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Based on record review and interview, the facility failed to develop an emergency preparedness program in accordance with 42 CFR 482.15 that includes the following elements:
a) An Emergency Plan
b) Policies and Procedures
c) A Communication Plan
d) Training and Testing
e) An Emergency and Standby Power System
This deficient practice could affect all occupants.

Findings include:

Based on record review on 05/20/19 from 9:00 a.m. to 11:30 a.m., no emergency preparedness documentation specific to NeuroDiagnostic Institute could be located or presented for review. Documentation was presented titled Larue Carter Memorial Hospital Emergency Operations Procedure, but this documentation was not site specific to the NeuroDiagnistic Institute facility. Based on interview on 05/21/19 at 12:20 p.m. prior to the exit conference, the Executive Physical Plant Director stated that he was advised by the Quality Improvement Director that there were no other facility specific Emergency Preparedness documents that could be provided for record review. During the exit conference with the facility Executive Physical Plant Director and the Maintenance Supervisor at 12:25 p.m., no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually in accordance with 42 CFR 482.15(a). This deficient practice could affect all occupants.

Findings include:

Based on record review on 05/20/19 from 9:00 a.m. to 11:30 a.m., no emergency preparedness documentation specific to NeuroDiagnostic Institute could be located or presented for review. Documentation was presented titled Larue Carter Memorial Hospital Emergency Operations Procedure, but this documentation was not site specific to the NeuroDiagnistic Institute facility. Based on interview on 05/21/19 at 12:20 p.m. prior to the exit conference, the Executive Physical Plant Director stated that he was advised by the Quality Improvement Director that there were no other facility specific Emergency Preparedness documents that could be provided for record review. During the exit conference with the facility Executive Physical Plant Director and the Maintenance Supervisor at 12:25 p.m., no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to develop and implement emergency preparedness policies and procedures. The policies and procedures must be reviewed and updated at least annually in accordance with 42 CFR 482.15(b). This deficient practice would affect all occupants.

Findings include:

Based on record review on 05/20/19 from 9:00 a.m. to 11:30 a.m., no emergency preparedness documentation specific to NeuroDiagnostic Institute could be located or presented for review. Documentation was presented titled Larue Carter Memorial Hospital Emergency Operations Procedure, but this documentation was not site specific to the NeuroDiagnistic Institute facility. Based on interview on 05/21/19 at 12:20 p.m. prior to the exit conference, the Executive Physical Plant Director stated that he was advised by the Quality Improvement Director that there were no other facility specific Emergency Preparedness documents that could be provided for record review. During the exit conference with the facility Executive Physical Plant Director and the Maintenance Supervisor at 12:25 p.m., no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws was reviewed and updated at least annually in accordance with 42 CFR 482.15(c). This deficient practice would affect all occupants.

Findings include:

Based on record review on 05/20/19 from 9:00 a.m. to 11:30 a.m., no emergency preparedness documentation specific to NeuroDiagnostic Institute could be located or presented for review. Documentation was presented titled Larue Carter Memorial Hospital Emergency Operations Procedure, but this documentation was not site specific to the NeuroDiagnistic Institute facility. Based on interview on 05/21/19 at 12:20 p.m. prior to the exit conference, the Executive Physical Plant Director stated that he was advised by the Quality Improvement Director that there were no other facility specific Emergency Preparedness documents that could be provided for record review. During the exit conference with the facility Executive Physical Plant Director and the Maintenance Supervisor at 12:25 p.m., no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness training and testing program that was reviewed and updated at least annually in accordance with 42 CFR 482.15(d). This deficient practice could affect all occupants.

Findings include:

Based on record review on 05/20/19 from 9:00 a.m. to 11:30 a.m., no emergency preparedness documentation specific to NeuroDiagnostic Institute could be located or presented for review. Documentation was presented titled Larue Carter Memorial Hospital Emergency Operations Procedure, but this documentation was not site specific to the NeuroDiagnistic Institute facility. Based on interview on 05/21/19 at 12:20 p.m. prior to the exit conference, the Executive Physical Plant Director stated that he was advised by the Quality Improvement Director that there were no other facility specific Emergency Preparedness documents that could be provided for record review. During the exit conference with the facility Executive Physical Plant Director and the Maintenance Supervisor at 12:25 p.m., no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to ensure the emergency preparedness training and testing program includes a training program. The hospital must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles; (ii) Provide emergency preparedness training at least annually; (iii) Maintain documentation of the training; (iv) Demonstrate staff knowledge of emergency procedures in accordance with 42 CFR 482.15(d)(1). This deficient practice could affect all occupants.

