HospitalInspections.org

Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect all occupants of the facility by allowing fire to spread more quickly and decreasing the time available for evacuation.

Findings include:

1. On 8/11/10 at approximately 11:00 AM it was observed that the facilities 2 north wing was Type II (000) construction. The 2 north wing is actually three stories above the lowest fire department access. Type II (000) construction is not permitted for a partially sprinkled three story building. The wing currently not being used for a patient care area, but has not been renovated for other uses. This observation was verified by the facilities Maintenance Supervisor.





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Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect 10% of the occupants of the facility if a fire went undetected in a space that is open to the corridor.

Findings include:

1. On 8/10/10 at approximately 10:25 AM, it was observed that the emergency department triage area has had the door removed, and there was a 4 foot by 4 foot opening in the wall causing the space to be open to the corridor of the emergency department. The triage area does not meet the requirements for an open space because there is not automatic smoke detection installed in the area. This observation was verified by the facilities Maintenance Manager.


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Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility by allowing heat and fire gases to escape the hazardous area and enter the corridor system during a fire emergency.

Findings include:

1. On 8/10/10 at approximately 11:10 AM, the basement soiled utility room door (near loading dock) failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

2. On 8/10/10 at approximately 10:43 AM, the first floor electrical closet near the main tower elevators was observed to have unprotected electrical conduits passing through the floor and corridor wall. This observation was verified by the facilities Maintenance Manager.

3. On 8/10/10 at approximately 10:35 AM, the first floor storage room 1404J was observed to have a self closing device on the door that locks in the open position and does not automatically release. This observation was verified by the facilities Maintenance Manager.

4. On 8/10/10 at approximately 10:05 AM, the second floor 2405D clean supply room did not have a self closing device installed on the corridor door. This observation was verified by the facilities Maintenance Manager.

5. On 8/10/10 at approximately 10:03 AM, the second floor 2200F storage room did not have a self closing device installed on the corridor door. This observation was verified by the facilities Maintenance Manager.

6. On 8/10/10 at approximately 10:00 AM, the 2 east soiled utility room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

7. On 8/10/10 at approximately 9:45 AM, the third floor 3403 storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

8. On 8/10/10 at approximately 9:41 AM, the door to the 4010 kitchen storage room was observed to be held in the open position by a wooden wedge . This observation was verified by the facilities Maintenance Manager.

9. On 8/10/10 at approximately 9:40 AM, the fourth floor 4030 storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

10. On 8/10/10 at approximately 9:30 AM, the fifth floor 5030 storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

11. On 8/10/10 at approximately 9:15 AM, the sixth floor 6420 communications room was observed to have unprotected 2 inch electrical conduit passing through the corridor wall. This observation was verified by the facilities Maintenance Manager.








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Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility by allowing heat and fire gases to escape the hazardous area and enter the corridor system during a fire emergency.

Findings include:

1. On 8/11/10 at approximately 10:15 AM, the W0017 Bio-Med storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.

2. On 8/11/10 at approximately 10:17 AM, the W009 IS Hardware storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.

3. On 8/11/10 at approximately 10:30 AM, the J1016 communications room was observed to have an unprotected 2 inch conduit passing through the north wall. This observation was verified by the facilities Maintenance Supervisor.

4. On 8/11/10 at approximately 10:40 AM, the E1050 janitor room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.

5. On 8/11/10 at approximately 11:05 AM, the J2042 communications room was observed to have an unprotected 1 inch conduit passing through the corridor wall above the door. This observation was verified by the facilities Maintenance Supervisor.

6. On 8/11/10 at approximately 11:20 AM, the S2008 clean linen room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.

7. On 8/11/10 at approximately 11:30 AM, the S2031 soiled utility room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.






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Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect all occupants of the facility by restricting or blocking access to the exit pathways during an evacuation.

Findings include:

1. On 8/10/10 at approximately 11:30 AM, storage of beds, file cabinets, and medical equipment was observed in the Chi Tower basement corridor near the mechanical storage room. This observation was verified by the facilities Maintenance Manager.

2. On 8/10/10 at approximately 10:40 AM, the stair #2 basement restriction gate did not self close. The gate causes an obstruction to the stairway landing area when partially open and allows occupants to continue to the lower level without exiting at the first floor grade level. This observation was verified by the facilities Maintenance Manager.

