HospitalInspections.org

Based on observation it was determined that the facility failed to provide for required construction type and protection of structural members and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 10:45 AM a non-fire protected steel beam was observed in the 7th floor south stair well. Fire proofing was also observed to be missing approximately 12 -16 inches on either side of the attachment points of the beam. This observation was verified by the director of engineering.









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Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect 20% of the occupants of the facility. Findings include:

1. On 8/2/11 at approximately 12:15 PM the 3rd floor surgical pharmacy was observed to be equipped with a sliding glass window in the corridor wall that creates an opening approximately 2 feet by 3 feet in size. The surgical pharmacy does not meet the requirements of Section 19.3.6.1 for spaces open to the corridor. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 1:30 PM the 1st floor cashiers office was observed to be equipped with a sliding glass window in the corridor wall that creates an opening approximately 2 feet by 3 feet in size. The cashiers office does not meet the requirements of Section 19.3.6.1 for spaces open to the corridor. This observation was verified by the director of engineering.





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Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/ or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 10% of the occupants of the facility by allowing heat and smoke to pass from or into the facility's exit corridor system. Findings include:

1. On 8/2/11 at approximately 1:45 PM The Emergency Department Pharmacy was observed to be equipped with a dutch door. The top leaf of the door was not equipped with a means to provide for positive latching when the door was closed. This observation was verified by the director of engineering.







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Based on observation 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 all occupants of the facility by allowing heat and smoke to pass between an affected smoke compartment to an adjacent un-affected smoke compartment. Findings include:

1. On 8/2/11 at approximately 10:40 AM an unprotected 1 inch conduit penetration was observed in the smoke barrier wall above the 7 north smoke barrier wall doors. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 11:00 AM an unprotected wire penetration was observed in the smoke barrier wall above the 6 south smoke barrier wall doors. This observation was verified by the director of engineering.

3. On 8/2/11 at approximately 11:15 AM a 6 inch by 12 inch hole was observed in the smoke barrier wall above the 5 south smoke barrier wall doors. The smoke barrier wall was not sealed at the deck. This observation was verified by the director of engineering.

4. On 8/2/11 at approximately 11:40 AM an unprotected wire penetration was observed in the smoke barrier wall above the 4 south smoke barrier wall doors. This observation was verified by the director of engineering.

5. On 8/2/11 at approximately 12:00 PM two unprotected 1 inch conduit penetrations were observed in the smoke barrier wall above the 3rd floor PACU smoke barrier wall doors. This observation was verified by the director of engineering.





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Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 10% occupants of the facility by allowing heat and smoke to pass from an affected smoke compartment to an adjacent non-affected smoke compartment. Findings include:

1. On 8/2/11 at approximately 12:20 PM the smoke barrier doors at the 3rd floor surgical step down unit were observed to be binding causing the doors to remain open leaving a gap greater than 1/8 inch. This observation was verified by the director of engineering.







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Based on observation 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 10% of the occupants of the facility by allowing heat and smoke to escape the hazardous are area and enter the facility's exit corridor system. Findings include:

1. On 8/3/11 at approximately 10:15 AM a bundle of white wires was observed passing through an unprotected hole in the north wall of the 2nd floor "bed hut" storage room. This observation was verified by the director of engineering.

2. On 8/3/11 at approximately 10:20 AM 4 electrical conduits (1 inch and 2 inch) were observed passing through unprotected holes in the west wall of the 2nd floor "bed hut" storage room. This observation was verified by the director of engineering.






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Based on observation 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 all occupants of the facility by allowing heat and smoke to pass from the hazardous area into the facility's exit corridor system. Findings include:

1. On 8/2/11 at approximately 10:50 AM the 6 north clean supply storage room door did not positively latch when closed. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 11:25 AM the 5 south clean supply storage room was observed to have a 3 x 3 inch hole in the corridor wall. This observation was verified by the director of engineering.

3. On 8/2/11 at approximately 2:00 PM the door to the #5 X-Ray storage room was observed not to be self closing in accordance with Section 19.3.2.1. This observation was verified by the director of engineering.






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Based on observation 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 20% of the occupants of the facility by allowing heat and smoke to pass into the exit stairway during a fire. Findings include:

1. On 8/2/11 at approximately 12:25 AM the 3rd floor stair D did not self close and positively latch. This observation was verified by the director of engineering.








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Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect 20% of the occupants of the facility by making the exit unaccessible during an evacuation emergency. Findings include:

1. On 8/2/11 at approximately 1:15 PM the exit corridor from the maintenance/boiler area was observed to discharge into the trash compactor room instead of a public way. This observation was verified by the director of engineering.







