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Based on observation and interview, the facility failed to ensure 1 of 2 pharmacy use areas were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception. LSC 19-3.6.1, Exception # 6, Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas may be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, and (b) Each space is protected by automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. This deficient practice could affect any occupant in the pharmacy and adjacent exit corridor.

Findings include:

Based on observation with the Physical Plant Director on 04/07/15 at 1:15 p.m., a four by three foot window provided access to the corridor from one room in the pharmacy by two sliding glass panel which gapped 1/4 to 1/2 inches when close. The corridor was protected by an electrically supervised automatic detection system but the room was not. The Physical Plant Director acknowledged, at the time of observation the windows could not prevent the passage of smoke between the pharmacy room and corridor.

Based on observation and interview, the facility failed to ensure 1 of 2 cafeteria doors likely to be mistaken for a way of exit was identified as "No Exit." LSC 7.10.8.1 requires any door that is neither an exit nor a way of exit access and is located or arranged so it is likely to be mistaken for an exit shall be identified by a sign that reads: NO exit. This deficient practice affects visitors, staff and any patient in the cafeteria.

Findings include:

Based on observation with the Physical Plant Director on 04/07/15 at 12:40 p.m., a glass panel door opened to the outside of the cafeteria. The Physical Plant Director said at the time of observation the door was not an emergency exit which was evidenced by the lack of any signage above the door to indicate it was to be used as an exit. The door was not posted with a sign indicating it was not an exit. The Physical Plant Director agreed at the time of observation, the door could be mistaken for a means of exit.

Based on observation and interview, the facility failed to ensure 1 of 8 exits were arranged to minimize tripping hazards in accordance with LSC Section 7.1. LSC Section 7.1 requires means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.1.6 requires walking surfaces in the means of egress shall comply with 7.1.6.4. LSC 7.1.6.4 requires walking surfaces to be nominally level. This deficient practice could affect occupants using exit #25 by the "old smoke shack."

Findings include:

Based on observation with the Physical Plant Director on 04/07/15 at 3:08 p.m., the concrete exit discharge surface for the exit discharge for exit #25 was damaged by pitting and holes in the concrete which made the surface unlevel. In addition, irregular cracks ran across the width of the surface adding to irregularities in the walking surface. The Physical Plant Director said at the time of observation, the damage was weather related.

Based on observation and interview, the facility failed to ensure the exterior exit discharge path for 1 of 8 emergency exits was provided with emergency powered egress lighting. LSC 7.9.1.1 requires emergency lighting be provided for means of egress, including walkways leading to a public way. This deficient practice could affect visitors, staff and 10 or more patients.

Findings include:

Based on observation with the Director of the Physical Plant on 04/08/15 at 1:05 p.m., the exit discharge path from the exit near Respiratory Therapy had a single bulb light fixture above the exit discharge connected to the emergency generator. There was no lighting for the 90 foot length of the exit discharge path winding around the building to an evacuation point at the public way. The Director of the Physical Plant acknowledged at the time of observation, the discharge lighting provided could not illuminate more than the point of exit discharge from the building to the public way for emergency evacuation purposes.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 quarters and included information about which staff participated. LSC 4.7.2 requires drills include suitable procedures to ensure that all persons subject to the drill participate. This deficient practice could affect all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of the facility's Fire Drill records and interview with the Physical Plant Director on 04/07/12 at 2:15 p.m., there was no record of a third shift fire drill for the second quarter of 2014. The Physical Plant Director immediately reviewed the records and acknowledged a drill for this period was missing. In addition, the Fire Drill records included signatures for staff on the unit where the drill was initiated. The Physical Plant Director said at the time of record review, all hospital staff participated during each fire drill. There were no other signatures to evidence the participation of all staff on duty. The Physical Plant Director acknowledged there was no way to tell who had participated in the drill.

Based on observation and interview, the facility failed to maintain 1 of 2 portable fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2- 3.2 requires fire extinguishers provided for the protection of cooking appliances use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect 4 or more staff, visitors and any patient using the corridor located adjacent to the kitchen.

Findings include:

Based on observation on 04/07/15 at 12:20 p.m. with the Physical Plant Director, no placard was posted near the K class fire extinguisher in the kitchen. The Physical Plant Director acknowledged at the time of observation, there was no placard.

