HospitalInspections.org

Based on observation and interview, the facility failed to provide approved interior finish materials in accordance with the LSC sections 18.3.3.1, 18.3.3.2. This deficient practice could potentially affect all 310 patients of the facility by increasing the spread of fire due to non-fire rated materials. Findings include:

1. On 4/17/14 at 10:15 AM an unrated cork bulletin board was observed in use on the second floor SDS across from the nurse station.

In an interview on 4/17/14 at 10:15 AM, maintenance staff verified the use of the cork bulletin board.

2. On 4/17/14 at 10:20 AM an unrated cork bulletin board was observed in use in the second floor small OR corridor.

In an interview on 4/17/14 at 10:20 AM, maintenance staff verified the use of the cork bulletin board.

3. On 4/17/14 at 10:40 AM multiple unrated cork bulletin board were observed in use in the first floor radiology center x-ray small corridor.

In an interview on 4/17/14 at 10:40 AM, maintenance staff verified the use of the cork bulletin boards.

4. On 4/17/14 at 10:45 AM multiple unrated cork bulletin board were observed in use in the first floor radiology center x-ray room corridor.

In an interview on 4/17/14 at 10:45 AM, maintenance staff verified the use of the cork bulletin boards.

Based on observation and interview, the facility failed to provide approved interior finish materials for rooms and spaces not used as corridors in accordance with the LSC sections 18.3.3.1, 18.3.3.2. This deficient practice could potentially affect all 310 patients of the facility by increasing the spread of fire due to non-fire rated materials. Findings include:

1. On 4/17/14 at 9:30 AM a large unrated cork bulletin board was observed in use in the third floor #3508 office.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the use of the cork bulletin board.

2. On 4/17/14 at 9:40 AM an unrated cork bulletin board was observed in use in the third floor #3552 staff room.

In an interview on 4/17/14 at 9:40 AM, maintenance staff verified the use of the cork bulletin board.

3. On 4/17/14 at 9:45 AM an unrated cork bulletin board was observed in use in the third floor housekeeping closet.

In an interview on 4/17/14 at 9:45 AM, maintenance staff verified the use of the cork bulletin board.

4. On 4/17/14 at 9:50 AM a large unrated cork bulletin board was observed in use in the third floor CCU waiting room.

In an interview on 4/17/14 at 9:50 AM, maintenance staff verified the use of the cork bulletin board.

5. On 4/17/14 at 9:55 AM a large unrated cork bulletin board was observed in use in the third floor CCU small cross corridor area.

In an interview on 4/17/14 at 9:55 AM, maintenance staff verified the use of the cork bulletin board.

7. On 4/17/14 at 10:20 AM an unrated cork bulletin board was observed in use in the second floor surgery office.

In an interview on 4/17/14 at 10:20 AM, maintenance staff verified the use of the cork bulletin board.

8. On 4/17/14 at 10:30 AM an unrated cork bulletin board was observed in use in the first floor ultra sound control room.

In an interview on 4/17/14 at 10:30 AM, maintenance staff verified the use of the cork bulletin board.

9. On 4/17/14 at 10:50 AM an unrated cork bulletin board was observed in use in the first floor heart station staff lounge.

In an interview on 4/17/14 at 10:50 AM, maintenance staff verified the use of the cork bulletin board.

Based on observation and interview, the facility failed to provide approved interior finish materials for rooms and spaces not used as corridors in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all 310 patients of the facility by increasing the spread of fire due to non-fire rated materials. Findings include:

1. On 4/17/14 at 9:30 AM a large unrated cork bulletin board was observed in use in the lower level maintenance office.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the use of the cork bulletin board.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 18.3.6.3.6. This deficient practice could potentially affect 40 occupants of the facility by allowing heat and smoke to pass into the corridor system. Findings include:

1. On 4/17/14 at 11:25 AM the corridor door to the kitchen #W012-2 failed to positively latch when closed.

In an interview on 4/17/14 at 11:25 AM, maintenance staff verified that the door did not latch when closed.

2. On 4/17/14 at 11:35 AM the door to x-ray room 4 and 5 S1002 failed to positively latch when closed.

In an interview on 4/17/14 at 11:35 AM, maintenance staff verified that the door did not latch when closed.

