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OSF SAINT LUKE MEDICAL CENTER
Number of Exits - Corridors
Tag No.: K0252
Based on observation during the survey walk-through, not all exit corridors are provided with at least two remote egress paths. This deficient practice could affect patients, staff, and visitors in the building because their ability to exit the building under emergency conditions if compliant egress paths are not available to them.
Findings include:
On March 6, 2018 at 11:16 AM, while accompanied by the LHT, observation determined that building occupants are directed, from the southwest, into the First Floor Emergency Department suite as prohibited by 19.2.5.4, because an exit sign is located directly above the southwest pair of doors into the suite.
Fire Alarm - Control Functions
Tag No.: K0344
Based on observation during the survey walk-through, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required.
Findings include:
On March 6, 2018, while accompanied by the LHT, observation determined that rooms, housing fire alarm system NAC Panels, which are not continuously occupied, lack smoke detectors required by NFPA 72 2010 10.15. Locations observed include:
A. 10:57 AM: First Floor Electrical Room 1017.
B. 12:45 PM: First Floor Electrical Room 1224.
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on document review, the facility failed to inspect, test, and maintain its fire alarm system. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate under emergency conditions if the fire alarm system is not properly maintained.
Findings include:
On March 6, 2018 at 1:49 PM, while accompanied by the LHT, document review determined the facility did not conduct an annual test of Smoke Detector L2D86, as required by NFPA 72 2010 Table 14.4.5.6 and Table 14.5.15(g), because two sequential reports from the fire alarm testing vendor indicated that this device (located in Patient Sleeping Room 1225) had been excluded. Vendor test reports in which this device was identified as having been excluded include:
A. March 22, 2017.
B. June 14, 2017.