3. On 8/10/10 at approximately 10:30 AM, storage of plywood, cabinets, and tables was observed in the first floor old radiology corridor. This observation was verified by the facilities Maintenance Manager.

4. On 8/10/10 at approximately 9:10 AM, a chair was observed on the fifth floor #1 stairwell landing. This observation was verified by the facilities Maintenance Manager.




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Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

1. On 8/11/10 at approximately 8:15 AM, during review of records it was observed that the facility failed to document a fire drill for each of the past 4 quarters on all shifts. Fire drills were not documented for 2nd and third shifts for 1st quarter 2010, 3rd quarter 2nd shift for 2009, and 4th quarter 1st shift. The facility filed false alarm or accidental alarm documentation for the missing drills, but did not include any critique of the staff response to the alarms. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 8:30 AM, during review of records it was observed that the facility failed to conduct fire drills at varied times on the third shift. Recorded fire drill times were 6:40 AM, 6:00 AM, and 5:30 AM which are all near the end of the third shift. This observation was verified by the facilities Physical Plant Supervisor.





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Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

1. On 8/11/10 at approximately 8:15 AM, during review of records it was observed that the facility failed to document a fire drill for each of the past 4 quarters on all shifts. Fire drills were not documented for the 1st quarter 3rd shift for 2010, and 2nd quarter 1st shift for 2010. The facility filed false alarm or accidental alarm documentation for the missing drills, but did not include any critique of the staff response to the alarms. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 8:30 AM, during review of records it was observed that the facility failed to conduct fire drills at varied times on the first shift. Recorded fire drill times were 1:40 PM, 2:13 PM, and 1:55 PM. This observation was verified by the facilities Physical Plant Supervisor.






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Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility in the event the automatic sprinkler system failed to operate as designed during a fire emergency.

Findings include:

1. On 8/11/10 at approximately 9:00 AM, during review of records it was observed that the facility failed to document quarterly flow tests of the automatic sprinkler system. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/10/10 at approximately 11:20 AM, the sprinkler head in the G030 freezer was observed to be missing an escutcheon ring. This observation was verified by the facilities Maintenance Manager.

3. On 8/10/10 at approximately 10:15 AM, the sprinkler head in the ED hall soiled utility room was observed to be missing an escutcheon ring. This observation was verified by the facilities Maintenance Manager.

4. On 8/10/10 at approximately 10:15 AM, the sprinkler head in the ED hall soiled utility room was observed to be missing a ceiling tile. This observation was verified by the facilities Maintenance Manager.

5. On 8/10/10 at approximately 10:17 AM, the sprinkler head in the 1405G janitor room was observed to be missing a ceiling tile. This observation was verified by the facilities Maintenance Manager.





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Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility in the event the automatic sprinkler system failed to operate as designed during a fire emergency.

Findings include:

1. On 8/11/10 at approximately 9:00 AM, during review of records it was observed that the facility failed to document quarterly flow tests of the automatic sprinkler system. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 10:20 AM, it was observed that the W0006 telephone equipment room Halon fire suppression tank was partially discharged and the pressure gauge was no longer in the "green" zone. This observation was verified by the facilities Maintenance Supervisor.

3. On 8/11/10 at approximately 11:15 AM, it was observed that a sprinkler head in the 253 research conference room was missing an escutcheon ring. This observation was verified by the facilities Maintenance Supervisor.

4. On 8/11/10 at approximately 10:10 AM, it was observed that the PHNS storage room was missing multiple ceiling tiles. This observation was verified by the facilities Maintenance Supervisor.




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Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility if the automatic kitchen hood suppression system failed to operate as designed during a fire involving the kitchen cooking appliances.

Findings include:

1. On 8/11/10 at approximately 9:30 AM, during review of records, the facility failed to produce current maintenance and testing documents for the kitchen hood fire suppression systems. This observation was verified by the facilities Physical Plant Supervisor.








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Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility if the automatic kitchen hood suppression system failed to operate as designed during a fire involving the kitchen cooking appliances.

Findings include:

1. On 8/11/10 at approximately 9:30 AM, during review of records, the facility failed to produce current maintenance and testing documents for the kitchen hood fire suppression systems. This observation was verified by the facilities Physical Plant Supervisor.