3. On 4/17/14 at 9:40 AM the door to lower level room #E0020 failed to positively latch when closed.

In an interview on 4/17/14 at 9:40 AM, maintenance staff verified that the door did not latch when closed.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 18.3.6.3.6. This deficient practice could potentially affect 40 occupants of the facility by allowing heat and smoke to pass into the corridor system. Findings include:

1. On 4/17/14 at 9:10 AM patient room 462 was observed to have a gap greater than 1/2 inch when closed.

In an interview on 4/17/14 at 9:10 AM, maintenance staff verified the gap in the door of patient room 462.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3.6. This deficient practice could potentially affect 40 occupants of the facility by allowing heat and smoke to pass into the corridor system. Findings include:

1. On 4/17/14 at 10:30 AM patient room #623 did not positively latch when closed.

In an interview on 4/17/14 at 10:30 AM, maintenance staff verified that the door did not latch when closed.

Based on observation and interview, 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 25 occupants of the facility by allowing heat and smoke to pass between smoke compartments during a fire. Findings include:

1. On 4/17/14 at 11:00 AM an unprotected penetration of data wires was observed in the smoke barrier wall at room #225.

In an interview on 4/17/14 at 11:00 AM, maintenance staff verified the unprotected data wires.

2. On 4/17/14 at 10:15 AM an unprotected penetration was observed in the smoke barrier wall at room #N2030.

In an interview on 4/17/14 at 10:15 AM, maintenance staff verified the unprotected penetration of the smoke barrier wall.




.

Based on observation and interview, the facility failed to provide for the smoke barrier doors to be in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 100 occupants of the facility by allowing heat and smoke to pass between smoke compartments during a fire. Findings include:

1. On 4/17/14 at 12:30 PM the smoke barrier doors at the ambulance entrance on the first floor were observed to missing pieces of required panic hardware.

In an interview on 4/17/14 at 12:30 PM, Maintenance staff verified the missing panic hardware on the fire rated doors.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect 25 patients in each smoke compartment. Findings include:

1. On 4/17/14 at 9:50 AM an unprotected penetration of the corridor wall was observed in room #E0007.

In an interview on 4/17/14 at 9:50 AM, maintenance staff verified the unprotected penetration.

2. On 4/17/14 at 10:10 AM the door to the IS Hardware storage room failed to positively latch when closed.

In an interview on 4/17/14 at 10:10 AM, maintenance staff verified that the door did not latch when closed.

3. On 4/17/14 at 11:15 AM the door to the soiled utility room J1009W failed to positively latch when closed.

In an interview on 4/17/14 at 11:15 AM, maintenance staff verified that the door did not latch when closed.

4. On 4/17/14 at 9:30 AM, an unprotected penetration of an abandon pipe was observed in the ceiling of room #N0002.

In an interview on 4/17/14 at 1:00 PM, maintenance staff verified the unprotected penetration of the pipe.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect 40 patients in each smoke compartment. Findings include:

1. On 4/17/14 at 9:20 AM the east wall of the clean utility storage room #4516 was observed not to extend above the ceiling tiles to the floor above.

In an interview on 4/17/14 at 9:20 AM, maintenance staff verified that the wall did not completely extend to the floor above.

2. On 4/17/14 at 9:35 AM patient room #366 was observed to be used as a storage area.

In an interview on 4/17/14 at 9:35 AM, maintenance staff verified that the patient room was being used for storage of extra beds and other supplies.

3. On 4/17/14 at 10:00 AM room #3510 was observed to be used as a storage area but did not have a self-closing door or 1 hour rated walls.

In an interview on 4/17/14 at 10:00 AM, maintenance staff verified that the room #3510 was being used for storage.

4. On 4/17/14 at 10:25 AM the door to the perfusion storage room was observed to be blocked in the open position by an oxygen rack.

In an interview on 4/17/14 at 10:25 AM, maintenance staff verified that the door to the storage room was held open with the oxygen rack.

5. On 4/17/14 at 10:30 AM MRI room #1064B was observed to be used as a storage area but did not have a self-closing door.

In an interview on 4/17/14 at 10:30 AM, maintenance staff verified that the storage room did not have a self-closing door.



.

Based on observation and interview, 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 40 patients in each smoke compartment. Findings include:

1. On 4/17/14 at 1:15 PM the door to storage room #626 failed to positively latch when closed.

In an interview on 4/17/14 at 1:15 PM, maintenance staff verified that the door did not latch when closed.

