HospitalInspections.org

Observations revealed that the fire rated door between the hospital and the ambulance garage is not in accordance with NFPA 101 "The Life Safety Code" (2000 edition) section 18.1.1.4.1. This deficient practice could negatively affect all of the residents, staff and visitors in the event of a fire by allowing fire and smoke to pass from the garage into the hospital.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations of the occupancy separation walls revealed that the 1 1/2 -hour fire door's north leaf between the ambulance garage and the ER, drags on the floor and the door sticks in the open position.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

Observations revealed that the facility has failed to maintain various corridor doors in accordance with NFPA 101 Life Safety Code 2000 edition, Section 18.3.6.3. This deficient practice could affect the safety of all residents, staff and visitors, if smoke where allowed to enter the exit access corridor making it untenable.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations and testing of various corridor doors revealed that the recovery room doors are no longer latching (the panic hardware was toggled in the released position).

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference

Observations revealed that the exit signage in the Marketing and Education suite is not in accordance with the "Life Safety Code" NFPA 101 (2000 edition) section 7.10.1.4. Lack of proper exit signage could delay egress by the staff, and guests in this suite of rooms.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations of the Marketing and Education suite revealed that the exits are not marked.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

Observations revealed that 4 of 25 hazardous areas observed are not in accordance with NFPA 101 "The Life Safety Code 2000 edition (LSC) section 18.3.2 This deficient practice could allow the products of combustion to travel throughout the building if a fire occurs within these rooms, which could negatively impact all of the residents,staff and visitors.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations revealed that:
1) The 2nd floor south utility room corridor door did not latch,
2) The storage room 2069 corridor door did not latch,
3) The storage room 2071A corridor doors did not latch, and
4) The large basement storage room (old shell space) has a double leaf door that does not have latches on the door leafs.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

Observations revealed that the exiting from 2 spaces is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition section 18.2.5.2. These deficiencies could trap staff using these areas if a fire occurs in the basement storage room.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations of the storage rooms revealed that the large south basement storage room (old shell space):

1) Has an office for the med tech which has it's only exit through the storage room which does not comply with NFPA 101 section 18.2.5.5, and

2) The large south basement storage room is over 2500 sq ft. but has only 1 exit and not 2, which are require by NFPA 101 section 18.2.5.3.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

A review of facility documentation revealed that testing of the facility smoke detectors does not meet the requirements of NFPA 72 "The National Fire Alarm Code" (1999 edition). This deficient practice could affect all residents, staff and visitors, if a smoke detector fails to alarm during a fire emergency.

Findings include:
Prior to the facility tour on August 18, 2011, at approximately 9:35 am, a review of the smoke detector maintenance logs for Lakewood Health Systems revealed that no documentation that the smoke detectors have had their sensitivity tested in accordance with NFPA 72 "The National Electrical Code" 1999 edition section 7-.2.2 was available.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

Observations revealed that an area of the facility may not be sprinkler protected to the proper density required by the communities protected and in accordance with NFPA 13 The Installation of Sprinkler Systems. 1999 edition. Lack of the proper automatic sprinkler installed to protect the communities involved could allow the fire to spread into the rest of the building which would negatively impact all the residents, staff, and guests of the facility.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations revealed that the basement shell space is now used for storage of various combustibles including x-ray film records and no documentation of the sprinkler system being updated to the proper sprinkler density for the commodities stored within the room was available for review.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

A review of records and an interview with staff revealed that the testing documentation of the battery power emergency lighting was not available as required by NFPA 99 Healthcare Facilities 1999 edition. Lack of testing of emergency lighting could allow them to fail which would negatively impact the patients in the area the lights protect.

