 19.3.7.1, 19.3.7.2.

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that on the third (3rd) floor of the facility, the Emergency Department and Hyperbaric Treatment areas lacked the required smoke barriers as required by the LSC section 19.3.7.1, 19.3.7.2.

The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self closing doors as required by 19.3.2.1

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that the left wall within the Medical Gas Main Manifold Room did not extend to the underside of the floor deck above as required by LSC section 19.3.2.1.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

On 07/14/10 the facility failed to provide the surveyor with documentation that the 5-year obstruction test had been completed on the facility ' s fire sprinkler system as required by NFPA 25.

The facility did not ensure that penetrations of smoke barriers by ductwork were protected in accordance with section 8.3.5 of the LSC.

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that exhaust fan flexible ductwork had been installed through the smoke barrier on the eighth (8th) floor outside of door # ME8085 and not being protected as required by LSC section 8.3.5.

The facility did not ensure that corridors were separated from use areas by walls constructed with at least a 30 minutes rating as required by the referenced LSC.

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that the corridor wall on the fifth (5th) floor next to the cafeteria entrance had HVAC ductwork installed within the barrier that was not protected as required by LSC section(s) 19.3.6.1, 19.3.6.2.1, and/or 19.3.6.5.

The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors.

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that the Clean Linen storage room door on the eighth (8) floor, West wing was split and damaged to the core, which does not meet the requirement of LSC section 19.3.6.3.6.

The facility did not ensure that smoke barriers were provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients or as required by the referenced LSC 19.3.7.1, 19.3.7.2.

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that on the third (3rd) floor of the facility, the Emergency Department and Hyperbaric Treatment areas lacked the required smoke barriers as required by the LSC section 19.3.7.1, 19.3.7.2.

The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self closing doors as required by 19.3.2.1

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that the left wall within the Medical Gas Main Manifold Room did not extend to the underside of the floor deck above as required by LSC section 19.3.2.1.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

On 07/14/10 the facility failed to provide the surveyor with documentation that the 5-year obstruction test had been completed on the facility ' s fire sprinkler system as required by NFPA 25.

The facility did not ensure that penetrations of smoke barriers by ductwork were protected in accordance with section 8.3.5 of the LSC.

On 07/14/10 the surveyor, accompanied by the Director of Facilities, observed that exhaust fan flexible ductwork had been installed through the smoke barrier on the eighth (8th) floor outside of door # ME8085 and not being protected as required by LSC section 8.3.5.