2. On 4/17/14 at 1:00 PM the door to the ED storage room #1405G failed to positively latch when closed.

In an interview on 4/17/14 at 1:00 PM, maintenance staff verified that the door did not latch when closed.

3. On 4/17/14 at 1:00 PM an unprotected penetration was observed in the corridor wall of the electrical/IT closet on the 1st floor near elevator #2.

In an interview on 4/17/14 at 1:00 PM, maintenance staff verified the unprotected penetration of the wall.

4. On 4/17/14 at 1:30 PM the door to the refrigeration storage room was observed to be held in the open position with a "wet floor" sign.

In an interview on 4/17/14 at 1:30 PM, maintenance staff verified that the door was being held open with the sign.

Based on observation and interview the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11. This deficient practice could potentially affect 60 occupants of the facility by allowing heat and smoke to enter one of the facilities exit stairways. Findings include:

1. On 4/17/14 at 1:20 PM, the lower level stairway door near general stores failed to completely self-close and positively latch.

In an interview on 4/17/14 at 1:20 PM, maintenance staff verified that the stairway door did not close and latch.

Based on review of records and interview, the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 18.7.1.2. This deficient practice could potentially affect all 310 occupants and staff of the facility if the staff failed to respond correctly to a fire emergency. Findings include:

1. On 4/17/14 at 9:30 AM during review of fire drill records, the facility failed to present documentation of a 4th quarter 2013 first shift fire drill.

In an interview on 4/17/14 at 9:30 AM, maintenance and security staff verified that a first shift drill was not conducted after checking other records.



.

Based on review of records and interview, the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all 310 occupants and staff of the facility if the staff failed to respond correctly to a fire emergency. Findings include:

1. On 4/17/14 at 9:30 AM during review of fire drill records, the facility failed to present documentation of a 4th quarter 2013 first shift fire drill.

In an interview on 4/17/14 at 9:30 AM, maintenance and security staff verified that a first shift drill was not conducted after checking other records.

Based on observation and/or review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect all 53 occupants of the facility if a fire went undetected. Findings include:

1. On 4/17/14 at 9:42 AM, it was observed that doctor sleep rooms in #E00020 did not have smoke detectors as required.

In an interview on 4/17/14 at 9:42 AM, maintenance staff agreed that all other sleep rooms did have smoke detectors and the rooms in question did not.

Based on observation and interview, the facility failed to maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect all 310 occupants of the facility if the sprinkler system failed to operate as designed. Findings include:

1. On 4/17/14 at 10:13 AM, wires were observed to be attached to the sprinkler piping in the MSU mechanical room.

In an interview on 4/17/14 at 10:13 AM, maintenance staff verified the wires attached to the sprinkler pipes.

2. On 4/17/14 at 10:18 AM, copper pipes observed to be attached and hung from the sprinkler piping in the MSU mechanical room.

In an interview on 4/17/14 at 10:18 AM, maintenance staff verified the copper pipes attached to the sprinkler pipes.

3. On 4/17/14 at 10:35 AM, wires were observed to be attached to the sprinkler piping in room S0012.

In an interview on 4/17/14 at 10:35 AM, maintenance staff verified the wires attached to the sprinkler pipes.

4. On 4/17/14 at 9:50 AM, wires were observed to be attached to the sprinkler piping in the boiler room near the office.

In an interview on 4/17/14 at 9:50 AM, maintenance staff verified the wires attached to the sprinkler pipes.

5. On 4/17/14 at 9:25 AM, wires were observed to be attached to the sprinkler piping in the lower level mechanical room #N0019.

In an interview on 4/17/14 at 9:25 AM, maintenance staff verified the wires attached to the sprinkler pipes.

Based on observation and interview, the facility failed to maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect all 310 occupants of the facility if the sprinkler system failed to operate as designed. Findings include:

1. On 4/17/14 at 2:00 PM, wires were observed to be zip tied to the 3 inch and 4 inch sprinkler piping in the central stores room.

Based on observation and interview, the facility failed to provide that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 20 occupants of the facility if the sprinkler system failed to operate as designed. Findings include:

1. On 4/17/14 at 10:10 AM, room #W0007 was observed to be missing 3 ceiling tiles.

In an interview on 4/17/14 at 10:10 AM, maintenance staff verified the missing ceiling tiles.