Findings include:

Based on record review on 05/20/19 from 9:00 a.m. to 11:30 a.m., no emergency preparedness documentation specific to NeuroDiagnostic Institute could be located or presented for review. Documentation was presented titled Larue Carter Memorial Hospital Emergency Operations Procedure, but this documentation was not site specific to the NeuroDiagnistic Institute facility. Based on interview on 05/21/19 at 12:20 p.m. prior to the exit conference, the Executive Physical Plant Director stated that he was advised by the Quality Improvement Director that there were no other facility specific Emergency Preparedness documents that could be provided for record review. During the exit conference with the facility Executive Physical Plant Director and the Maintenance Supervisor at 12:25 p.m., no additional information or evidence could be provided contrary to this deficient finding.

Based on observation and interview, the facility failed to maintain a minimum two-hour rated construction for 1 of 1 separation walls between business occupancy and health care occupancy. This deficient practice could affect 10 patients, staff, and visitors on the second floor.

Findings include:

Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, the minimum two-hour fire rated construction for the occupancy separation wall between the adjoining Community Hospital and the first floor of the facility was not maintained. At the southwest fire barrier door set on the first floor, drywall only extended for one foot above the suspended ceiling and left exposed metal studs which extended another six inches above the drywall. Exposed concrete block which had been the exterior wall for Community Hospital extended another six feet above the metal studs. In addition, the west door in the southwest fire barrier door set on the first floor failed to self close and latch into the door frame when tested to close multiple times. Based on interview at the time of the observations, the Executive Physical Plant Director agreed the occupancy separation wall did not extend to the deck of the floor above leaving exposed metal studs and concrete which failed to maintain a minimum two-hour fire rated construction for the southwest tenant separation wall on the first floor.

Based on record review, observation and interview; the facility failed to ensure 1 of 3 exit passageways serving as a discharge from a stair enclosure was in accordance with LSC 18.2.2.7. LSC 18.2.2.7 states exit passageways complying with 7.2.6 shall be permitted. LSC 7.2.6.3 states an exit passageway that serves as a discharge from a stair enclosure shall have not less than the same fire resistance an opening protection rating as those required for the stair enclosure. This deficient practice could affect over 20 patients and staff if utilizing the center stairwell exit passageway on the first floor.

Findings include:

Based on review of facility blueprint documentation with the Executive Physical Plant Director during record review from 9:30 a.m. to 11:30 a.m. on 05/20/19, the center stairwell exit discharge on the first floor does not exit directly to the public way but into an internal passageway which is not protected with the same fire resistance rating of the center stairwell vertical opening. Based on the facility blueprints, the north wall and the west wall which forms an 'L' shaped wall directly west of the stairwell exit door on the first floor were not rated at a minimum 2-hour fire resistance rating. Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, "Smoke Barrier" was printed above the suspended ceiling on the north wall and the west wall which forms an 'L' shaped wall directly west of the center stairwell exit door on the first floor. In addition, exposed metal studs were noted above the suspended ceiling in the south wall of the center stairwell exit passageway west of the center stairwell exit door on the first floor. The south wall of the passageway is an exterior wall of the facility. Based on interview at the time of record review and of the observations, the Executive Physical Plant Director stated he was not certain if the exit passageway was constructed per the blueprints and all walls in the exit passageway were constructed with not less than the same fire resistance required for the center stairwell enclosure.

Based on observation and interview, the facility failed to maintain protection of 2 of 3 interior stairwells. LSC 18.3.1 requires vertical openings shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 8.6.5 states see 7.1.3.2.1 for enclosures of exits. LSC 7.1.3.2.1 states the separation shall have a minimum 2-hr fire resistance rating where the exit connects four or more stories. Existing penetrations shall be protected in accordance with 8.3.5. This deficient practice could affect over 20 patients, staff and visitors.

