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Based on observation, the facility failed to provide corridor walls that resisted the passage of smoke for one wall in the facility. This could potentially affect approximately 50 patients, in the outpatient clinic areas of the Hospital during the survey, in the event of a smoke or fire emergency in the affected area..

Findings: During a tour of the facility on 12/15/11 at 9:00am, the corridor at the Outpatient clinic area had a Pelican State Bank teller window in the corridor wall that is open to the corridor and did not resist the passage of smoke.

Actual NFPA Standard: 19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

Based on observation, the facility failed to provide corridor doors that were positive latching for 1 door on the 4th floor area. This could potentially affect 20 patients in the 4th floor area in the event of a smoke and fire emergency by allowing smoke and fire to penetrate the corridor door.

Findings: During a tour of the facility on 12/15/11 at 11:00am, the door to the Doctors Charting room on the 4th floor by SICU Waiting room was observed to not be positive latching and appeared to have had the positive latching hardware removed from the door.

Actual NFPA Standard: 19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Based on observation, the facility failed to provide exit corridors that were free of all obstructions for the full use of the corridor for 2 of 5 smoke compartments on the 3rd floor area. This could potentially affect 30 patients in the 3rd floor clinic area of the Hospital in the event of an emergency requiring the full evacuation of the facility, patients and staff could become injured due to the obstructions.

Findings: During a tour of the 3rd floor on 12/15/11 at 10:30am, the 3rd floor clinic area of the Hospital was observed to have 4 of the 6 charting station down on one Hall and 5 of 6 charting station down on the the other hall. None of the charting stations were in use at the time of survey and extended out approximately 18 inches from the wall on both sides of the corridor reducing the corridor width by approximately 36 inches.

Actual NFPA Citation: 7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on record review, the facility failed to provide a Fire Alarm system that is in reliable operating condition for 1 of 1 Fire Alarm systems. This could potentially affect 104 of 104 patients in the facility at the time of survey in the event of a smoke or fire emergency and the Fire Alarm System did not function as designed.

Findings: During a review of records of the Fire Alarm system on 12/15/11 at 8:00am, the Fire alarm system was observed to have a Yellow Impairment Tag affixed to it due to several bad Chime/Strobes in the facility, devices in incorrect location and the elevator recall not functioning correctly. The Annual Fire alarm certification was conducted 12/8/11 and the above deficiencies were noted.

Actual NFPA Standard: 9.6.1.4
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Based on observation, the facility failed to provide corridor walls that resisted the passage of smoke for one wall in the facility. This could potentially affect approximately 50 patients, in the outpatient clinic areas of the Hospital during the survey, in the event of a smoke or fire emergency in the affected area..

Findings: During a tour of the facility on 12/15/11 at 9:00am, the corridor at the Outpatient clinic area had a Pelican State Bank teller window in the corridor wall that is open to the corridor and did not resist the passage of smoke.

Actual NFPA Standard: 19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

Based on observation, the facility failed to provide corridor doors that were positive latching for 1 door on the 4th floor area. This could potentially affect 20 patients in the 4th floor area in the event of a smoke and fire emergency by allowing smoke and fire to penetrate the corridor door.

Findings: During a tour of the facility on 12/15/11 at 11:00am, the door to the Doctors Charting room on the 4th floor by SICU Waiting room was observed to not be positive latching and appeared to have had the positive latching hardware removed from the door.

Actual NFPA Standard: 19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Based on observation, the facility failed to provide exit corridors that were free of all obstructions for the full use of the corridor for 2 of 5 smoke compartments on the 3rd floor area. This could potentially affect 30 patients in the 3rd floor clinic area of the Hospital in the event of an emergency requiring the full evacuation of the facility, patients and staff could become injured due to the obstructions.

Findings: During a tour of the 3rd floor on 12/15/11 at 10:30am, the 3rd floor clinic area of the Hospital was observed to have 4 of the 6 charting station down on one Hall and 5 of 6 charting station down on the the other hall. None of the charting stations were in use at the time of survey and extended out approximately 18 inches from the wall on both sides of the corridor reducing the corridor width by approximately 36 inches.

Actual NFPA Citation: 7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on record review, the facility failed to provide a Fire Alarm system that is in reliable operating condition for 1 of 1 Fire Alarm systems. This could potentially affect 104 of 104 patients in the facility at the time of survey in the event of a smoke or fire emergency and the Fire Alarm System did not function as designed.

Findings: During a review of records of the Fire Alarm system on 12/15/11 at 8:00am, the Fire alarm system was observed to have a Yellow Impairment Tag affixed to it due to several bad Chime/Strobes in the facility, devices in incorrect location and the elevator recall not functioning correctly. The Annual Fire alarm certification was conducted 12/8/11 and the above deficiencies were noted.

Actual NFPA Standard: 9.6.1.4
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.