2. On 4/17/14 at 10:10 AM, it was observed that the sprinkler head in the transformer room near old OB delivery room A was missing the required escutcheon ring.

In an interview on 4/17/14 at 10:10 AM, maintenance staff verified the missing escutcheon ring.


.

Based on observation and interview, the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect 15 occupants in the pharmacy area if the extinguisher failed to operate when used. Findings include:

1. On 4/17/14 at 1:30 PM the fire extinguisher near the back door of the pharmacy was observed to missing the required inspection tag.

In an interview on 4/17/14 at 1:30 PM, maintenance staff verified that the extinguisher was missing the inspection tag.

Based on observation and interview, the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect 20 occupants of the facility. Findings include:

1. On 4/17/14 at 1:00 PM, a portable space heater was observed in use in the sterile processing office #G032A. The facility did not produce documentation that the heater meets the requirements of section 19.7.8

In an interview on 4/17/14 at 1:00 PM, maintenance staff indicated the employee must have brought the portable heater into the hospital without authorization.

Based on observation and interview, the facility failed to provide protection of medical gases in accordance with NFPA 99. This deficient practice could potentially affect all 310 occupants of the facility. Findings include:

1. On 4/17/14 at 9:15 AM oxygen tanks were observed to be stored within 5 feet of combustibles in room #4520

In an interview on 4/17/14 at 9:15 AM, maintenance staff verified the storage of the combustibles next to the oxygen tanks.

2. On 4/17/14 at 10:35 AM oxygen tanks were observed to be stored loose on top of wheel chairs in MRI room #1064.

In an interview on 4/17/14 at 10:35 AM, maintenance staff verified the storage of the oxygen tanks on the wheel chairs.

3. On 4/17/14 at 11:35 AM oxygen tanks were observed to be stored loose on top of beds in the lower level general storage room.

In an interview on 4/17/14 at 11:35 AM, maintenance staff verified the storage of the oxygen tanks on the beds.

Based on observation and interview, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 10 occupants of the facility. Findings include:

1. On 4/17/14 at 9:31 AM, two open electrical junction boxes were observed in mechanical room #N0002.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the open electrical junction boxes.

2. On 4/17/14 at 9:45 AM, two open electrical junction boxes were observed in room #E0016.

In an interview on 4/17/14 at 9:45 AM, maintenance staff verified the open electrical junction boxes.

3. On 4/17/14 at 9:48 AM, open electrical junction boxes were observed in room #E0007.

In an interview on 4/17/14 at 9:48 AM, maintenance staff verified the open electrical junction box.

4. On 4/17/14 at 10:15 AM, open electrical junction boxes were observed in the MSU mechanical room near the east wall.

In an interview on 4/17/14 at 10:15 AM, maintenance staff verified the open electrical junction box.

5. On 4/17/14 at 9:37 AM, multiple strip plugs were observed plugged into each other in room #E0023.

In an interview on 4/17/14 at 10:15 AM, maintenance staff verified the multiple strip plugs.

6. On 4/17/14 at 10:00 AM, open electrical junction boxes were observed in electrical room #E2001.

In an interview on 4/17/14 at 10:00 AM, maintenance staff verified the open electrical junction box.

7. On 4/17/14 at 10:47 AM, an electrical multi plug adapter was observed in the corridor near stair #4.

In an interview on 4/17/14 at 10:47 AM, maintenance staff verified the use of the multi plug adapter.


.

Based on observation and interview, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 40 occupants of the facility. Findings include:

1. On 4/17/14 at 2:15 PM combustible storage observed in front of the electrical panels in the lower level boiler room.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the storage of combustibles in front of the electrical panels.

Based on observation and interview, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 40 occupants of the facility. Findings include:

1. On 4/17/14 at 9:30 AM trash containers were observed in front of the electrical panels in soiled utility room #3518.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the storage of trash in front of the electrical panels.

2. On 4/17/14 at 11:00 AM a housekeeping cart was observed in front of the electrical panels in room #1034.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the storage of the cart in front of the electrical panels.

3. On 4/17/14 at 11:15 AM multiple strip plugs were observed to be plugged into each other and not directly into an outlet in room #1004K.

In an interview on 4/17/14 at 11:15 AM, maintenance staff verified the use of multiple strip plugs.

.