Findings include:
A review of facility documentation prior to the facility tour on August 18, 2011, at approximately 9:20 am revealed that the documentation of the monthly and annual testing of the battery operated emergency lighting in the ORs was not available.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

Observations revealed that the fire rated door between the hospital and the ambulance garage is not in accordance with NFPA 101 "The Life Safety Code" (2000 edition) section 18.1.1.4.1. This deficient practice could negatively affect all of the residents, staff and visitors in the event of a fire by allowing fire and smoke to pass from the garage into the hospital.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations of the occupancy separation walls revealed that the 1 1/2 -hour fire door's north leaf between the ambulance garage and the ER, drags on the floor and the door sticks in the open position.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

Observations revealed that the facility has failed to maintain various corridor doors in accordance with NFPA 101 Life Safety Code 2000 edition, Section 18.3.6.3. This deficient practice could affect the safety of all residents, staff and visitors, if smoke where allowed to enter the exit access corridor making it untenable.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations and testing of various corridor doors revealed that the recovery room doors are no longer latching (the panic hardware was toggled in the released position).

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference

Observations revealed that the exit signage in the Marketing and Education suite is not in accordance with the "Life Safety Code" NFPA 101 (2000 edition) section 7.10.1.4. Lack of proper exit signage could delay egress by the staff, and guests in this suite of rooms.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations of the Marketing and Education suite revealed that the exits are not marked.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

Observations revealed that 4 of 25 hazardous areas observed are not in accordance with NFPA 101 "The Life Safety Code 2000 edition (LSC) section 18.3.2 This deficient practice could allow the products of combustion to travel throughout the building if a fire occurs within these rooms, which could negatively impact all of the residents,staff and visitors.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations revealed that:
1) The 2nd floor south utility room corridor door did not latch,
2) The storage room 2069 corridor door did not latch,
3) The storage room 2071A corridor doors did not latch, and
4) The large basement storage room (old shell space) has a double leaf door that does not have latches on the door leafs.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

Observations revealed that the exiting from 2 spaces is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition section 18.2.5.2. These deficiencies could trap staff using these areas if a fire occurs in the basement storage room.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations of the storage rooms revealed that the large south basement storage room (old shell space):

1) Has an office for the med tech which has it's only exit through the storage room which does not comply with NFPA 101 section 18.2.5.5, and

2) The large south basement storage room is over 2500 sq ft. but has only 1 exit and not 2, which are require by NFPA 101 section 18.2.5.3.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

A review of facility documentation revealed that testing of the facility smoke detectors does not meet the requirements of NFPA 72 "The National Fire Alarm Code" (1999 edition). This deficient practice could affect all residents, staff and visitors, if a smoke detector fails to alarm during a fire emergency.

Findings include:
Prior to the facility tour on August 18, 2011, at approximately 9:35 am, a review of the smoke detector maintenance logs for Lakewood Health Systems revealed that no documentation that the smoke detectors have had their sensitivity tested in accordance with NFPA 72 "The National Electrical Code" 1999 edition section 7-.2.2 was available.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

Observations revealed that an area of the facility may not be sprinkler protected to the proper density required by the communities protected and in accordance with NFPA 13 The Installation of Sprinkler Systems. 1999 edition. Lack of the proper automatic sprinkler installed to protect the communities involved could allow the fire to spread into the rest of the building which would negatively impact all the residents, staff, and guests of the facility.

Findings include:
During the facility tour on August 18, 2011, between 09:30 am and 11:45 am, observations revealed that the basement shell space is now used for storage of various combustibles including x-ray film records and no documentation of the sprinkler system being updated to the proper sprinkler density for the commodities stored within the room was available for review.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.

A review of records and an interview with staff revealed that the testing documentation of the battery power emergency lighting was not available as required by NFPA 99 Healthcare Facilities 1999 edition. Lack of testing of emergency lighting could allow them to fail which would negatively impact the patients in the area the lights protect.

Findings include:
A review of facility documentation prior to the facility tour on August 18, 2011, at approximately 9:20 am revealed that the documentation of the monthly and annual testing of the battery operated emergency lighting in the ORs was not available.

The Director of Maintenance (SG) and Maintenance Man (BG) verified this finding during the inspection and at the exit conference.