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Based on observation and/or review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility if the Type I ESS failed to supply emergency electrical power to the facility during an electrical power outage.

Findings include:

1. On 8/11/10 at approximately 10:00 AM, during review of records, the facility failed to provide complete maintenance and testing documents for the four emergency generators. Weekly visual inspection documents did not include all 4 weeks of each month. There was no documentation of weekly visual inspections for the month of July 2010. This observation was verified by the facilities Physical Plant Supervisor.






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Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility by increasing the likelihood of an electrical ignition source or failure due to improper installation of electrical wiring.

Findings include:

1. On 8/10/10 at approximately 10:20 AM, the ED blanket warmer near 1403A was observed to be plugged into an electrical extension cord which was passed up into the ceiling and over a corridor wall to an outlet on the other side. This observation was verified by the facilities Maintenance Manager.

2. On 8/10/10 at approximately 10:30 AM, open electrical boxes were observed in the corridor walls on the first floor old radiology hall. This observation was verified by the facilities Maintenance Manager.






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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

1. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the automatic sprinkler system did not include the outage time of more than 4 hours in a 24 hour period. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the automatic sprinkler system indicated that the individual assigned to fire watch duties may have other assignments not related to the fire watch. This observation was verified by the facilities Physical Plant Supervisor.






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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

1. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the automatic sprinkler system did not include the outage time of more than 4 hours in a 24 hour period. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the automatic sprinkler system indicated that the individual assigned to fire watch duties may have other assignments not related to the fire watch. This observation was verified by the facilities Physical Plant Supervisor.





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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

1. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the fire alarm system did not include the outage time of more than 4 hours in a 24 hour period. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the fire alarm system indicated that the individual assigned to fire watch duties may have other assignments not related to the fire watch. This observation was verified by the facilities Physical Plant Supervisor.









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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

1. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the fire alarm system did not include the outage time of more than 4 hours in a 24 hour period. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the fire alarm system indicated that the individual assigned to fire watch duties may have other assignments not related to the fire watch. This observation was verified by the facilities Physical Plant Supervisor.





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Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect all occupants of the facility by allowing fire to spread more quickly and decreasing the time available for evacuation.

Findings include:

1. On 8/11/10 at approximately 11:00 AM it was observed that the facilities 2 north wing was Type II (000) construction. The 2 north wing is actually three stories above the lowest fire department access. Type II (000) construction is not permitted for a partially sprinkled three story building. The wing currently not being used for a patient care area, but has not been renovated for other uses. This observation was verified by the facilities Maintenance Supervisor.





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Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect 10% of the occupants of the facility if a fire went undetected in a space that is open to the corridor.

Findings include:

1. On 8/10/10 at approximately 10:25 AM, it was observed that the emergency department triage area has had the door removed, and there was a 4 foot by 4 foot opening in the wall causing the space to be open to the corridor of the emergency department. The triage area does not meet the requirements for an open space because there is not automatic smoke detection installed in the area. This observation was verified by the facilities Maintenance Manager.


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Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility by allowing heat and fire gases to escape the hazardous area and enter the corridor system during a fire emergency.

Findings include:

1. On 8/10/10 at approximately 11:10 AM, the basement soiled utility room door (near loading dock) failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

2. On 8/10/10 at approximately 10:43 AM, the first floor electrical closet near the main tower elevators was observed to have unprotected electrical conduits passing through the floor and corridor wall. This observation was verified by the facilities Maintenance Manager.

3. On 8/10/10 at approximately 10:35 AM, the first floor storage room 1404J was observed to have a self closing device on the door that locks in the open position and does not automatically release. This observation was verified by the facilities Maintenance Manager.

4. On 8/10/10 at approximately 10:05 AM, the second floor 2405D clean supply room did not have a self closing device installed on the corridor door. This observation was verified by the facilities Maintenance Manager.

5. On 8/10/10 at approximately 10:03 AM, the second floor 2200F storage room did not have a self closing device installed on the corridor door. This observation was verified by the facilities Maintenance Manager.

6. On 8/10/10 at approximately 10:00 AM, the 2 east soiled utility room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

7. On 8/10/10 at approximately 9:45 AM, the third floor 3403 storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

8. On 8/10/10 at approximately 9:41 AM, the door to the 4010 kitchen storage room was observed to be held in the open position by a wooden wedge . This observation was verified by the facilities Maintenance Manager.