Based on observation and interview, the facility failed to provide approved interior finish materials in accordance with the LSC sections 18.3.3.1, 18.3.3.2. This deficient practice could potentially affect all 310 patients of the facility by increasing the spread of fire due to non-fire rated materials. Findings include:

1. On 4/17/14 at 10:15 AM an unrated cork bulletin board was observed in use on the second floor SDS across from the nurse station.

In an interview on 4/17/14 at 10:15 AM, maintenance staff verified the use of the cork bulletin board.

2. On 4/17/14 at 10:20 AM an unrated cork bulletin board was observed in use in the second floor small OR corridor.

In an interview on 4/17/14 at 10:20 AM, maintenance staff verified the use of the cork bulletin board.

3. On 4/17/14 at 10:40 AM multiple unrated cork bulletin board were observed in use in the first floor radiology center x-ray small corridor.

In an interview on 4/17/14 at 10:40 AM, maintenance staff verified the use of the cork bulletin boards.

4. On 4/17/14 at 10:45 AM multiple unrated cork bulletin board were observed in use in the first floor radiology center x-ray room corridor.

In an interview on 4/17/14 at 10:45 AM, maintenance staff verified the use of the cork bulletin boards.

Based on observation and interview, the facility failed to provide approved interior finish materials for rooms and spaces not used as corridors in accordance with the LSC sections 18.3.3.1, 18.3.3.2. This deficient practice could potentially affect all 310 patients of the facility by increasing the spread of fire due to non-fire rated materials. Findings include:

1. On 4/17/14 at 9:30 AM a large unrated cork bulletin board was observed in use in the third floor #3508 office.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the use of the cork bulletin board.

2. On 4/17/14 at 9:40 AM an unrated cork bulletin board was observed in use in the third floor #3552 staff room.

In an interview on 4/17/14 at 9:40 AM, maintenance staff verified the use of the cork bulletin board.

3. On 4/17/14 at 9:45 AM an unrated cork bulletin board was observed in use in the third floor housekeeping closet.

In an interview on 4/17/14 at 9:45 AM, maintenance staff verified the use of the cork bulletin board.

4. On 4/17/14 at 9:50 AM a large unrated cork bulletin board was observed in use in the third floor CCU waiting room.

In an interview on 4/17/14 at 9:50 AM, maintenance staff verified the use of the cork bulletin board.

5. On 4/17/14 at 9:55 AM a large unrated cork bulletin board was observed in use in the third floor CCU small cross corridor area.

In an interview on 4/17/14 at 9:55 AM, maintenance staff verified the use of the cork bulletin board.

7. On 4/17/14 at 10:20 AM an unrated cork bulletin board was observed in use in the second floor surgery office.

In an interview on 4/17/14 at 10:20 AM, maintenance staff verified the use of the cork bulletin board.

8. On 4/17/14 at 10:30 AM an unrated cork bulletin board was observed in use in the first floor ultra sound control room.

In an interview on 4/17/14 at 10:30 AM, maintenance staff verified the use of the cork bulletin board.

9. On 4/17/14 at 10:50 AM an unrated cork bulletin board was observed in use in the first floor heart station staff lounge.

In an interview on 4/17/14 at 10:50 AM, maintenance staff verified the use of the cork bulletin board.

Based on observation and interview, the facility failed to provide approved interior finish materials for rooms and spaces not used as corridors in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all 310 patients of the facility by increasing the spread of fire due to non-fire rated materials. Findings include:

1. On 4/17/14 at 9:30 AM a large unrated cork bulletin board was observed in use in the lower level maintenance office.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the use of the cork bulletin board.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 18.3.6.3.6. This deficient practice could potentially affect 40 occupants of the facility by allowing heat and smoke to pass into the corridor system. Findings include:

1. On 4/17/14 at 11:25 AM the corridor door to the kitchen #W012-2 failed to positively latch when closed.

In an interview on 4/17/14 at 11:25 AM, maintenance staff verified that the door did not latch when closed.

2. On 4/17/14 at 11:35 AM the door to x-ray room 4 and 5 S1002 failed to positively latch when closed.

In an interview on 4/17/14 at 11:35 AM, maintenance staff verified that the door did not latch when closed.

