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Based on record review, observation and interview, the facility failed to ensure 5 of 15 horizontal-sliding room doors in ICU and the Emergency Department were provided with means for keeping the door closed (see tag K224), failed to ensure complete automatic sprinkler system was provided for 2 of 2 walk-in cooler/freezer in accordance with NFPA 13-2010 (see tag K351), failed to maintain 1 of 1 sprinkler system in accordance with 19.3.5.3 (see tag K353) and failed to maintain the ceiling construction of 1 of 1 I.T. rooms (see tag K353).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

1. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with 19.3.5.3. NFPA 25, 2011 Edition, 14.2.1 states except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficient practice could affect all occupants.

Findings include:

Based on records review with the Vice President of Facilities, the Facilities Manager, and the Safety Coordinator on 05/24/21 at 10:34 a.m., there was no documentation to show when the last time an internal pipe inspection was conducted on the sprinkler system, or when the next inspection was due. Based on interview at the time of record review, the Facilities Manager did not know if or when the last internal pipe inspection was conducted and could not find internal pipe inspection paperwork.

2. Based on observation and interview, the facility failed to maintain the ceiling construction of 1 of 1 I.T. rooms. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect 5 patients in suite five.

Findings include:

Based on observation during a tour of the facility with the Vice President of Facilities, the Facilities Manager, and the Safety Coordinator on 05/25/21 at 1:30 p.m., the suspended ceiling in the suite five I.T. room had two ceiling tiles missing. This condition could delay the activation of the sprinklers installed on the suspended ceiling. Based on interview at the time of the observations, the Facilities Manager stated the I.T. department did not replace the tiles after completing work.

The findings were reviewed with the Vice President of Facilities, the Facilities Manager, and the Safety Coordinator during the exit conference.

Based on observation and interview, the facility failed to ensure complete automatic sprinkler system was provided for 2 of 2 walk-in cooler/freezer in accordance with NFPA 13-2010, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice could affect up to 30 people in the in the kitchen and dining area.

Findings include:

Based on observation during a tour of the facility with the Vice President of Facilities, the Facilities Manager, and the Safety Coordinator on 05/25/21 at 12:30 p.m., the walk-in cooler and walk-in freezer in the kitchen were not provided with sprinkler coverage. Based on interview during observation, the Facilities Manager agreed the walk-in cooler and freezer were not provided with sprinklers.

The finding was reviewed with the Vice President of Facilities, the Facilities Manager, and the Safety Coordinator during the exit conference.

Based on observation and interview, the facility failed to ensure 5 of 15 horizontal-sliding room doors in ICU and the Emergency Department were provided with means for keeping the door closed. LSC 19.3.6.3.5 stated doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction. LSC 19.2.2.2.10.1 states horizontal-sliding doors, as permitted by 7.2.1.14, that are not automatic-closing shall be limited to a single leaf and shall have a latch or other mechanism that ensures that the doors will not rebound into a partially open position if forcefully closed. This deficient practice could affect 5 patients.

Findings include:

Based on observation during a tour of the facility with the Vice President of Facilities, the Facilities Manager, and the Safety Coordinator on 05/25/21 between 11:20 a.m. and 2:00 p.m., patient rooms 1, 2, 5, and 6 in ICU and room 9 in the Emergency Department were provided with horizontal-sliding doors. The doors were provided with latches, but when tested the doors did not latch into the frame. Based on interview during observation, the Facilities Manager agreed the doors did not latch into the door frame when tested and stated the door latches will need to be repaired.

The finding was reviewed with the Vice President of Facilities, the Facilities Manager, and the Safety Coordinator during the exit conference.