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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.

Based on observation, the facility failed to meet the clear width requirement for 1 of 8 fist floor corridors or met an exception per 19.2.3.4(5). LSC 19.2.3.4(5) states where the corridor width is at least 8 feet, projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) the fixed furniture is securely attached to the floor or to the wall.
(b) the fixed furniture does not reduce the clear unobstructed corridor width to less than six feet, except as permitted by 19.2.3.4(2).
(c) the fixed furniture is located only on one side of the corridor.
(d) the fixed furniture is grouped such that each grouping does not exceed an area of 50 square feet.
(e) the fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 feet.
(f) the fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurse's station or similar space.
(h) the smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8
This deficient practice could affect 20 patients in the OB/Rehab outpatient hall.

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 1:20 p.m., chairs and a bench were in the OB/Rehab outpatient exit corridor, extended about two feet into the corridor, and were not affixed to the floor or to the wall when tested. Based on interview at the time of the observations, the Facilities Manager agreed the chairs and bench were not securely attached to the floor or to the wall when tested.

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 1 of 1 walk-in clinic janitor closets containing trash and soiled linens was protected as a hazardous area. This deficient practice could affect 10 patients in the walk-in clinic.

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 2:10 p.m., the walk-in clinic janitor closet contained bags of trash and soiled linens. The closet was not protected as a hazardous area because the corridor door to the closet was not self-closing or automatic closing. Based on interview at the time of observation, the Facilities Manager agreed the janitor closet contained soiled linens and trash, and the corridor door to the room was not self-closing.

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 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.

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 4 of 4 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. This deficient practice could affect staff and patients throughout the building

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 11:05 a.m. and 2:00 p.m., refrigerators, microwaves, and coffeepots which are high power draw equipment were plugged into and supplied power by a power strips in several staff offices including the case management office and in the OB brake room. Based on interview at the time of observation, the Facilities Manager acknowledged power strips were supplying power to high power draw equipment in staff areas.

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