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Based on observation and/or review of records 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 occupants of the facility in the event that the staff failed to respond according to the facility's emergency fire plan. Findings include:

1. On 8/2/11 at approximately 8:30 AM during review of the facility's fire drill records, it was observed that the facility failed to conduct fire drills at varied times on the 3rd shift. Documented times for 3rd shift drills were:

June 30, 2011 at 6:30 AM
March 27, 2011 at 11:15 PM
December 7, 2010 at 6:45 AM
September 8, 2010 at 6:30 AM

This observation was verified by the director of engineering.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could potentially affect all occupants of the facility in the event the sprinkler system failed to operate as designed during a fire emergency. Findings include:

1. On 8/3/11 at approximately 11:00 AM it was observed that the old locker room area in the 2nd floor "bed hut" room had a lower ceiling than the rest of the surrounding room. The locker room area did not have sprinkler heads installed below the ceiling on the interior of the locker room. This created an approximate 30 x 30 foot area of unprotected space. This observation was verified by the director of engineering.






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Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect 20% of the occupants of the facility if the sprinkler system failed to operate as designed. Findings include:

1. On 8/2/11 at approximately 1:15 PM a ceiling tile was observed to be missing in the maintenance exit corridor. This observation was verified by the director of engineering.







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Based on observation the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could potentially affect 10% of the occupants of the facility in the areas of insufficient sprinkler installation if the sprinklers failed to operate as designed during a fire emergency. Findings include:

1. On 8/311 at approximately 9:00 AM the sprinkler head on the 4th floor near the family alcove/room 4905 was observed to be missing the required escutcheon ring. This observation was verified by the director of engineering.

2. On 8/311 at approximately 10:00 AM the sprinkler head in the 3rd floor pre-op storage room was observed to be missing the required escutcheon ring. This observation was verified by the director of engineering.




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Based on observation and/or review of records the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect all occupants of the facility if the portable extinguishers were unavailable for use during a fire emergency. Findings include:

1. On 8/2/11 at approximately 12:45 PM the portable ABC fire extinguisher in the main lab RO room was observed to be mounted with the handle more than 60 inches above the floor. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 1:00 PM the portable ABC fire extinguisher in the kitchen prep room was observed to be mounted with the handle more than 60 inches above the floor. This observation was verified by the director of engineering.






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Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect 20 occupants of the facility if the kitchen portable fire extinguishers were unavailable for use during a fire. Findings include:

1. On 8/2/11 at approximately 1:10 PM the kitchen "K" fire extinguisher was observed to be mounted within 1 foot of a protected cooking appliance (stove) and was also mounted with the handle more than 60 inches above the floor. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 1:10 PM the kitchen "K" fire extinguisher was observed to be missing the required instructional placard indicating it's use in conjunction with the kitchen hood fire suppression system. This observation was verified by the director of engineering.







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Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 20 occupants of the facility. Findings include:

1. On 8/2/11 at approximately 11:10 AM a unsecured oxygen "E" tank was observed sitting on the floor in the 5th floor activities room. This observation was verified by the director of engineering.







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Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 20% of the occupants of the facility by increasing the availability of an electrical ignition source to start a fire. Findings include:

1. On 8/2/11 at approximately 10:40 AM an open electrical junction box was observed above the ceiling near the 7 north smoke barrier doors. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 11:50 AM an open electrical junction box was observed above the ceiling near the 4 north smoke barrier doors. This observation was verified by the director of engineering.








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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 9:30 AM during review of the facility's fire watch policy for the sprinkler system it was observed that the policy allowed for the individual assigned to fire watch to have other responsibilities and duties while performing fire watch. This observation was verified by the director of engineering.







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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 9:30 AM during review of the facility's fire watch policy for the sprinkler system it was observed that the policy allowed for the individual assigned to fire watch to have other responsibilities and duties while performing fire watch. This observation was verified by the director of engineering.






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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 9:30 AM during review of the facility's fire watch policy for the fire alarm system it was observed that the policy allowed for the individual assigned to fire watch to have other responsibilities and duties while performing fire watch. This observation was verified by the director of engineering.







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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 9:30 AM during review of the facility's fire watch policy for the fire alarm system it was observed that the policy allowed for the individual assigned to fire watch to have other responsibilities and duties while performing fire watch. This observation was verified by the director of engineering.