Based on observation and interview, the facility failed to ensure 1 of 2 pharmacy use areas were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception. LSC 19-3.6.1, Exception # 6, Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas may be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, and (b) Each space is protected by automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. This deficient practice could affect any occupant in the pharmacy and adjacent exit corridor.

Findings include:

Based on observation with the Physical Plant Director on 04/07/15 at 1:15 p.m., a four by three foot window provided access to the corridor from one room in the pharmacy by two sliding glass panel which gapped 1/4 to 1/2 inches when close. The corridor was protected by an electrically supervised automatic detection system but the room was not. The Physical Plant Director acknowledged, at the time of observation the windows could not prevent the passage of smoke between the pharmacy room and corridor.

Based on observation and interview, the facility failed to ensure 1 of 2 cafeteria doors likely to be mistaken for a way of exit was identified as "No Exit." LSC 7.10.8.1 requires any door that is neither an exit nor a way of exit access and is located or arranged so it is likely to be mistaken for an exit shall be identified by a sign that reads: NO exit. This deficient practice affects visitors, staff and any patient in the cafeteria.

Findings include:

Based on observation with the Physical Plant Director on 04/07/15 at 12:40 p.m., a glass panel door opened to the outside of the cafeteria. The Physical Plant Director said at the time of observation the door was not an emergency exit which was evidenced by the lack of any signage above the door to indicate it was to be used as an exit. The door was not posted with a sign indicating it was not an exit. The Physical Plant Director agreed at the time of observation, the door could be mistaken for a means of exit.

Based on observation and interview, the facility failed to ensure 1 of 8 exits were arranged to minimize tripping hazards in accordance with LSC Section 7.1. LSC Section 7.1 requires means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.1.6 requires walking surfaces in the means of egress shall comply with 7.1.6.4. LSC 7.1.6.4 requires walking surfaces to be nominally level. This deficient practice could affect occupants using exit #25 by the "old smoke shack."

Findings include:

Based on observation with the Physical Plant Director on 04/07/15 at 3:08 p.m., the concrete exit discharge surface for the exit discharge for exit #25 was damaged by pitting and holes in the concrete which made the surface unlevel. In addition, irregular cracks ran across the width of the surface adding to irregularities in the walking surface. The Physical Plant Director said at the time of observation, the damage was weather related.

Based on observation and interview, the facility failed to ensure the exterior exit discharge path for 1 of 8 emergency exits was provided with emergency powered egress lighting. LSC 7.9.1.1 requires emergency lighting be provided for means of egress, including walkways leading to a public way. This deficient practice could affect visitors, staff and 10 or more patients.

Findings include:

Based on observation with the Director of the Physical Plant on 04/08/15 at 1:05 p.m., the exit discharge path from the exit near Respiratory Therapy had a single bulb light fixture above the exit discharge connected to the emergency generator. There was no lighting for the 90 foot length of the exit discharge path winding around the building to an evacuation point at the public way. The Director of the Physical Plant acknowledged at the time of observation, the discharge lighting provided could not illuminate more than the point of exit discharge from the building to the public way for emergency evacuation purposes.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 quarters and included information about which staff participated. LSC 4.7.2 requires drills include suitable procedures to ensure that all persons subject to the drill participate. This deficient practice could affect all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of the facility's Fire Drill records and interview with the Physical Plant Director on 04/07/12 at 2:15 p.m., there was no record of a third shift fire drill for the second quarter of 2014. The Physical Plant Director immediately reviewed the records and acknowledged a drill for this period was missing. In addition, the Fire Drill records included signatures for staff on the unit where the drill was initiated. The Physical Plant Director said at the time of record review, all hospital staff participated during each fire drill. There were no other signatures to evidence the participation of all staff on duty. The Physical Plant Director acknowledged there was no way to tell who had participated in the drill.

Based on observation and interview, the facility failed to maintain 1 of 2 portable fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2- 3.2 requires fire extinguishers provided for the protection of cooking appliances use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect 4 or more staff, visitors and any patient using the corridor located adjacent to the kitchen.

Findings include:

Based on observation on 04/07/15 at 12:20 p.m. with the Physical Plant Director, no placard was posted near the K class fire extinguisher in the kitchen. The Physical Plant Director acknowledged at the time of observation, there was no placard.