HospitalInspections.org

Based on observation, it was determined that the facility failed to ensure that the building construction type and heights is in accordance with NFPA 101, LSC, Section 19.1.6.2. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the facility is subjected to structural collapse earlier than anticipated due to the lack of proper sprinkler protection.

Findings include:

On April 28, 2011 between approximately 10:22 and 11:02 a.m., the following conditions were observed.

A) The new entry enclosure outside the kitchen corridor exit was observed to be of Type V(000) construction and was not provided with sprinkler protection. Sprinkler protection is required.

B) The new "pad warmer" closet in physical therapy was observed to have no sprinkler protection. This area is of Type II(111) construction. Sprinkler protection is required.

Based on observation it was determined that the facility failed to maintain exits so that they are readily accessible at all times in accordance with NFPA 101. LSC, Sections 19.2.1 and 7.1. This deficiency could affect an undetermined number of patients, staff and visitors in the event of a fire where the rapid evacuation of the facility is required.

Findings include:

On April 28, 2011 at approximately 10:22 a.m., the exit from the enclosed MRI dock was obstructed by use of a concrete wheel block which blocked access to the required exit.

Based on observation, it was determined that the facility failed to provide horizontal exits which are in accordance with NFPA 101, LSC, Sections 19.2.2.5 and 7.2.4. This deficient practice could affect an undetermined number of patients in the event of a fire where the means of egress is compromised due to the spread of smoke or other products of combustion through the defective horizontal exit.

Findings include:

On April 28, 2011 at approximately 11:05 a.m., the south leaf of the horizontal exit between cardiac rehab and physical therapy was observed to not close completely and latch.

Based on observation, it was determined that the facility failed to provide illumination of the means of egress including exit discharge so that failure of any single lighting fixture would not leave the area in darkness in accordance with NFPA 101, LSC, Section 19.2.8. This deficiency could affect an undetermined number of patients, staff and visitors in the event of a failure of the single lighting fixture installed at an exit discharge of the building.

Findings include:

On April 28, 2011 at approximately 10:32 a.m., the new entry enclosure outside of the kitchen corridor was observed to be equipped with a single bulb lighting fixture which is activated by motion by person approaching from the exterior of the facility.

Based on observation, it was determined that the facility failed to ensure that the building construction type and heights is in accordance with NFPA 101, LSC, Sections 19.1.6.2 and 19.3.5. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the facility is subjected to structural collapse earlier than anticipated due to the lack of proper sprinkler protection.

Findings include:

On April 28, 2011 between approximately 10:22 and 11:02 a.m., the following conditions were observed.

A) The new entry enclosure outside the kitchen corridor exit was observed to be of Type V(000) construction and was not provided with sprinkler protection. Sprinkler protection is required.

B) The new "pad warmer" closet in physical therapy was observed to have no sprinkler protection. This area is of Type II(111) construction. Sprinkler protection is required.

Based on observation, it was determined that the facility failed to provide loosely hanging fabrics serving as decorations that are in accordance with NFPA 101, LSC, Section 10.3.1 and NFPA 701. This deficiency could affect an undetermined number of patients, staff and visitors in the event of a fire where these improper fabrics readily ignite, causing a rapid spread or development of the fire.

Findings include:

On April 28, 2011 at approximately 10:44 a.m., tapestries were observed to be hanging from the walls in the E.R. waiting room area and in the "Grand Hall". The tapestries were not provided with labels stating that they were in compliance with NFPA 701. No documentation could be provided by the facility indicating that these hanging tapestries were in compliance.

Based on observation, it was determined that the facility failed to ensure that the building construction type and heights is in accordance with NFPA 101, LSC, Section 19.1.6.2. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the facility is subjected to structural collapse earlier than anticipated due to the lack of proper sprinkler protection.

Findings include:

On April 28, 2011 between approximately 10:22 and 11:02 a.m., the following conditions were observed.

A) The new entry enclosure outside the kitchen corridor exit was observed to be of Type V(000) construction and was not provided with sprinkler protection. Sprinkler protection is required.

B) The new "pad warmer" closet in physical therapy was observed to have no sprinkler protection. This area is of Type II(111) construction. Sprinkler protection is required.

Based on observation it was determined that the facility failed to maintain exits so that they are readily accessible at all times in accordance with NFPA 101. LSC, Sections 19.2.1 and 7.1. This deficiency could affect an undetermined number of patients, staff and visitors in the event of a fire where the rapid evacuation of the facility is required.

Findings include:

On April 28, 2011 at approximately 10:22 a.m., the exit from the enclosed MRI dock was obstructed by use of a concrete wheel block which blocked access to the required exit.

Based on observation, it was determined that the facility failed to provide horizontal exits which are in accordance with NFPA 101, LSC, Sections 19.2.2.5 and 7.2.4. This deficient practice could affect an undetermined number of patients in the event of a fire where the means of egress is compromised due to the spread of smoke or other products of combustion through the defective horizontal exit.

Findings include:

On April 28, 2011 at approximately 11:05 a.m., the south leaf of the horizontal exit between cardiac rehab and physical therapy was observed to not close completely and latch.

Based on observation, it was determined that the facility failed to provide illumination of the means of egress including exit discharge so that failure of any single lighting fixture would not leave the area in darkness in accordance with NFPA 101, LSC, Section 19.2.8. This deficiency could affect an undetermined number of patients, staff and visitors in the event of a failure of the single lighting fixture installed at an exit discharge of the building.

Findings include:

On April 28, 2011 at approximately 10:32 a.m., the new entry enclosure outside of the kitchen corridor was observed to be equipped with a single bulb lighting fixture which is activated by motion by person approaching from the exterior of the facility.

Based on observation, it was determined that the facility failed to ensure that the building construction type and heights is in accordance with NFPA 101, LSC, Sections 19.1.6.2 and 19.3.5. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the facility is subjected to structural collapse earlier than anticipated due to the lack of proper sprinkler protection.

Findings include:

On April 28, 2011 between approximately 10:22 and 11:02 a.m., the following conditions were observed.

A) The new entry enclosure outside the kitchen corridor exit was observed to be of Type V(000) construction and was not provided with sprinkler protection. Sprinkler protection is required.

B) The new "pad warmer" closet in physical therapy was observed to have no sprinkler protection. This area is of Type II(111) construction. Sprinkler protection is required.

Based on observation, it was determined that the facility failed to provide loosely hanging fabrics serving as decorations that are in accordance with NFPA 101, LSC, Section 10.3.1 and NFPA 701. This deficiency could affect an undetermined number of patients, staff and visitors in the event of a fire where these improper fabrics readily ignite, causing a rapid spread or development of the fire.

Findings include:

On April 28, 2011 at approximately 10:44 a.m., tapestries were observed to be hanging from the walls in the E.R. waiting room area and in the "Grand Hall". The tapestries were not provided with labels stating that they were in compliance with NFPA 701. No documentation could be provided by the facility indicating that these hanging tapestries were in compliance.