Findings include:

Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the following was noted:
a. The annular space surrounding a one inch in diameter electrical conduit which penetrated the south wall of the west stairwell on the first floor was not firestopped.
b. The annular space surrounding a one inch in diameter electrical conduit which penetrated the south wall of the center stairwell on the sixth floor was not firestopped.
c. The annular space surrounding a one inch in diameter electrical conduit which penetrated the south wall of the west stairwell on the sixth floor was not firestopped.
d. The annular space surrounding a structural support in the center stairwell in the penthouse was not firestopped.
Based on interview at the time of the observations, the Executive Physical Plant Director agreed it could not be assured the two interior stairwells were enclosed with a minimum 2-hr fire resistance rating.

Based on observation and interview, the facility failed to ensure 1 of 28 hazardous areas such as soiled linen rooms were separated from other spaces by smoke resistant partitions and doors. Doors shall be self-closing or automatic closing in accordance with 7.2.1.8. This deficient practice could affect 20 patients, staff and visitors in the vicinity of the Soiled Linen room #E 435.

Findings include:

Based on observation with the Maintenance Supervisor during a tour of the facility at 9:48 a.m. on 05/21/19, the corridor door to the Soiled Linen room # 435 was equipped with a self-closing device but the door failed to fully close and latch into the door frame when tested three separate times. When swinging to close, the door stopped just short of the door jamb on the latching side and left a one-half inch gap between the door and the door jamb on the latching side of the door. Based on interview at the time of observation, the Maintenance Supervisor acknowledged the corridor door to the aforementioned hazardous area failed to self-close and latch into the door frame.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. Interface equipment such as elevator recall and elevator shutdown shall be installed, tested and maintained in accordance with NFPA 72. NFPA 72, 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. Section 14.6.2.4 states a record of all inspections, testing and maintenance shall be provided that includes all applicable information requested in Figure 14.6.2.4. This deficient practice could affect over three patients, staff and visitors.

Findings include:

Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, electronic shunt trip fire alarm system interface equipment monitoring devices for Elevator 2 was listed as "out" on control panels in the first floor emergency command center for this high-rise building. Based on interview at the time of the observations, the Executive Physical Plant Director agreed the fire alarm system interface equipment for Elevator 2 was not working properly and is scheduled for repair.









36620

Based on record review, observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Executive Physical Plant Director on 05/20/19 at 11:15 a.m., the initial fire alarm system testing report was dated 03/11/19 by SafeCare. The report indicated "all tested devices are working properly. Based on observations during a tour of the facility, the following was noticed:
1) Room W 534 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
2) Room W 551 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
3) Room W 552 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
4) Room E 534 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
5) Room E 562 had a smoke detector mounted on the ceiling of the room with the initial orange dust cover still installed on the detector.
6) The west stairwell smoke detector mounted on the ceiling of the landing had the initial orange dust cover still installed on the detector.
Based on interview at the time of each observation, the Maintenance Supervisor acknowledged each above mentioned smoke detector as having the orange dust cover as being in place on the smoke detector, and stated that she would have the dust cover removed by her staff as soon as she could have them get the necessary items to have them remove the dust covers.

Based on observation and interview, the facility failed to ensure 3 of over 50 rooms were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 18.3.6.5. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5 (see also 18.2.5.4), unless otherwise permitted by one of the following:
(1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that all of the following criteria are met:
(a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(d) The space does not obstruct access to required exits.
(2) Waiting areas shall be permitted to be open to the corridor, provided that all of the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 ft2 (55.7 m2).
(b) Each area is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.
(3)*This requirement shall not apply to spaces for nurses' stations.
(4) Gift shops not exceeding 500 ft2 (46.4 m2) shall be permitted to be open to the corridor or lobby.
(5) In a limited care facility, group meeting or multipurpose therapeutic spaces shall be permitted to open to the corridor, provided that all of the following criteria are met:
(a) The space is not a hazardous area.
(b) The space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the space is arranged and located to allow direct supervision by the facility staff from the nurses' station or similar location.
(c) The space does not obstruct access to required exits.
(6) Cooking facilities in accordance with 18.3.2.5.3.
This deficient practice could affect over 20 patients and staff.

