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Based on observation and interview, the facility failed to ensure the lighting in 3 of 10 exit means of egress was arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. LSC Section 7.8.1.4 requires illumination be arranged so the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area. This deficient practice could affect any patients in Nursing Services and the ER entrance as well as staff and visitors if the facility were required to evacuate and the single bulb outside failed leaving the area in darkness.

Findings include:

Based on observations on 11/17/15 during the tour between 12:05 p.m. to 3:00 p.m. with the Maintenance Supervisor, the light fixtures outside of the north and east exits of the Nursing Services and the west exit out of the ER entrance had only one bulb in the light fixture. Based on interview on 11/17/15 concurrent with the observations it was acknowledged by the Maintenance Supervisor the outside light providing illumination for the exit discharge out of the aforementioned units were equipped with only a single bulb light fixture.

Based on observations and interview, the facility failed to provide emergency lighting in 2 of 2 operating rooms where general anesthesia or life support equipment is used. LSC Section 19.2.9.1 requires emergency lighting shall be in accordance with LSC Section 7.9. LSC Section 7.9.2.5 states an emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities.
LSC Section 7.9.2.5 requires the emergency lighting system to either be in continuous operation or be capable of repeated automatic operation without manual intervention. This deficient practice could any client or staff in the operating rooms.

Findings include:

Based on observation on 11/17/15 at 1:50 p.m., there were no battery operated emergency lighting to provide continuous illumination in the operating rooms on the north end of the building. Based on interview on 11/17/15 concurrent with the observation the Maintenance Supervisor acknowledged an emergency generator is utilized to provide emergency lighting in the operating room but there is no battery operated back up emergency lighting system to provide continuous illumination in the operating room during the time it takes for the generator to resume electrical service.

Based on observation and interview, the facility failed to ensure the care and maintenance of 1 of 1 rolling fire doors were in accordance with NFPA 80. NFPA 80, 1999 Edition, the Standard for Fire Doors and Fire Windows, Section 15-2.4.3 requires all horizontal or vertical sliding and rolling fire doors to be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction. This deficient practice could affect 3 patients on Main hall lounge adjacent to the Kitchen as well as staff and visitors.

Findings include:

Based on observation on 11/17/15 at 12:35 p.m. with the Maintenance Supervisor, there was one metal rolling fire door protecting the opening from the kitchen to the Main hall lounge which did not have an attached inspection tag. Furthermore, the Main hall lounge was open to the corridor and the rolling metal fire door did not close automatically when the fire alarm was activated. Based on interview concurrent with the observation with the Maintenance Supervisor there was no additional documentation of an annual inspection or test to check for proper operation and full closure and it was further stated it did not close automatically with actuation of the fire alarm system.

Based on observation and interview, the facility failed to ensure 1 of 3 surge protectors observed including extension cords, non-fused extension cords and/or multiplug adapters were not used to power medical appliances. NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect 3 patients as well as visitors and staff.

Findings include:

Based on observation on 11/17/15 at 2:10 p.m. a surge protector was used to provide power to two refrigerating units in the laboratory on main hall. Based on interview on 11/17/15 concurrent with the observation it was acknowledged by the Maintenance Supervisor, a surge protector was used to provide power to the aforementioned electrical appliances.

Based on observation and interview, the facility failed to ensure the lighting in 3 of 10 exit means of egress was arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. LSC Section 7.8.1.4 requires illumination be arranged so the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area. This deficient practice could affect any patients in Nursing Services and the ER entrance as well as staff and visitors if the facility were required to evacuate and the single bulb outside failed leaving the area in darkness.

Findings include:

Based on observations on 11/17/15 during the tour between 12:05 p.m. to 3:00 p.m. with the Maintenance Supervisor, the light fixtures outside of the north and east exits of the Nursing Services and the west exit out of the ER entrance had only one bulb in the light fixture. Based on interview on 11/17/15 concurrent with the observations it was acknowledged by the Maintenance Supervisor the outside light providing illumination for the exit discharge out of the aforementioned units were equipped with only a single bulb light fixture.

Based on observations and interview, the facility failed to provide emergency lighting in 2 of 2 operating rooms where general anesthesia or life support equipment is used. LSC Section 19.2.9.1 requires emergency lighting shall be in accordance with LSC Section 7.9. LSC Section 7.9.2.5 states an emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities.
LSC Section 7.9.2.5 requires the emergency lighting system to either be in continuous operation or be capable of repeated automatic operation without manual intervention. This deficient practice could any client or staff in the operating rooms.

Findings include:

Based on observation on 11/17/15 at 1:50 p.m., there were no battery operated emergency lighting to provide continuous illumination in the operating rooms on the north end of the building. Based on interview on 11/17/15 concurrent with the observation the Maintenance Supervisor acknowledged an emergency generator is utilized to provide emergency lighting in the operating room but there is no battery operated back up emergency lighting system to provide continuous illumination in the operating room during the time it takes for the generator to resume electrical service.

Based on observation and interview, the facility failed to ensure the care and maintenance of 1 of 1 rolling fire doors were in accordance with NFPA 80. NFPA 80, 1999 Edition, the Standard for Fire Doors and Fire Windows, Section 15-2.4.3 requires all horizontal or vertical sliding and rolling fire doors to be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction. This deficient practice could affect 3 patients on Main hall lounge adjacent to the Kitchen as well as staff and visitors.

Findings include:

Based on observation on 11/17/15 at 12:35 p.m. with the Maintenance Supervisor, there was one metal rolling fire door protecting the opening from the kitchen to the Main hall lounge which did not have an attached inspection tag. Furthermore, the Main hall lounge was open to the corridor and the rolling metal fire door did not close automatically when the fire alarm was activated. Based on interview concurrent with the observation with the Maintenance Supervisor there was no additional documentation of an annual inspection or test to check for proper operation and full closure and it was further stated it did not close automatically with actuation of the fire alarm system.

Based on observation and interview, the facility failed to ensure 1 of 3 surge protectors observed including extension cords, non-fused extension cords and/or multiplug adapters were not used to power medical appliances. NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect 3 patients as well as visitors and staff.

Findings include:

Based on observation on 11/17/15 at 2:10 p.m. a surge protector was used to provide power to two refrigerating units in the laboratory on main hall. Based on interview on 11/17/15 concurrent with the observation it was acknowledged by the Maintenance Supervisor, a surge protector was used to provide power to the aforementioned electrical appliances.