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BON SECOURS ST FRANCIS MEDICAL CENTER
No Description Available
Tag No.: K0012
Based upon observations the fire rated walls that are not constructed to maintain the required fire resistance rating.
Findings include
On 10/24/14 around 9:05 AM it is observed that there is a fire rated wall that is not installed according the listed design at inpatient rehabilitation on the fourth floor.
On 10/24/14 around 9:15 AM it is observed that there is exposed combustible foam board at the north side behind the wall on near inpatient rehabilitation on the fourth floor.
30721
Based on observations the facility failed to properly maintain fire/smoke rated barrier walls.
Findings Include:
At 1:55 PM on October 23, 2014 it is observed through inspection that there is a missing section of wall in the one hour rated fire/smoke barrier wall located above the ceiling, in the corridor, on the fourth floor near the door to the inpatient rehab gym, room number BT466.
No Description Available
Tag No.: K0018
Based upon observations of all corridor doors there are doors found that did not have positive latching that could allow smoke to pass through the doors.
Findings include
On 10/21/14 around 2:10 PM it is observed that the door coordinator to the corridor door to radiation room 1 is not working properly and not allowing the doors to be self closing and latching.
No Description Available
Tag No.: K0025
Based upon observations the fire rated smoke barrier walls have penetrations, joints at top of wall, and openings that are not fire stopped and could allow smoke to pass from one side of the smoke barrier to the other side.
Findings include
On 10/21/14 around 3:25 PM it is observed that there is an opening in smoke barrier wall above the door to impinging wing on first floor that is not fire stopped with a listed design and product.
On 10/21/14 around 4:06 PM it is observed that there are openings in smoke barrier wall in ultrasound that is not fire stopped with a listed design and product on the second floor.
On 10/21/14 around 5:00 PM it is observed that there is a penetration in the smoke barrier wall above the back door of woman's imaging that is not fire stopped with a listed design and product.
No Description Available
Tag No.: K0027
Based upon observations the smoke barrier fire rated doors are not fully closing and could allow smoke to pass through the doors.
Findings include
On 10/21/14 around 2:02 PM it is observed that the smoke barrier door by radiation 2 is not fully closing.
On 10/21/14 around 5:01 PM it is observed that rear smoke barrier door is not self closing in suite 230.
No Description Available
Tag No.: K0047
Based upon observations there are locations in the facility where there are no exit signs to direct occupants to the exits.
Findings include
On 10/24/14 between 11:52 AM and 12:25 PM it is observed that that there are no exit signs directing occupants to the exits two means of exits at atrium on fourth and third floor.
30721
It is observed that the facility failed to continuously maintain Illuminated exit directional signs.
Findings Include:
At 3:48 PM on October 23, 2014 it is observed through inspection that an illuminated exit sign located in lab 101, on the first floor is nonoperational.
No Description Available
Tag No.: K0051
Based upon observations of the the fire alarm system that there are areas where the visual notification devices that are installed according to NFPA 72.
Findings include
On 10/21/14 around 4:15 PM it is observed that there is a visual fire alarm device that is above the ceiling in procedure room on the south side of the second.
No Description Available
Tag No.: K0052
During review of documentation of the fire alarm inspection reports it is noted that the reports show that all of the fire alarm initiation devices were not tested.
Findings include:
On 10/17/14 during review of the fire alarm inspection reports between 12:00 PM and 3:30 PM for the testing and inspection of the fire alarm system, the documentation dated 6/16/14 through 7/1/14 conducted by Siemens that there were smoke and beam detectors that were not test for functionality. The locations of the are as follows: rooms 521, 522,425,335, 330, 323, and the atrium beam detectors.
No Description Available
Tag No.: K0062
Based upon observations of the sprinkler system that there where the sprinklers are not parallel with the ceiling and the piping is not supported from the structure.
Findings include
On 10/21/14 around 1:48 PM it is observed that the sprinkler heads are not parallel with the ceiling in the equipment storage room on the first floor.
On 10/21/14 around 1:50 PM it is observed that the sprinkler pipe is supported by sheet rock and not the structure.
On 10/21/14 between 1:55 PM and 2:02 PM it is observed that the sprinkler heads are not parallel with the ceiling in the Medication room.
No Description Available
Tag No.: K0072
Based on observations, the means of egress is not being continuously maintained free of obstructions or impediments.
Findings Include:
At 2:03 PM on October 23, 2014 it is observed that there is 3 beds in the corridor located near room 410 on the fourth floor. These items obstruct the path of egress travel and diminishes the path of egress travel corridor width.
At 2:22 PM on October 23, 2014 it is observed that the path of egress travel leading to the MIU is obstructed by chairs and desks located near room 316.
It is noted that the current wall configuration differs from the approved building construction plans provided by the facility.
No Description Available
Tag No.: K0130
Based upon observations that the requirements for the HVAC systems and electrical systems are not being maintained.
Findings Include
On 10/24/14 around 11:00 AM it is observed that there is an electrical room and there is no sign designating that the room is an electrical room on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2
On 10/24/14 around 11:00 AM it is observed that there are screws missing to the cover of panel R in the electrical room on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2
On 10/24/14 between 11:10 AM and 11:15 AM it is observed that there are combustible materials located above the return air plenum ceiling in suite 510 on the 5th floor in the medical office building. Referenced Sections 38.3.4.2, 9.6.2.1
On 10/24/14 around 11:15 AM it is observed that there is a junction box for battery powered emergency lighting is supported by ceiling tile only and not supported to the structure in suite 510 on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2
On 10/24/14 around 11:25 AM it is observed that there is a junction box that has fire alarm cable that not connected in suite 510 on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2
No Description Available
Tag No.: K0141
Based upon observations there are oxygen tanks stored in a room and there is no no smoking sign near the door.
Findings include
On 10/21/14 around 1:55 PM it is observed that there is oxygen stored in the equipment storage room and there is no " No Smoking " sign on or near the door.
No Description Available
Tag No.: K0144
Based upon review of documentation and interviews that there is not complete documentation of the testing and inspection of the emergency generator according NFPA 110.
Findings include
During review of documentation on 10/27/14 between 1:15 PM and 1:48 PM that there is no documentation noting that the weekly inspections of the emergency generator is being done. The monthly generator load is less than 30% and there is no documentation showing the emergency generator has been tested using a load bank annually.
No Description Available
Tag No.: K0145
Based upon observations the emergency electrical systems and equipment is not being maintained.
Findings include
On 10/21/14 around 3:15 PM it is observed that there are circuits originating from the emergency life safety branch panel 1LLS that are not allowed to be fed from the life safety branch. The circuits are; low voltage tree lights, GFCI receptacle in med gas area and irrigation controls.
No Description Available
Tag No.: K0147
Based upon observations the electrical systems and equipment is not being maintained.
Findings include
On 10/21/14 around 3:02 PM it is observed that the electrical panels at generator are not labeled noting what circuits or equipment that the breaker supplies.
On 10/21/14 around 3:40 PM it is observed that there is an opening in electrical trough that is not closed in electrical room on the second floor.
On 10/21/14 around 3:40 PM it is observed that there is an opening in electrical panel 2DPEQ in the electrical room on the second floor that is not closed.