Findings include:

Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the following was noted:
a. A non fire rated rolling door was noted in the corridor wall to the Nourishment Room identified as Room E353 on the third floor. The Nourishment Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
b. A non fire rated rolling door was noted in the corridor wall to the Med Room on the third floor. The Med Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
c. A non fire rated rolling door was noted in the corridor wall to the Nutrition Room on the seventh floor. The Nutrition Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
Based on interview at the time of observations, the Executive Physical Plant Director agreed the aforementioned rooms were open to the corridor and not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.

Based on observation and interview, the facility failed to ensure closets in 4 of over 5 alcoves for drinking water dispensers were provided with an automatic sprinkler to ensure sprinkler coverage in all portions of the building. This deficient practice could affect over 20 patients, staff and visitors.

Findings include:

Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the alcoves for drinking water dispensers on the third floor near the southwest dining area, the west alcove on the third floor, the alcove by Room E651 on the sixth floor and the alcove on the seventh floor in the northeast wing were not sprinklered. Based on interview at the time of the observations, the Physical Plant Director agreed the aforementioned locations did not have sprinkler coverage.

Based on record review and interview, the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.2.4.2 states gauges on dry pipe sprinkler systems shall be inspected weekly to ensure that normal air and water pressures are being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff, and visitors within the facility.

Findings include:

Based on review of the facility's sprinkler vendor "Report of Inspection" documentation for the inspection dated August 15, 2018 with the Executive Physical Plant Director during record review from 9:00 a.m. to 11:30 a.m. on 05/20/19, weekly dry sprinkler system gauge inspection documentation from the facility open date of 03/20/2019 to the present was not available for review. Monthly wet sprinkler system gauge inspection documentation from the facility open date was also not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 12 months of the most recent 12 month period was not available for review. Based on interview at the time of record review, the Executive Physical Plant Director acknowledged sprinkler system gauge and control valve inspection documentation for the aforementioned weekly and monthly periods was not available for review.

Based on observation and interview, the facility failed to ensure 1 of 55 portable fire extinguishers was given maintenance at periods not more than one year apart. NFPA 10, the Standard for Portable Fire Extinguishers, at Section 7.3.1.1.1 requires that fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification. Section 3.3.15 defines extinguisher maintenance as a thorough examination of the fire extinguisher that is intended to give maximum assurance that a fire extinguisher will operate effectively and safely and to determine if physical damage or condition will prevent its operation, if any repair or replacement is necessary, and if hydrostatic testing or internal maintenance is required. Section 7.3.3 states each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed, identifies the person performing the work, and identifies the name of the agency performing the work. This deficient practice could affect over 10 patients and staff.

Findings include:

Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19, the portable ABC type fire extinguisher installed in the Nourishment Room identified as E764 on the seventh floor had no tag or label securely attached that indicated the month and year maintenance was performed, identifies the person performing the work, and identifies the name of the agency performing the work. Based on interview at the time of the observations, the Executive Physical Plant Director agreed annual inspection documentation within the most recent twelve month period for the aforementioned portable fire extinguisher was not available for review.

Based on observation and interview, the facility failed to ensure 3 of over 50 rooms were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 18.3.6.1(1). LSC 18.3.6.1(1) states that spaces shall be permitted to be unlimited in area and open to the corridor provided that all of the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, and hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurse's station or a similar space.
(d) The space does not obstruct access to required exits.
This deficient practice could affect over 20 patients and staff.

Findings include:

Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the following was noted:
a. A non fire rated rolling door was noted in the corridor wall to the Nourishment Room identified as Room E353 on the third floor. The Nourishment Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
b. A non fire rated rolling door was noted in the corridor wall to the Med Room on the third floor. The Med Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
c. A non fire rated rolling door was noted in the corridor wall to the Nutrition Room on the seventh floor. The Nutrition Room was not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.
Based on interview at the time of observation, the Executive Physical Plant Director agreed the aforementioned rooms were open to the corridor and not provided with an electrically supervised automatic smoke detection system or provided with direct supervision by a nurse's station or a similar space.

Based on observation and interview, the facility failed to ensure openings through 2 of 8 ceiling smoke barriers were protected to maintain the fire resistance rating of the smoke barrier. LSC 18.3.7.3 states smoke barriers shall be constructed in accordance with Section 8.5 and shall have a minimum 1-hour fire resistance rating unless, otherwise permitted. This deficient practice could affect patients and staff.