9. On 8/10/10 at approximately 9:40 AM, the fourth floor 4030 storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

10. On 8/10/10 at approximately 9:30 AM, the fifth floor 5030 storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Manager.

11. On 8/10/10 at approximately 9:15 AM, the sixth floor 6420 communications room was observed to have unprotected 2 inch electrical conduit passing through the corridor wall. This observation was verified by the facilities Maintenance Manager.








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Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility by allowing heat and fire gases to escape the hazardous area and enter the corridor system during a fire emergency.

Findings include:

1. On 8/11/10 at approximately 10:15 AM, the W0017 Bio-Med storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.

2. On 8/11/10 at approximately 10:17 AM, the W009 IS Hardware storage room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.

3. On 8/11/10 at approximately 10:30 AM, the J1016 communications room was observed to have an unprotected 2 inch conduit passing through the north wall. This observation was verified by the facilities Maintenance Supervisor.

4. On 8/11/10 at approximately 10:40 AM, the E1050 janitor room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.

5. On 8/11/10 at approximately 11:05 AM, the J2042 communications room was observed to have an unprotected 1 inch conduit passing through the corridor wall above the door. This observation was verified by the facilities Maintenance Supervisor.

6. On 8/11/10 at approximately 11:20 AM, the S2008 clean linen room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.

7. On 8/11/10 at approximately 11:30 AM, the S2031 soiled utility room door failed to properly self-close and positively latch. This observation was verified by the facilities Maintenance Supervisor.






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Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect all occupants of the facility by restricting or blocking access to the exit pathways during an evacuation.

Findings include:

1. On 8/10/10 at approximately 11:30 AM, storage of beds, file cabinets, and medical equipment was observed in the Chi Tower basement corridor near the mechanical storage room. This observation was verified by the facilities Maintenance Manager.

2. On 8/10/10 at approximately 10:40 AM, the stair #2 basement restriction gate did not self close. The gate causes an obstruction to the stairway landing area when partially open and allows occupants to continue to the lower level without exiting at the first floor grade level. This observation was verified by the facilities Maintenance Manager.

3. On 8/10/10 at approximately 10:30 AM, storage of plywood, cabinets, and tables was observed in the first floor old radiology corridor. This observation was verified by the facilities Maintenance Manager.

4. On 8/10/10 at approximately 9:10 AM, a chair was observed on the fifth floor #1 stairwell landing. This observation was verified by the facilities Maintenance Manager.




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Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

1. On 8/11/10 at approximately 8:15 AM, during review of records it was observed that the facility failed to document a fire drill for each of the past 4 quarters on all shifts. Fire drills were not documented for 2nd and third shifts for 1st quarter 2010, 3rd quarter 2nd shift for 2009, and 4th quarter 1st shift. The facility filed false alarm or accidental alarm documentation for the missing drills, but did not include any critique of the staff response to the alarms. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 8:30 AM, during review of records it was observed that the facility failed to conduct fire drills at varied times on the third shift. Recorded fire drill times were 6:40 AM, 6:00 AM, and 5:30 AM which are all near the end of the third shift. This observation was verified by the facilities Physical Plant Supervisor.





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Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

1. On 8/11/10 at approximately 8:15 AM, during review of records it was observed that the facility failed to document a fire drill for each of the past 4 quarters on all shifts. Fire drills were not documented for the 1st quarter 3rd shift for 2010, and 2nd quarter 1st shift for 2010. The facility filed false alarm or accidental alarm documentation for the missing drills, but did not include any critique of the staff response to the alarms. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 8:30 AM, during review of records it was observed that the facility failed to conduct fire drills at varied times on the first shift. Recorded fire drill times were 1:40 PM, 2:13 PM, and 1:55 PM. This observation was verified by the facilities Physical Plant Supervisor.






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Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility in the event the automatic sprinkler system failed to operate as designed during a fire emergency.

Findings include:

1. On 8/11/10 at approximately 9:00 AM, during review of records it was observed that the facility failed to document quarterly flow tests of the automatic sprinkler system. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/10/10 at approximately 11:20 AM, the sprinkler head in the G030 freezer was observed to be missing an escutcheon ring. This observation was verified by the facilities Maintenance Manager.

