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Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire and smoke into the corridor, exposing occupants to fire and the products of combustion, rendering the corridor unusable for evacuation of the facility.

Findings include:

1. On 04/09/15 at approximately 9:35 AM during an inspection of corridor doors with the maintenance supervisor, the following observation was made:

Observed the corridor door to the clean utility room 3-10 not close to a positive latch.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

2. On 04/09/15 at approximately 1:20 PM during an inspection of corridor doors with the maintenance supervisor, the following observations was made:

Observed the corridor doors to patient room # 186 to have a gap between the doors that does not resist the passage of smoke when in the closed position.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire and the products of combustion between smoke compartments, exposing occupants to the products of combustion.

Findings include:

On 04/09/15 at approximately 10:00 AM during an inspection of smoke barrier walls with the maintenance supervisor, the following observation was made:

1. Observed the Women's Changing Room corridor door to be in a smoke barrier wall. The window in the door is not fire rated glass as required.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Inspection of smoke barrier walls was a random sample inspection and not all inclusive of all penetrations of the smoke barrier walls. The facility is responsible to insure that all penetrations are properly fire stopped and sealed in all areas of the smoke barrier walls throughout the facility.

Based on observation and interview, the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect occupants of the facility by permitting smoke and fire to travel between smoke compartments, exposing occupants to the products of combustion.

Findings include:

1. On 04/09/15 at approximately 10:20 AM during an inspection of smoke barrier doors with the maintenance supervisor, the following observation was made:

Observed the smoke barrier doors from elevator lobby # 1 & # 2 to not close completely due to air balance.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, 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 occupants of the facility by contributing to the spread of fire between a protected area and unprotected area, exposing occupants to fire and the products of combustion.

Findings include:

On 04/09/15 between approximately 9:30 AM -1:00 PM during an inspection of hazard rooms with the maintenance supervisor, the following observations were made:

1. Observed the fire rated door to the Soiled Utility Room in the Surgery corridor to be held open with an unapproved hold open device (plastic door wedge).

2. Observed the old Whirlpool Room on the first floor being used as a Storage Room. The room does not meet storage requirements.

3. Observed a large hole around an electrical conduit above the corridor door to the lower level trash chute room. The hole is in the fire rated corridor wall.

4. The # 1 Generator Room does not have a 90 minute door and the door is missing the self-closing device.

These deficiencies were confirmed by interview with the maintenance supervisor at the time of observation.

Based on review of records and interview, 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 occupants of the facility if staff are not properly trained in approved emergency procedures because it may lead to a delay in response to an emergency, exposing occupants to a hazardous condition.

Findings include:

On 04/09/15 between approximately 1:30 PM -2: 30 PM during a review of records titled: Fire Drills 2014 and dated: 1/31/14, 2/26/14, 3/25/14, 4/30/14, 5/30/14, 6/26/14, 7/22/14, 8/29/14, 9/30/14, 10/24/14, 11/28/14 and 12/17/14 with the maintenance supervisor, the following discovery was made:

Fire drills are not being conducted at varying times and conditions as required. 3 of the 4 required second shift fire drills were conducted between 7:10 PM and 8:01 PM. The required third shift fire drills were all conducted between 1:29 AM and 3:15 AM.

This deficiency was confirmed by interview with the maintenance supervisor at the time of discovery.

Based on observation and interview, the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect occupants of the facility by contributing to a delay in notification of occupants and emergency services in the event of a fire.

Findings include:

On 04/09/15 between approximately 10:00 AM & 1:00 PM during an inspection of the fire alarm system with the maintenance supervisor, the following observations were made:

1. Observed smoke detector outside of Emergency Room # 10 to be located with-in three feet of an HVAC opening.
2. Observed smoke detector in ICU Clean Utility Room to be located with-in three feet of an HVAC opening.
3. Observed smoke detector outside of second floor staff elevators to be located with-in three feet of an HVAC opening.
4. Observed smoke detector in 2N old Kitchen to be located with-in three feet of an HVAC opening.

These deficiencies were confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, the facility failed to provide chutes that are in accordance with the LSC sections 9.5, 9.7, 8.4. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire due to improperly installed and maintained chutes, exposing occupants to fire and the products of combustion.

Findings include:

1. On 04/09/15 at approximately 12:15 PM during an inspection of chutes with the maintenance supervisor, the following observation was made:

Observed the 6th floor linen chute door not self-close to a positive latch.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect occupants of the facility by contributing to the development and spread of fire, exposing occupants to fire and the products of combustion.