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Based on observation it was determined that the facility failed to provide for required construction type and protection of structural members and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 10:45 AM a non-fire protected steel beam was observed in the 7th floor south stair well. Fire proofing was also observed to be missing approximately 12 -16 inches on either side of the attachment points of the beam. This observation was verified by the director of engineering.









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Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect 20% of the occupants of the facility. Findings include:

1. On 8/2/11 at approximately 12:15 PM the 3rd floor surgical pharmacy was observed to be equipped with a sliding glass window in the corridor wall that creates an opening approximately 2 feet by 3 feet in size. The surgical pharmacy does not meet the requirements of Section 19.3.6.1 for spaces open to the corridor. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 1:30 PM the 1st floor cashiers office was observed to be equipped with a sliding glass window in the corridor wall that creates an opening approximately 2 feet by 3 feet in size. The cashiers office does not meet the requirements of Section 19.3.6.1 for spaces open to the corridor. This observation was verified by the director of engineering.





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Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/ or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 10% of the occupants of the facility by allowing heat and smoke to pass from or into the facility's exit corridor system. Findings include:

1. On 8/2/11 at approximately 1:45 PM The Emergency Department Pharmacy was observed to be equipped with a dutch door. The top leaf of the door was not equipped with a means to provide for positive latching when the door was closed. This observation was verified by the director of engineering.







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Based on observation 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 all occupants of the facility by allowing heat and smoke to pass between an affected smoke compartment to an adjacent un-affected smoke compartment. Findings include:

1. On 8/2/11 at approximately 10:40 AM an unprotected 1 inch conduit penetration was observed in the smoke barrier wall above the 7 north smoke barrier wall doors. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 11:00 AM an unprotected wire penetration was observed in the smoke barrier wall above the 6 south smoke barrier wall doors. This observation was verified by the director of engineering.

3. On 8/2/11 at approximately 11:15 AM a 6 inch by 12 inch hole was observed in the smoke barrier wall above the 5 south smoke barrier wall doors. The smoke barrier wall was not sealed at the deck. This observation was verified by the director of engineering.

4. On 8/2/11 at approximately 11:40 AM an unprotected wire penetration was observed in the smoke barrier wall above the 4 south smoke barrier wall doors. This observation was verified by the director of engineering.

5. On 8/2/11 at approximately 12:00 PM two unprotected 1 inch conduit penetrations were observed in the smoke barrier wall above the 3rd floor PACU smoke barrier wall doors. This observation was verified by the director of engineering.





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Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 10% occupants of the facility by allowing heat and smoke to pass from an affected smoke compartment to an adjacent non-affected smoke compartment. Findings include:

1. On 8/2/11 at approximately 12:20 PM the smoke barrier doors at the 3rd floor surgical step down unit were observed to be binding causing the doors to remain open leaving a gap greater than 1/8 inch. This observation was verified by the director of engineering.







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Based on observation 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 10% of the occupants of the facility by allowing heat and smoke to escape the hazardous are area and enter the facility's exit corridor system. Findings include:

1. On 8/3/11 at approximately 10:15 AM a bundle of white wires was observed passing through an unprotected hole in the north wall of the 2nd floor "bed hut" storage room. This observation was verified by the director of engineering.

2. On 8/3/11 at approximately 10:20 AM 4 electrical conduits (1 inch and 2 inch) were observed passing through unprotected holes in the west wall of the 2nd floor "bed hut" storage room. This observation was verified by the director of engineering.






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Based on observation 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 all occupants of the facility by allowing heat and smoke to pass from the hazardous area into the facility's exit corridor system. Findings include:

1. On 8/2/11 at approximately 10:50 AM the 6 north clean supply storage room door did not positively latch when closed. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 11:25 AM the 5 south clean supply storage room was observed to have a 3 x 3 inch hole in the corridor wall. This observation was verified by the director of engineering.

3. On 8/2/11 at approximately 2:00 PM the door to the #5 X-Ray storage room was observed not to be self closing in accordance with Section 19.3.2.1. This observation was verified by the director of engineering.






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Based on observation 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 20% of the occupants of the facility by allowing heat and smoke to pass into the exit stairway during a fire. Findings include:

1. On 8/2/11 at approximately 12:25 AM the 3rd floor stair D did not self close and positively latch. This observation was verified by the director of engineering.








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Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect 20% of the occupants of the facility by making the exit unaccessible during an evacuation emergency. Findings include:

1. On 8/2/11 at approximately 1:15 PM the exit corridor from the maintenance/boiler area was observed to discharge into the trash compactor room instead of a public way. This observation was verified by the director of engineering.