3. On 8/10/10 at approximately 10:15 AM, the sprinkler head in the ED hall soiled utility room was observed to be missing an escutcheon ring. This observation was verified by the facilities Maintenance Manager.

4. On 8/10/10 at approximately 10:15 AM, the sprinkler head in the ED hall soiled utility room was observed to be missing a ceiling tile. This observation was verified by the facilities Maintenance Manager.

5. On 8/10/10 at approximately 10:17 AM, the sprinkler head in the 1405G janitor room was observed to be missing a ceiling tile. This observation was verified by the facilities Maintenance Manager.





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Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility in the event the automatic sprinkler system failed to operate as designed during a fire emergency.

Findings include:

1. On 8/11/10 at approximately 9:00 AM, during review of records it was observed that the facility failed to document quarterly flow tests of the automatic sprinkler system. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 10:20 AM, it was observed that the W0006 telephone equipment room Halon fire suppression tank was partially discharged and the pressure gauge was no longer in the "green" zone. This observation was verified by the facilities Maintenance Supervisor.

3. On 8/11/10 at approximately 11:15 AM, it was observed that a sprinkler head in the 253 research conference room was missing an escutcheon ring. This observation was verified by the facilities Maintenance Supervisor.

4. On 8/11/10 at approximately 10:10 AM, it was observed that the PHNS storage room was missing multiple ceiling tiles. This observation was verified by the facilities Maintenance Supervisor.




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Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility if the automatic kitchen hood suppression system failed to operate as designed during a fire involving the kitchen cooking appliances.

Findings include:

1. On 8/11/10 at approximately 9:30 AM, during review of records, the facility failed to produce current maintenance and testing documents for the kitchen hood fire suppression systems. This observation was verified by the facilities Physical Plant Supervisor.








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Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility if the automatic kitchen hood suppression system failed to operate as designed during a fire involving the kitchen cooking appliances.

Findings include:

1. On 8/11/10 at approximately 9:30 AM, during review of records, the facility failed to produce current maintenance and testing documents for the kitchen hood fire suppression systems. This observation was verified by the facilities Physical Plant Supervisor.






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Based on observation and/or review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility if the Type I ESS failed to supply emergency electrical power to the facility during an electrical power outage.

Findings include:

1. On 8/11/10 at approximately 10:00 AM, during review of records, the facility failed to provide complete maintenance and testing documents for the four emergency generators. Weekly visual inspection documents did not include all 4 weeks of each month. There was no documentation of weekly visual inspections for the month of July 2010. This observation was verified by the facilities Physical Plant Supervisor.






.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility by increasing the likelihood of an electrical ignition source or failure due to improper installation of electrical wiring.

Findings include:

1. On 8/10/10 at approximately 10:20 AM, the ED blanket warmer near 1403A was observed to be plugged into an electrical extension cord which was passed up into the ceiling and over a corridor wall to an outlet on the other side. This observation was verified by the facilities Maintenance Manager.

2. On 8/10/10 at approximately 10:30 AM, open electrical boxes were observed in the corridor walls on the first floor old radiology hall. This observation was verified by the facilities Maintenance Manager.






.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

1. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the automatic sprinkler system did not include the outage time of more than 4 hours in a 24 hour period. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the automatic sprinkler system indicated that the individual assigned to fire watch duties may have other assignments not related to the fire watch. This observation was verified by the facilities Physical Plant Supervisor.






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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

1. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the automatic sprinkler system did not include the outage time of more than 4 hours in a 24 hour period. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the automatic sprinkler system indicated that the individual assigned to fire watch duties may have other assignments not related to the fire watch. This observation was verified by the facilities Physical Plant Supervisor.





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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

1. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the fire alarm system did not include the outage time of more than 4 hours in a 24 hour period. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the fire alarm system indicated that the individual assigned to fire watch duties may have other assignments not related to the fire watch. This observation was verified by the facilities Physical Plant Supervisor.









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Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

1. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the fire alarm system did not include the outage time of more than 4 hours in a 24 hour period. This observation was verified by the facilities Physical Plant Supervisor.

2. On 8/11/10 at approximately 12:30 PM, during review of records, it was observed that the facilities fire watch policy for the fire alarm system indicated that the individual assigned to fire watch duties may have other assignments not related to the fire watch. This observation was verified by the facilities Physical Plant Supervisor.





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