Findings include:

Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19 and from 9:30 a.m. to 12:00 p.m. on 05/21/19, the alcoves for drinking water dispensers on the third floor near the west dining area and on sixth floor by Room E651 did not have a ceiling smoke barrier which exposed the unprotected decking of the floor above. Based on interview at the time of the observations, the Executive Physical Plant Director agreed the aforementioned locations did not have a ceiling smoke barrier which exposed the unprotected decking of the floor above and did not maintain the 1-hour fire resistance rating of the ceiling smoke barrier.

Based on record review, observation and interview; the facility failed to ensure 5 of over 22 smoke barrier doors were provided with an astragal, rabbet or bevel. This deficient practice could affect over 30 residents, staff and visitors in the vicinity of the fire barrier door set by the new administrative office wing.

Findings include:

Based on review of facility blueprint documentation with the Executive Physical Plant Director during record review from 9:30 a.m. to 11:30 a.m. on 05/20/19, each story is divided into at least two smoke compartments from outside wall to outside wall with smoke barrier walls and doors. Floor plans were provided by the facility indicating the location of smoke barrier walls and doors on each floor. Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, the following sets of swinging smoke barrier doors in smoke barrier walls were not equipped with an astragal, rabbet or bevel at the meeting edges of the steel doors which caused a gap in between the meeting edges of the doors when in the fully closed position:
a. In the first floor lobby by the center elevator lobby.
b. In the south corridor on the first floor by the locker room.
c. On the third floor by the center stairwell.
d. On the sixth floor near the center stairwell.
e. On the seventh floor near the center stairwell and by Room W732.
Based on interview at the time of the observations, the Executive Physical Plant Director agreed the aforementioned smoke barrier door sets were not provided with an astragal, rabbet or bevel.

Based on record review, observation and interview; the facility failed to ensure fire-rated vision panels were installed in 1 of over 22 smoke barrier doors in the facility. LSC Section 18.3.7.10 states vision panels in doors in smoke barriers shall be of fire-rated glazing in approved frames. This deficient practice could affect over 10 patients, staff and visitors.

Findings include:

Based on review of facility blueprint documentation with the Executive Physical Plant Director during record review from 9:30 a.m. to 11:30 a.m. on 05/20/19, each story is divided into at least two smoke compartments from outside wall to outside wall with smoke barrier walls and doors. Floor plans were provided by the facility indicating the location of smoke barrier walls and doors on each floor. Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, a fire-rated vision panel was not installed in the single leaf smoke barrier door for Room C300 in the smoke barrier wall near the center elevator lobby on the third floor. The door was identified as being in the smoke barrier wall based on the review of facility blueprint documentation and the provided floor plans. Based on interview at the time of the observations, the Executive Physical Plant Director agreed the door to Room C300 was in the third floor smoke barrier wall and was not provided with a fire-rated vision panel.

Based on observation and interview, the facility failed to ensure 1 of over 100 electrical junction boxes were maintained in a safe operating condition. LSC 19.5.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition. NFPA 70, 2011 Edition, Article 314.28(c) requires all junction boxes shall be provided with covers compatible with the box. This deficient practice could affect up to 6 maintenance staff working in the basement.

Findings include:

Based on observation with the Maintenance Supervisor during the tour of the facility at 11:02 a.m. on 05/21/19, there was a junction box that measured approximately 12 inches by 12 inches square in the basement ceiling that had exposed wires hanging from it. The cover plate was sitting on a piece of machinery in close proximity to the junction box. Based on interview at the time of the observation, the Maintenance Supervisor acknowledged the missing cover plate on the junction box, and thought someone was currently working on it. There was no ladder, toolboxes, or personnel in the immediate area to support this thought.