3. On 4/17/14 at 9:40 AM the door to lower level room #E0020 failed to positively latch when closed.

In an interview on 4/17/14 at 9:40 AM, maintenance staff verified that the door did not latch when closed.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 18.3.6.3.6. This deficient practice could potentially affect 40 occupants of the facility by allowing heat and smoke to pass into the corridor system. Findings include:

1. On 4/17/14 at 9:10 AM patient room 462 was observed to have a gap greater than 1/2 inch when closed.

In an interview on 4/17/14 at 9:10 AM, maintenance staff verified the gap in the door of patient room 462.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3.6. This deficient practice could potentially affect 40 occupants of the facility by allowing heat and smoke to pass into the corridor system. Findings include:

1. On 4/17/14 at 10:30 AM patient room #623 did not positively latch when closed.

In an interview on 4/17/14 at 10:30 AM, maintenance staff verified that the door did not latch when closed.

Based on observation and interview, 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 25 occupants of the facility by allowing heat and smoke to pass between smoke compartments during a fire. Findings include:

1. On 4/17/14 at 11:00 AM an unprotected penetration of data wires was observed in the smoke barrier wall at room #225.

In an interview on 4/17/14 at 11:00 AM, maintenance staff verified the unprotected data wires.

2. On 4/17/14 at 10:15 AM an unprotected penetration was observed in the smoke barrier wall at room #N2030.

In an interview on 4/17/14 at 10:15 AM, maintenance staff verified the unprotected penetration of the smoke barrier wall.




.

Based on observation and interview, the facility failed to provide for the smoke barrier doors to be in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 100 occupants of the facility by allowing heat and smoke to pass between smoke compartments during a fire. Findings include:

1. On 4/17/14 at 12:30 PM the smoke barrier doors at the ambulance entrance on the first floor were observed to missing pieces of required panic hardware.

In an interview on 4/17/14 at 12:30 PM, Maintenance staff verified the missing panic hardware on the fire rated doors.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect 25 patients in each smoke compartment. Findings include:

1. On 4/17/14 at 9:50 AM an unprotected penetration of the corridor wall was observed in room #E0007.

In an interview on 4/17/14 at 9:50 AM, maintenance staff verified the unprotected penetration.

2. On 4/17/14 at 10:10 AM the door to the IS Hardware storage room failed to positively latch when closed.

In an interview on 4/17/14 at 10:10 AM, maintenance staff verified that the door did not latch when closed.

3. On 4/17/14 at 11:15 AM the door to the soiled utility room J1009W failed to positively latch when closed.

In an interview on 4/17/14 at 11:15 AM, maintenance staff verified that the door did not latch when closed.

4. On 4/17/14 at 9:30 AM, an unprotected penetration of an abandon pipe was observed in the ceiling of room #N0002.

In an interview on 4/17/14 at 1:00 PM, maintenance staff verified the unprotected penetration of the pipe.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect 40 patients in each smoke compartment. Findings include:

1. On 4/17/14 at 9:20 AM the east wall of the clean utility storage room #4516 was observed not to extend above the ceiling tiles to the floor above.

In an interview on 4/17/14 at 9:20 AM, maintenance staff verified that the wall did not completely extend to the floor above.

2. On 4/17/14 at 9:35 AM patient room #366 was observed to be used as a storage area.

In an interview on 4/17/14 at 9:35 AM, maintenance staff verified that the patient room was being used for storage of extra beds and other supplies.

3. On 4/17/14 at 10:00 AM room #3510 was observed to be used as a storage area but did not have a self-closing door or 1 hour rated walls.

In an interview on 4/17/14 at 10:00 AM, maintenance staff verified that the room #3510 was being used for storage.

4. On 4/17/14 at 10:25 AM the door to the perfusion storage room was observed to be blocked in the open position by an oxygen rack.

In an interview on 4/17/14 at 10:25 AM, maintenance staff verified that the door to the storage room was held open with the oxygen rack.

5. On 4/17/14 at 10:30 AM MRI room #1064B was observed to be used as a storage area but did not have a self-closing door.

In an interview on 4/17/14 at 10:30 AM, maintenance staff verified that the storage room did not have a self-closing door.



.

Based on observation and interview, 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 40 patients in each smoke compartment. Findings include:

1. On 4/17/14 at 1:15 PM the door to storage room #626 failed to positively latch when closed.

In an interview on 4/17/14 at 1:15 PM, maintenance staff verified that the door did not latch when closed.