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Based on observation and/or review of records 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 occupants of the facility in the event that the staff failed to respond according to the facility's emergency fire plan. Findings include:

1. On 8/2/11 at approximately 8:30 AM during review of the facility's fire drill records, it was observed that the facility failed to conduct fire drills at varied times on the 3rd shift. Documented times for 3rd shift drills were:

June 30, 2011 at 6:30 AM
March 27, 2011 at 11:15 PM
December 7, 2010 at 6:45 AM
September 8, 2010 at 6:30 AM

This observation was verified by the director of engineering.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could potentially affect all occupants of the facility in the event the sprinkler system failed to operate as designed during a fire emergency. Findings include:

1. On 8/3/11 at approximately 11:00 AM it was observed that the old locker room area in the 2nd floor "bed hut" room had a lower ceiling than the rest of the surrounding room. The locker room area did not have sprinkler heads installed below the ceiling on the interior of the locker room. This created an approximate 30 x 30 foot area of unprotected space. This observation was verified by the director of engineering.






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Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect 20% of the occupants of the facility if the sprinkler system failed to operate as designed. Findings include:

1. On 8/2/11 at approximately 1:15 PM a ceiling tile was observed to be missing in the maintenance exit corridor. This observation was verified by the director of engineering.







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Based on observation the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could potentially affect 10% of the occupants of the facility in the areas of insufficient sprinkler installation if the sprinklers failed to operate as designed during a fire emergency. Findings include:

1. On 8/311 at approximately 9:00 AM the sprinkler head on the 4th floor near the family alcove/room 4905 was observed to be missing the required escutcheon ring. This observation was verified by the director of engineering.

2. On 8/311 at approximately 10:00 AM the sprinkler head in the 3rd floor pre-op storage room was observed to be missing the required escutcheon ring. This observation was verified by the director of engineering.




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Based on observation and/or review of records the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect all occupants of the facility if the portable extinguishers were unavailable for use during a fire emergency. Findings include:

1. On 8/2/11 at approximately 12:45 PM the portable ABC fire extinguisher in the main lab RO room was observed to be mounted with the handle more than 60 inches above the floor. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 1:00 PM the portable ABC fire extinguisher in the kitchen prep room was observed to be mounted with the handle more than 60 inches above the floor. This observation was verified by the director of engineering.






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Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect 20 occupants of the facility if the kitchen portable fire extinguishers were unavailable for use during a fire. Findings include:

1. On 8/2/11 at approximately 1:10 PM the kitchen "K" fire extinguisher was observed to be mounted within 1 foot of a protected cooking appliance (stove) and was also mounted with the handle more than 60 inches above the floor. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 1:10 PM the kitchen "K" fire extinguisher was observed to be missing the required instructional placard indicating it's use in conjunction with the kitchen hood fire suppression system. This observation was verified by the director of engineering.







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Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 20 occupants of the facility. Findings include:

1. On 8/2/11 at approximately 11:10 AM a unsecured oxygen "E" tank was observed sitting on the floor in the 5th floor activities room. This observation was verified by the director of engineering.







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Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 20% of the occupants of the facility by increasing the availability of an electrical ignition source to start a fire. Findings include:

1. On 8/2/11 at approximately 10:40 AM an open electrical junction box was observed above the ceiling near the 7 north smoke barrier doors. This observation was verified by the director of engineering.

2. On 8/2/11 at approximately 11:50 AM an open electrical junction box was observed above the ceiling near the 4 north smoke barrier doors. This observation was verified by the director of engineering.








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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 9:30 AM during review of the facility's fire watch policy for the sprinkler system it was observed that the policy allowed for the individual assigned to fire watch to have other responsibilities and duties while performing fire watch. This observation was verified by the director of engineering.







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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 9:30 AM during review of the facility's fire watch policy for the sprinkler system it was observed that the policy allowed for the individual assigned to fire watch to have other responsibilities and duties while performing fire watch. This observation was verified by the director of engineering.






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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 9:30 AM during review of the facility's fire watch policy for the fire alarm system it was observed that the policy allowed for the individual assigned to fire watch to have other responsibilities and duties while performing fire watch. This observation was verified by the director of engineering.







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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

1. On 8/2/11 at approximately 9:30 AM during review of the facility's fire watch policy for the fire alarm system it was observed that the policy allowed for the individual assigned to fire watch to have other responsibilities and duties while performing fire watch. This observation was verified by the director of engineering.






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