Based on record review, interview and observation, the facility failed to maintain testing of 5 of 5 elevator firefighter recall in accordance with 9.4.6, Elevator Testing. LSC 9.4.6.2 states that all elevators with firefighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on record review with the Executive Physical Plant Director on 05/21/19 at 9:00 a.m., documentation for the monthly firefighter recall testing was not available for review for all five of the facility elevators. Based on observations with the Executive Physical Plant Director and the Maintenance Supervisor during a tour of the facility from 11:00 a.m. to 3:04 p.m. on 05/20/19 and again on 05/21/19 from 9:02 a.m. to 12:18 p.m., the facility had a total of five elevators, all with the firefighter recall ability. Based on interview at the time of record review, the Executive Physical Plant Director acknowledged the lack of documentation for monthly firefighter emergency operations recall testing on all facility elevators.

Based on observation, records review, and interview, the facility failed to ensure annual inspection and testing of 33 of 33 fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1 communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all occupants.

Findings include:

Based on record review with the Executive Physical Plant Director on 05/21/19 at 9:00 a.m., no annual inspection of the fire door assembly documentation was available for review. Based on observations with the Executive Physical Plant Director and the Maintenance Supervisor during a tour of the facility from 11:00 a.m. to 3:04 p.m. on 05/20/19 and again on 05/21/19 from 9:02 a.m. to 12:18 p.m., there were at least 21 sets of fire door assemblies throughout the facility that needed to have a documented annual fire door assemble inspection. Based on interview at the time of records review, the Executive Physical Plant Director stated an annual inspection was not conducted for the fire door assemblies and confirmed the aforementioned doors were all in a one or two hour fire barrier.

Based on record review, observation and interview; the facility failed to ensure documentation of electrical outlet receptacle testing at all patient bed locations in patient sleeping rooms which have hospital-grade receptacles was available for review in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.4.1.1 states hospital-grade receptacles testing shall be performed after initial installation, replacement or servicing of the device. Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). Section 6.3.4.2.1.2 states, at a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This could affect over three patients.

Findings include:

Based on record review with the Executive Physical Plant Director during record review from 9:30 a.m. to 11:30 a.m. on 05/20/19, documentation of hospital-grade receptacle testing after initial installation was not available for review. Based on observations with the Executive Physical Plant Director during a tour of the facility from 12:40 p.m. to 3:10 p.m. on 05/20/19, hospital-grade receptacles were installed at patient bed locations in Rooms E718, W715 and W716 on the seventh floor. Based on interview at the time of the record review and of the observations, the Executive Physical Plant Director agreed documentation of hospital-grade receptacle testing after initial installation was not available for review.


36620

Based on record review, observation and interview; the facility failed to ensure documentation of electrical outlet receptacle testing at all patient bed locations in all resident sleeping rooms was available for review in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.4.1.1 states hospital-grade receptacles testing shall be performed after initial installation, replacement or servicing of the device. Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). Section 6.3.4.2.1.2 states, at a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This could affect all patients.

Findings include:

Based on record review with the Executive Physical Plant Director on 05/20/19 at 11:15 a.m. and during the exit interview on 05/21/19 at 12:25 p.m., documentation of hospital-grade receptacle testing after initial installation was not available for review. Based on observations with the Executive Physical Plant Director and the Maintenance Supervisor during a tour of the facility from 11:00 a.m. to 3:04 p.m. on 05/20/19 and again on 05/21/19 from 9:02 a.m. to 12:18 p.m., hospital-grade receptacles were installed at all resident bed locations in all resident sleeping rooms. Based on interview at the time of the exit interview on 05/21/19 at 12:25 p.m., the Executive Physical Plant Director agreed documentation of hospital-grade receptacle testing after initial installation documentation was not available for review.

Based on observation and interview, the facility failed to ensure 1 of 1 remote manual stops for the facility's emergency generator was labeled in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 15.5.1.3 states emergency generators and standby power system, where required for compliance with this code, shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 2010 edition, 5.6.5.6 states all installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. The remote manual stop station shall be labeled. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Executive Physical Plant Director during a tour of the facility from 9:30 a.m. to 12:00 p.m. on 05/21/19, the facility's remote manual stop which was located near the emergency generator outside the facility on the exterior wall of the ambulance bay on the west side of the facility was not labeled. Manufacturer's nameplate information affixed to the diesel fired emergency generator indicated it was rated at 1000 kW. Based on interview at the time of the observations, the Executive Physical Plant Director identified the location of the remote manual stop and agreed the remote manual stop station was not labeled.