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Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facilities Services Supervisor on 01/31/19 at 11:07 a.m., the wet system gauges and control valves were inspected quarterly instead of monthly. Based on interview at the time of record review, the Facilities Services Supervisor confirmed the lack of documentation.

Based on observation and interview, the facility failed to ensure the penetration in 1 of 1 ASC/HC Outpatient Surgery fire barrier wall was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect staff and up to 12 patients.

Findings include:

Based on an observation with the Maintenance Director on 01/30/19 at 2:35 p.m., the ASC/HC Outpatient Surgery occupancy separation fire barrier had a half inch gap around a PVC pipe above the drop ceiling. Based on interview at the time of observation, the Maintenance Director confirmed the penetration and provided the measurement.

Based on record review, observation and interview, the facility failed to ensure 1 of 1 1st floor ASC/ Business fire barrier occupancy separation wall was protected in accordance with 19.1.3.3. LSC 19.1.3.3 states sections of health care facilities shall be permitted to be classified as other occupancies, provided they meet all the of following conditions: (2) they are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. LSC 8.3.3.1 states openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies. Table 8.3.4.2 requires 2 hour fire rated walls and partitions to have fire door assemblies with a rating of at least 1 1/2 hours fire rating. This deficient practice could affect staff and up to 12 patients.

Findings include:

Based on record review with the Maintenance Director on 01/30/19, the facility site plans indicated a two hour occupancy separation wall between the 1st floor ASC Outpatient Surgery and the Business occupancy. Based on observation at 2:44 p.m., two separate penetrations around wires in the ASC/Business fire barrier above the drop ceiling. Based on interview at the time of observation, the Maintenance Director confirmed the occupancy separation fire barrier and the two penetrations.

Based on observation and interview, the facility failed to maintain 1 of 4 Imaging corridors from obstructions per 19.2.1 LSC 19.2.1 states that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. LSC 7.1.10. 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. LSC 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof. This deficient practice could affect staff and at least 4 patients.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 1:09 p.m., a trash can was in the Imaging corridor. Based on interview at the time of observation, the Maintenance Director acknowledged that impediments such as the trash can was a potential impediment to full use of the means of egress access corridors.

Based on observation, the facility failed to meet 1 of 4 Imaging corridors clear width requirement exception per 19.2.3.4(5). LSC 19.2.3.4(5) requires where the corridor width is at least 8 feet, projections into the required width shall be permitted for fixed furniture. LSC 19.2.3.4(5)(a) the fixed furniture is securely attached to the floor or to the wall. This deficient practice could affect staff and up to 4 patients.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 1:09 p.m., two chairs were located in the Imaging corridor. When tested, the each chair was able to be moved around the corridor. Based on interview at the time of observation, the Maintenance Director acknowledged the chairs were not secured to the floor or wall.

Based on record review and interview; the facility failed to install exit signage in 1 of 3 ED exits in the facility in accordance with LSC 7.10. LSC 7.10.1.2.1 exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. This deficient practice could affect staff and at least 10 patients.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 12:47 p.m., the ED exit door near the exterior exit contained five separate signs stating "STOP" with an exit sign above the door. Based on interview at the time of observation, the Maintenance Director confirmed the conflicting exit directions.

1. Based on observation and interview, the facility failed to maintain protection of 1 of 1 Surgery Soiled Utility room in accordance of 19.3.2. This deficient practice could affect staff and up to 5 patients.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 1:20 p.m., the Surgery Utility room corridor door failed to positively latch into the frame. Based on interview at the time of observation, the Maintenance Director confirmed the soiled linen collection room failed to fully close and positively latch into the frame.

2. Based on observation and interview, the facility failed to maintain protection of 1 of 1 2nd floor Mechanical room in accordance of 19.3.2. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 10:53 a.m., the 2nd floor Mechanical room contained fuel-fired equipment. The corridor double doors contained an astragal and a coordinating device. When tested, the coordinator failed to prevent the door with an astragal to close last. Based on interview at the time of observation, the Maintenance Director confirmed the coordinating device was unable to ensure the astragal door closed last.

Based on observation and interview, the facility failed to ensure materials used as an interior finish on the ceiling in 1 of 1 2nd floor Center corridor had a flame spread rating of Class A or Class B in accordance with 19.3.3.1. LSC 101 10.2.3.4 states products required to be tested in accordance with ASTM E 84, Standard Test Method For Surface Burning Characteristics of Building Materials or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect staff and at least 15 patients.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 11:01 a.m., the 2nd floor Center corridor had wood panels on the lower third of the walls. Based on interview at the time of observation, the Maintenance Director was unable to provide interior finish documentation for a flame spread classification of Class A or B for the aforementioned interior finishes.

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. 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, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect staff and up to 5 patients.

Findings include:

Based on observation with the Maintenance Director on 1/30/19 between 9:32 a.m. and 2:47 p.m., the following was locations had a smoke detector within twelve inches from an HVAC vent:
a) 2nd floor Med Surge Storage room
b) ENDO Short Stay room 1
c) ENDO Short Stay room 2
d) ENDO Short Stay room 11
e) ENDO Short Stay room 12
Based on interview at the time of each observation, the Maintenance Director acknowledged each smoke detectors were located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening.

2. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. 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, 17.7.3.1.2 requires the location and spacing requirements shall be based on six factors. (2) Ceiling height. (5) Compartment ventilation. NFPA 72 17.7.3.2.1 spot-type smoke detectors shall be located on the ceiling, or, if on a sidewall, between the ceiling and 12 inches down from the ceiling to the top of the detector. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 01/31/19 at 9:52 a.m., the Elevator Machine room contained a smoke detector within four feet from the ceiling. Based on interview at the time of observation, the Maintenance Director confirmed the smoke detector location and provided the measurement.

1. Based on observation and interview, the facility failed to install 1 of 1 sprinkler head deflectors within 12 inches of the ceiling. NFPA 13, 2010 Edition, Section 8.6.4.1.1.1 under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches throughout the area of coverage of the sprinkler. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 10:50 a.m., the 2nd floor Telecommunications room contained one sprinkler head. The sprinkler head deflector was estimated at eight feet from the ceiling. Based on interview at the time of observation, the Maintenance Director confirmed the drop ceiling was mostly removed and planned on moving the sprinkler head.

2. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms in accordance with NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 8.15.5.3 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. A.8.15.5.3 ASME A17.1, Safety Code for Elevators and Escalators, requires the shutdown of power to the elevator upon or prior to the application of water in elevator machine rooms or hoistways. This shutdown can be accomplished by a detection system with sufficient sensitivity that operates prior to the activation of the sprinklers (see also NFPA72, National Fire Alarm and Signaling Code). As an alternative, the system can be arranged using devices or sprinklers capable of effecting power shutdown immediately upon sprinkler activation, such as a waterflow switch without a time delay. This alternative arrangement is intended to interrupt power before significant sprinkler discharge.

LSC Section 9.7.3. allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. The elevator equipment room was located in the basement and could affect any number of staff.

Findings include:

Based on an observation with the Maintenance Director on 01/31/19 at 9:52 a.m., the elevator equipment room lacked sprinkler coverage. Based on interview at the time of observation, the Maintenance Director confirmed the fully sprinklered building contained an elevator equipment room which did not contain any sprinkler protection.

1. Based on observation and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with 19.3.5.3. NFPA 25, 2011 Edition, 5.3.2.1 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 between 9:32 a.m. and 2:47 p.m., the LL-3 stairwell sprinkler gauge did not have a manufacturer date or recalibration date documented. Then again, the 2nd floor stairwell #1 sprinkler gauge did not have a manufacturer date or recalibration date documented. Based on interview at the time of observation, the Maintenance Director confirmed the gauges had no install/recalibration date.

2. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facilities Services Supervisor on 01/30/19 at 11:07 a.m., the wet system gauges and control valves were inspected quarterly instead of monthly. Based on interview at the time of record review, the Facilities Services Supervisor confirmed the lack of documentation.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 4 3rd floor smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect staff and at least 8 patients.

Findings include:

Based on observations with the Maintenance Director on 01/30/19 at 10:06 a.m., a half inch gap inside conduit in the 3rd floor Mother Baby East Wing smoke barrier above the drop ceiling.
Based on interview at the time of observation, the Maintenance Director acknowledged the aforementioned penetrations and provided the measurement.

Based on observation and interview, the facility failed to ensure 1 of 3 Lower level sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC, Section 19.3.7.8 requires that doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, Section 8.5.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 01/31/19 at 9:40 a.m., the D Hall set of smoke barrier doors had a one quarter inch gap along the center where the doors came together in the closed position. Based on interview at the time of observation, the Environmental Services Director and the Maintenance Technician #1 acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to provide 1 of 1 2nd floor Med Surge Ortho Soiled Utility room which contained a laundry chute with self-closing openings. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 10:58 a.m., the 2nd floor Med Surge Ortho laundry chute door was open when discovered. The chute door can be opened to the point the door no longer self-closes. Based on interview at the time of observation, the Maintenance Director confirmed the laundry chute door was left open.

Based on observation and interview, the facility failed to ensure 3 of 3 multiplug and 9 of 9 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff and at least 22 patients.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 between 11:04 a.m. and 2:17 p.m., the following was discovered:
a) a surge protector was powering a refrigerator in the 2nd floor Education office
b) a surge protector was powering another surge protector powering a phone charger in 2nd floor MME office
c) an extension cord was powering a refrigerator in the 2nd floor DOB
d) an extension cord was powering a lamp and a surge protector was powering a refrigerator in the OB On-call room 2
e) a surge protector was powering a microwave in the Security office
f) a surge protector was powering another surge protector powering a microwave in the Case Management office
g) three separate multiplug adapters were powering computer components in the PACU Pediatric room
Based on interview at the time of each observation, the Maintenance Director confirmed each wiring situation and attempted to fix the wiring after observation.