HospitalInspections.org

Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 1.1.4.1, 19.1.1.4.2.

Findings include:

On 10/15/12 at approximately 11:20am, the West Exit door to the Clinic was observed to be equipped with a powered opening device. The door is in the 2-hour fire separation to the non-compliant clinic building. The door operator does not disengage with the operation of the fire alarm system in accordance with Section 7.2.1.9.2. This condition was noted with the Facilities Director present.

Based on observation 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.

Findings include:

On 10/15/12 at approximately 11:26am, the door to the Education Office was observed to be held open with a wedge. This prevents the door from being closed in a single motion. The wedge was removed at the time of inspection. This condition was noted with the Facilities Director present.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1.

Findings include:

On 10/15/12 at approximately 11:50am, the door to the Ambulance Garage was observed to be equipped with a powered opening device. The door is in the 1-hour fire separation to the hazardous area. The door operator does not disengage with the operation of the fire alarm system in accordance with Section 7.2.1.9.2. This condition was noted with the Facilities Director present.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3.

Findings include:

On 10/15/12 at approximately 11:18am, the Lobby Corridor outside the Gift Shop was observed to have tables and other items located within the required corridor width. The facility was designed with 8-foot corridors throughout. The items were removed at the time of inspection. This condition was noted with the Facilities Director present.

Based on observation the facility failed to maintain emergency lighting in accordance with the LSC section 19.2.9.1.

Findings include:

On 10/15/12 between 9:15am and 10:15am during records review, the facility documentation showed that no monthly 30-second testing of the battery operated emergency lights was conducted for June or July of 2012. This condition was noted with the Facilities Director present.

Based on review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1.

Findings include:

On 10/15/12 between 9:15am and 10:15am during records review, the facility Code Red Plan did not include designation of a person to ensure transmission of the fire alarm to the fire department in accordance with Section 19.7.2.2(2). This condition was noted with the Facilities Director present.

Based on observation the facility failed to ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5.

Findings include:

On 10/15/12 at approximately 10:59am, a sprinkler head in AMBU2 was observed to be covered with dust that could delay the operation of the sprinkler head in violation of NFPA 25, Section 2-2.1.1. This condition was noted with the Facilities Director present.

Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 1.1.4.1, 19.1.1.4.2.

Findings include:

On 10/15/12 at approximately 11:20am, the West Exit door to the Clinic was observed to be equipped with a powered opening device. The door is in the 2-hour fire separation to the non-compliant clinic building. The door operator does not disengage with the operation of the fire alarm system in accordance with Section 7.2.1.9.2. This condition was noted with the Facilities Director present.

Based on observation 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.

Findings include:

On 10/15/12 at approximately 11:26am, the door to the Education Office was observed to be held open with a wedge. This prevents the door from being closed in a single motion. The wedge was removed at the time of inspection. This condition was noted with the Facilities Director present.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1.

Findings include:

On 10/15/12 at approximately 11:50am, the door to the Ambulance Garage was observed to be equipped with a powered opening device. The door is in the 1-hour fire separation to the hazardous area. The door operator does not disengage with the operation of the fire alarm system in accordance with Section 7.2.1.9.2. This condition was noted with the Facilities Director present.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3.

Findings include:

On 10/15/12 at approximately 11:18am, the Lobby Corridor outside the Gift Shop was observed to have tables and other items located within the required corridor width. The facility was designed with 8-foot corridors throughout. The items were removed at the time of inspection. This condition was noted with the Facilities Director present.

Based on observation the facility failed to maintain emergency lighting in accordance with the LSC section 19.2.9.1.

Findings include:

On 10/15/12 between 9:15am and 10:15am during records review, the facility documentation showed that no monthly 30-second testing of the battery operated emergency lights was conducted for June or July of 2012. This condition was noted with the Facilities Director present.

Based on review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1.

Findings include:

On 10/15/12 between 9:15am and 10:15am during records review, the facility Code Red Plan did not include designation of a person to ensure transmission of the fire alarm to the fire department in accordance with Section 19.7.2.2(2). This condition was noted with the Facilities Director present.

Based on observation the facility failed to ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5.

Findings include:

On 10/15/12 at approximately 10:59am, a sprinkler head in AMBU2 was observed to be covered with dust that could delay the operation of the sprinkler head in violation of NFPA 25, Section 2-2.1.1. This condition was noted with the Facilities Director present.