2. On 4/17/14 at 1:00 PM the door to the ED storage room #1405G failed to positively latch when closed.

In an interview on 4/17/14 at 1:00 PM, maintenance staff verified that the door did not latch when closed.

3. On 4/17/14 at 1:00 PM an unprotected penetration was observed in the corridor wall of the electrical/IT closet on the 1st floor near elevator #2.

In an interview on 4/17/14 at 1:00 PM, maintenance staff verified the unprotected penetration of the wall.

4. On 4/17/14 at 1:30 PM the door to the refrigeration storage room was observed to be held in the open position with a "wet floor" sign.

In an interview on 4/17/14 at 1:30 PM, maintenance staff verified that the door was being held open with the sign.

Based on observation and interview the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11. This deficient practice could potentially affect 60 occupants of the facility by allowing heat and smoke to enter one of the facilities exit stairways. Findings include:

1. On 4/17/14 at 1:20 PM, the lower level stairway door near general stores failed to completely self-close and positively latch.

In an interview on 4/17/14 at 1:20 PM, maintenance staff verified that the stairway door did not close and latch.

Based on review of records and interview, the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 18.7.1.2. This deficient practice could potentially affect all 310 occupants and staff of the facility if the staff failed to respond correctly to a fire emergency. Findings include:

1. On 4/17/14 at 9:30 AM during review of fire drill records, the facility failed to present documentation of a 4th quarter 2013 first shift fire drill.

In an interview on 4/17/14 at 9:30 AM, maintenance and security staff verified that a first shift drill was not conducted after checking other records.



.

Based on review of records and interview, the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all 310 occupants and staff of the facility if the staff failed to respond correctly to a fire emergency. Findings include:

1. On 4/17/14 at 9:30 AM during review of fire drill records, the facility failed to present documentation of a 4th quarter 2013 first shift fire drill.

In an interview on 4/17/14 at 9:30 AM, maintenance and security staff verified that a first shift drill was not conducted after checking other records.

Based on observation and/or review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect all 53 occupants of the facility if a fire went undetected. Findings include:

1. On 4/17/14 at 9:42 AM, it was observed that doctor sleep rooms in #E00020 did not have smoke detectors as required.

In an interview on 4/17/14 at 9:42 AM, maintenance staff agreed that all other sleep rooms did have smoke detectors and the rooms in question did not.

Based on observation and interview, the facility failed to maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect all 310 occupants of the facility if the sprinkler system failed to operate as designed. Findings include:

1. On 4/17/14 at 10:13 AM, wires were observed to be attached to the sprinkler piping in the MSU mechanical room.

In an interview on 4/17/14 at 10:13 AM, maintenance staff verified the wires attached to the sprinkler pipes.

2. On 4/17/14 at 10:18 AM, copper pipes observed to be attached and hung from the sprinkler piping in the MSU mechanical room.

In an interview on 4/17/14 at 10:18 AM, maintenance staff verified the copper pipes attached to the sprinkler pipes.

3. On 4/17/14 at 10:35 AM, wires were observed to be attached to the sprinkler piping in room S0012.

In an interview on 4/17/14 at 10:35 AM, maintenance staff verified the wires attached to the sprinkler pipes.

4. On 4/17/14 at 9:50 AM, wires were observed to be attached to the sprinkler piping in the boiler room near the office.

In an interview on 4/17/14 at 9:50 AM, maintenance staff verified the wires attached to the sprinkler pipes.

5. On 4/17/14 at 9:25 AM, wires were observed to be attached to the sprinkler piping in the lower level mechanical room #N0019.

In an interview on 4/17/14 at 9:25 AM, maintenance staff verified the wires attached to the sprinkler pipes.

Based on observation and interview, the facility failed to maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect all 310 occupants of the facility if the sprinkler system failed to operate as designed. Findings include:

1. On 4/17/14 at 2:00 PM, wires were observed to be zip tied to the 3 inch and 4 inch sprinkler piping in the central stores room.

Based on observation and interview, the facility failed to provide that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 20 occupants of the facility if the sprinkler system failed to operate as designed. Findings include:

1. On 4/17/14 at 10:10 AM, room #W0007 was observed to be missing 3 ceiling tiles.

In an interview on 4/17/14 at 10:10 AM, maintenance staff verified the missing ceiling tiles.

