HospitalInspections.org

Based on observation and interview, the facility failed to separate the new and existing construction in accordance with LCS (2000) Section 18.1.1.4.1. This deficienct practice could affect all patients.

Findings include:

During facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the Adminstration Office is part of the 2-hour fire wall. The door to the administration office and the adjacent Firelite windows are only fire rated for 60 minutes.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observations and document review, the automatic sprinkler system in not installed in accordance with NFPA 13. This deficient practice could affect some patients.

Findings include:

During facility tour between 9:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that:

1. There are fire sprinkler heads of different type and manufacturer located on the first floor near the old pharmacy.
2. There are no pressure gauges at the top of the fire standpipes in stairwells B, E and G.
3. In room G-215, the sidewall fire sprinkler head is located 7 feet down from the ceiling deck above.
4. The decorative wood slatted ceiling in the first floor lobby and corridor has 1" gaps between the slats that may affect the proper operation of the fire sprinkler system.

These deficient practices were verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observations and interviews, it could not be verified that the facility's general ventilating and air conditioning system (HVAC) is installed in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 2-3.11. A noncompliant HVAC system could affect all patients.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that the corridor on the seventh floor is being used as a return air plenum above the suspended ceiling grid. The seventh floor is not completely fire sprinkler protected.

This deficiency practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of the patients in an emergency situation.

Findings include:

On facility tour between 1:30 PM on 01/24/2011 and 4:30 PM on 01/25/2011, observation revealed that there are unattended, wheeled computer work stations stored in the corridors for more than 30 minutes during all times of the day on all floors of the hospital.

This deficient practice was verified by the Senior Manager of Maintenance Operations at the time of the inspection.