HospitalInspections.org

Based on observation and interview, the facility failed to ensure 2 of 21 room wall and ceilings in the outpatient rehabilitation services building were provided with an interior finish with a flame spread rating of a class A, class B, or class C. LSC 39.3.3.2 requires interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in exits and in enclosed corridors furnishing access to exits, and Class A, Class B, or Class C in office areas. This deficient practice could affect any patients who use the athletic strengthening gymnasium or the swimming pool.

Findings include:

Based on observation with the senior director on 12/03/14 during a tour of the facility from 10:50 a.m. to 12:40 p.m., the outpatient rehabilitation services building had a forty foot by thirty foot south wall in the athletic strengthening gymnasium with no interior finish and no interior finish on the ceiling in the swimming pool pump room. The lack of an interior finish in the outpatient rehabilitation services building athletic strengthening gymnasium south wall and swimming pool pump room ceiling was verified by the senior director at the time of observation and acknowledged at the exit conference on 12/04/14 at 2:20 p.m.

Based on observation and interview, the facility failed to ensure 3 of 17 room walls and ceilings in the rehabilitation services building were provided with an interior finish with a flame spread rating of a class A, class B, or class C. LSC 39.3.3.2 requires interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in exits and in enclosed corridors furnishing access to exits, and Class A, Class B, or Class C in office areas. This deficient practice could affect any patients who use the basement rehabilitation room.

Findings include:

Based on observation with plumber #1 on 12/03/14 from 8:00 a.m. to 10:00 a.m., the rehabilitation services building basement furnace room and basement mechanical room lacked interior finish on the ceilings, with two by twelve floor joists exposed. Furthermore, the basement furnace room north wall had a two foot by three foot square section of drywall missing above the main electrical panel. The lack of a ceiling interior finish in the basement furnace room and basement mechanical room and missing drywall above the main electrical panel north wall was verified by plumber #1 at the time of observations and acknowledged by the senior director at the exit conference on 12/04/14 at 2:20 p.m.

Based on observation and interview, the facility failed to ensure 4 of 4 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 18-3.6.1, Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas, and (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers, and (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space, and (d) The space does not obstruct access to required exits. This deficient practice could affect any number of patients, as well as staff and visitors while in the third and fourth floor waiting rooms, second floor sitting room, and second floor Material Management Intake area.

Findings include:

Based on observations on 12/02/14 between 10:00 a.m. and 2:00 p.m. during a tour of the facility with the Facility Operations Manager, the following areas were open to the corridor:
1. The fourth floor Waiting Room
2. The third floor Waiting Room
3. The second floor Sitting Area
4. The second floor Material Management Intake area
Exception #1 requirement (c) of LSC 18.3.6.1 was not met as follows: The third and fourth floor Waiting Rooms, the second floor Sitting Area, and the second floor Material Management Intake area were not protected by an electrically supervised automatic smoke detection system, or the entire spaces were not arranged and located to allow direct supervision by the facility staff from nurses' stations or similar staffed spaces. This was acknowledged by the Facility Operations Manager at the time of each observation.

1. Based on observation and interview, the facility failed to ensure 1 of over 50 sprinklered hazardous areas/rooms, such as the Material Management Intake area, an area/room over 50 square feet containing combustible material, was separated from other spaces by smoke resisting partitions and doors. This deficient practice could affect any number of patients, as well as staff and visitors while in the Material Management Intake area.

Findings include:

Based on observation on 12/02/14 at 12:40 p.m. during a tour of the facility with the Facility Operations Manager, the Material Management Intake area/room was open to the corridor. This area was filled with over 25 hard plastic medical storage totes, cardboard boxes, and other items. This was acknowledged by the Facility Operations Manager at the time of observation.

2. Based on observation and interview, the facility failed to ensure 1 of over 50 hazardous area room doors, such as a kitchen door, was equipped with a self closing device on the door. This deficient practice could affect any number of patients, staff and visitors while in the first floor dining room.

Findings include:

Based on observation on 12/02/14 at 1:30 p.m. during a tour of the facility with the Facility Operations Manager, the kitchen dishwashing room door to the dining room was not provided with a self closing device. This was acknowledged by the Facility Operations Manager at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 1 basement combustible liquid storage room was provided with an approved storage cabinet. NFPA 99, 10-7.2.2 requires established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 sq ft (9.23 sq m).
The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 sq ft (9.23 sq m).
No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor, or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 3000 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory. This deficient practice affects staff only who work near the basement flammable liquid storage room.

Findings include:

Based on observation with the senior director on 12/02/14 at 12:50 p.m., the basement flammable storage room had ninety six gallons of xylene, which was labeled as a Class II flammable liquid, stored in one gallon containers and in cardboard boxes on wooden pallets. Furthermore, the flammable storage room measured seven hundred twelve square feet. Based on the measurement of the room, the maximum amount of xylene allowed to be stored in the open outside of an approved storage cabinet is seven gallons. The lack of storage cabinets for the ninety six gallons of flammable liquid xylene was verified by the senior director at the time of observation and acknowledged at the exit conference on 12/04/14 at 2:20 p.m.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generator with over 100 horsepower in the King's Daughters' Health hospital building was equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation on 12/02/14 at 1:30 p.m. with the senior director, the emergency generator, located in the front of the main hospital building, was in an enclosure and was equipped with a manual stop switch mounted on the emergency generator, but not at a remote location. This was verified by the senior director at the time of observation and acknowledged at the exit conference on 12/04/14 at 2:20 p.m.