2. On 4/17/14 at 10:10 AM, it was observed that the sprinkler head in the transformer room near old OB delivery room A was missing the required escutcheon ring.

In an interview on 4/17/14 at 10:10 AM, maintenance staff verified the missing escutcheon ring.


.

Based on observation and interview, the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect 15 occupants in the pharmacy area if the extinguisher failed to operate when used. Findings include:

1. On 4/17/14 at 1:30 PM the fire extinguisher near the back door of the pharmacy was observed to missing the required inspection tag.

In an interview on 4/17/14 at 1:30 PM, maintenance staff verified that the extinguisher was missing the inspection tag.

Based on observation and interview, the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect 20 occupants of the facility. Findings include:

1. On 4/17/14 at 1:00 PM, a portable space heater was observed in use in the sterile processing office #G032A. The facility did not produce documentation that the heater meets the requirements of section 19.7.8

In an interview on 4/17/14 at 1:00 PM, maintenance staff indicated the employee must have brought the portable heater into the hospital without authorization.

Based on observation and interview, the facility failed to provide protection of medical gases in accordance with NFPA 99. This deficient practice could potentially affect all 310 occupants of the facility. Findings include:

1. On 4/17/14 at 9:15 AM oxygen tanks were observed to be stored within 5 feet of combustibles in room #4520

In an interview on 4/17/14 at 9:15 AM, maintenance staff verified the storage of the combustibles next to the oxygen tanks.

2. On 4/17/14 at 10:35 AM oxygen tanks were observed to be stored loose on top of wheel chairs in MRI room #1064.

In an interview on 4/17/14 at 10:35 AM, maintenance staff verified the storage of the oxygen tanks on the wheel chairs.

3. On 4/17/14 at 11:35 AM oxygen tanks were observed to be stored loose on top of beds in the lower level general storage room.

In an interview on 4/17/14 at 11:35 AM, maintenance staff verified the storage of the oxygen tanks on the beds.

Based on observation and interview, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 10 occupants of the facility. Findings include:

1. On 4/17/14 at 9:31 AM, two open electrical junction boxes were observed in mechanical room #N0002.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the open electrical junction boxes.

2. On 4/17/14 at 9:45 AM, two open electrical junction boxes were observed in room #E0016.

In an interview on 4/17/14 at 9:45 AM, maintenance staff verified the open electrical junction boxes.

3. On 4/17/14 at 9:48 AM, open electrical junction boxes were observed in room #E0007.

In an interview on 4/17/14 at 9:48 AM, maintenance staff verified the open electrical junction box.

4. On 4/17/14 at 10:15 AM, open electrical junction boxes were observed in the MSU mechanical room near the east wall.

In an interview on 4/17/14 at 10:15 AM, maintenance staff verified the open electrical junction box.

5. On 4/17/14 at 9:37 AM, multiple strip plugs were observed plugged into each other in room #E0023.

In an interview on 4/17/14 at 10:15 AM, maintenance staff verified the multiple strip plugs.

6. On 4/17/14 at 10:00 AM, open electrical junction boxes were observed in electrical room #E2001.

In an interview on 4/17/14 at 10:00 AM, maintenance staff verified the open electrical junction box.

7. On 4/17/14 at 10:47 AM, an electrical multi plug adapter was observed in the corridor near stair #4.

In an interview on 4/17/14 at 10:47 AM, maintenance staff verified the use of the multi plug adapter.


.

Based on observation and interview, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 40 occupants of the facility. Findings include:

1. On 4/17/14 at 2:15 PM combustible storage observed in front of the electrical panels in the lower level boiler room.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the storage of combustibles in front of the electrical panels.

Based on observation and interview, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 40 occupants of the facility. Findings include:

1. On 4/17/14 at 9:30 AM trash containers were observed in front of the electrical panels in soiled utility room #3518.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the storage of trash in front of the electrical panels.

2. On 4/17/14 at 11:00 AM a housekeeping cart was observed in front of the electrical panels in room #1034.

In an interview on 4/17/14 at 9:30 AM, maintenance staff verified the storage of the cart in front of the electrical panels.

3. On 4/17/14 at 11:15 AM multiple strip plugs were observed to be plugged into each other and not directly into an outlet in room #1004K.

In an interview on 4/17/14 at 11:15 AM, maintenance staff verified the use of multiple strip plugs.

.