Based on observation and interview, the facility failed to ensure 2 of 21 room wall and ceilings in the outpatient rehabilitation services building were provided with an interior finish with a flame spread rating of a class A, class B, or class C. LSC 39.3.3.2 requires interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in exits and in enclosed corridors furnishing access to exits, and Class A, Class B, or Class C in office areas. This deficient practice could affect any patients who use the athletic strengthening gymnasium or the swimming pool.

Findings include:

Based on observation with the senior director on 12/03/14 during a tour of the facility from 10:50 a.m. to 12:40 p.m., the outpatient rehabilitation services building had a forty foot by thirty foot south wall in the athletic strengthening gymnasium with no interior finish and no interior finish on the ceiling in the swimming pool pump room. The lack of an interior finish in the outpatient rehabilitation services building athletic strengthening gymnasium south wall and swimming pool pump room ceiling was verified by the senior director at the time of observation and acknowledged at the exit conference on 12/04/14 at 2:20 p.m.

Based on observation and interview, the facility failed to ensure 3 of 17 room walls and ceilings in the rehabilitation services building were provided with an interior finish with a flame spread rating of a class A, class B, or class C. LSC 39.3.3.2 requires interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in exits and in enclosed corridors furnishing access to exits, and Class A, Class B, or Class C in office areas. This deficient practice could affect any patients who use the basement rehabilitation room.

Findings include:

Based on observation with plumber #1 on 12/03/14 from 8:00 a.m. to 10:00 a.m., the rehabilitation services building basement furnace room and basement mechanical room lacked interior finish on the ceilings, with two by twelve floor joists exposed. Furthermore, the basement furnace room north wall had a two foot by three foot square section of drywall missing above the main electrical panel. The lack of a ceiling interior finish in the basement furnace room and basement mechanical room and missing drywall above the main electrical panel north wall was verified by plumber #1 at the time of observations and acknowledged by the senior director at the exit conference on 12/04/14 at 2:20 p.m.

Based on observation and interview, the facility failed to ensure 4 of 4 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 18-3.6.1, Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas, and (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers, and (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space, and (d) The space does not obstruct access to required exits. This deficient practice could affect any number of patients, as well as staff and visitors while in the third and fourth floor waiting rooms, second floor sitting room, and second floor Material Management Intake area.

Findings include:

Based on observations on 12/02/14 between 10:00 a.m. and 2:00 p.m. during a tour of the facility with the Facility Operations Manager, the following areas were open to the corridor:
1. The fourth floor Waiting Room
2. The third floor Waiting Room
3. The second floor Sitting Area
4. The second floor Material Management Intake area
Exception #1 requirement (c) of LSC 18.3.6.1 was not met as follows: The third and fourth floor Waiting Rooms, the second floor Sitting Area, and the second floor Material Management Intake area were not protected by an electrically supervised automatic smoke detection system, or the entire spaces were not arranged and located to allow direct supervision by the facility staff from nurses' stations or similar staffed spaces. This was acknowledged by the Facility Operations Manager at the time of each observation.

1. Based on observation and interview, the facility failed to ensure 1 of over 50 sprinklered hazardous areas/rooms, such as the Material Management Intake area, an area/room over 50 square feet containing combustible material, was separated from other spaces by smoke resisting partitions and doors. This deficient practice could affect any number of patients, as well as staff and visitors while in the Material Management Intake area.

Findings include:

Based on observation on 12/02/14 at 12:40 p.m. during a tour of the facility with the Facility Operations Manager, the Material Management Intake area/room was open to the corridor. This area was filled with over 25 hard plastic medical storage totes, cardboard boxes, and other items. This was acknowledged by the Facility Operations Manager at the time of observation.

2. Based on observation and interview, the facility failed to ensure 1 of over 50 hazardous area room doors, such as a kitchen door, was equipped with a self closing device on the door. This deficient practice could affect any number of patients, staff and visitors while in the first floor dining room.

Findings include:

Based on observation on 12/02/14 at 1:30 p.m. during a tour of the facility with the Facility Operations Manager, the kitchen dishwashing room door to the dining room was not provided with a self closing device. This was acknowledged by the Facility Operations Manager at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 1 basement combustible liquid storage room was provided with an approved storage cabinet. NFPA 99, 10-7.2.2 requires established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 sq ft (9.23 sq m).
The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 sq ft (9.23 sq m).
No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor, or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 3000 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory. This deficient practice affects staff only who work near the basement flammable liquid storage room.

Findings include:

Based on observation with the senior director on 12/02/14 at 12:50 p.m., the basement flammable storage room had ninety six gallons of xylene, which was labeled as a Class II flammable liquid, stored in one gallon containers and in cardboard boxes on wooden pallets. Furthermore, the flammable storage room measured seven hundred twelve square feet. Based on the measurement of the room, the maximum amount of xylene allowed to be stored in the open outside of an approved storage cabinet is seven gallons. The lack of storage cabinets for the ninety six gallons of flammable liquid xylene was verified by the senior director at the time of observation and acknowledged at the exit conference on 12/04/14 at 2:20 p.m.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generator with over 100 horsepower in the King's Daughters' Health hospital building was equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation on 12/02/14 at 1:30 p.m. with the senior director, the emergency generator, located in the front of the main hospital building, was in an enclosure and was equipped with a manual stop switch mounted on the emergency generator, but not at a remote location. This was verified by the senior director at the time of observation and acknowledged at the exit conference on 12/04/14 at 2:20 p.m.