Findings include:

On 04/09/15 at approximately 1:00 PM during an inspection of oxygen storage with the maintenance supervisor, the following observation was made:

1. Observed Surgery Gas Storage Room to have four unsecured cylinders.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, the facility failed to maintain the emergency generators in accordance with NFPA 99 & NFPA 110. This deficient practice could potentially affect occupants of the facility contributing to the failure of emergency systems in the event of a power failure, delaying notification to occupants and emergency services, and evacuation of the building.

Findings include:

On 04/09/15 at approximately 1:40 PM during an inspection of the emergency generators with the maintenance supervisor, the following discoveries were made:

1. Emergency generators # 2 & # 3 do not have remote stop buttons.

2. The three emergency generators are equipped with maintenance free batteries. Maintenance free batteries are not permitted in Type 1 EES.

These deficiencies were confirmed with the maintenance supervisor at the time of discovery.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire and smoke into the corridor, exposing occupants to fire and the products of combustion, rendering the corridor unusable for evacuation of the facility.

Findings include:

1. On 04/09/15 at approximately 9:35 AM during an inspection of corridor doors with the maintenance supervisor, the following observation was made:

Observed the corridor door to the clean utility room 3-10 not close to a positive latch.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

2. On 04/09/15 at approximately 1:20 PM during an inspection of corridor doors with the maintenance supervisor, the following observations was made:

Observed the corridor doors to patient room # 186 to have a gap between the doors that does not resist the passage of smoke when in the closed position.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire and the products of combustion between smoke compartments, exposing occupants to the products of combustion.

Findings include:

On 04/09/15 at approximately 10:00 AM during an inspection of smoke barrier walls with the maintenance supervisor, the following observation was made:

1. Observed the Women's Changing Room corridor door to be in a smoke barrier wall. The window in the door is not fire rated glass as required.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Inspection of smoke barrier walls was a random sample inspection and not all inclusive of all penetrations of the smoke barrier walls. The facility is responsible to insure that all penetrations are properly fire stopped and sealed in all areas of the smoke barrier walls throughout the facility.

Based on observation and interview, the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect occupants of the facility by permitting smoke and fire to travel between smoke compartments, exposing occupants to the products of combustion.

Findings include:

1. On 04/09/15 at approximately 10:20 AM during an inspection of smoke barrier doors with the maintenance supervisor, the following observation was made:

Observed the smoke barrier doors from elevator lobby # 1 & # 2 to not close completely due to air balance.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, 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 occupants of the facility by contributing to the spread of fire between a protected area and unprotected area, exposing occupants to fire and the products of combustion.

Findings include:

On 04/09/15 between approximately 9:30 AM -1:00 PM during an inspection of hazard rooms with the maintenance supervisor, the following observations were made:

1. Observed the fire rated door to the Soiled Utility Room in the Surgery corridor to be held open with an unapproved hold open device (plastic door wedge).

2. Observed the old Whirlpool Room on the first floor being used as a Storage Room. The room does not meet storage requirements.

3. Observed a large hole around an electrical conduit above the corridor door to the lower level trash chute room. The hole is in the fire rated corridor wall.

4. The # 1 Generator Room does not have a 90 minute door and the door is missing the self-closing device.

These deficiencies were confirmed by interview with the maintenance supervisor at the time of observation.

Based on review of records and interview, 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 occupants of the facility if staff are not properly trained in approved emergency procedures because it may lead to a delay in response to an emergency, exposing occupants to a hazardous condition.

Findings include:

On 04/09/15 between approximately 1:30 PM -2: 30 PM during a review of records titled: Fire Drills 2014 and dated: 1/31/14, 2/26/14, 3/25/14, 4/30/14, 5/30/14, 6/26/14, 7/22/14, 8/29/14, 9/30/14, 10/24/14, 11/28/14 and 12/17/14 with the maintenance supervisor, the following discovery was made:

Fire drills are not being conducted at varying times and conditions as required. 3 of the 4 required second shift fire drills were conducted between 7:10 PM and 8:01 PM. The required third shift fire drills were all conducted between 1:29 AM and 3:15 AM.

This deficiency was confirmed by interview with the maintenance supervisor at the time of discovery.

Based on observation and interview, the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect occupants of the facility by contributing to a delay in notification of occupants and emergency services in the event of a fire.

Findings include:

On 04/09/15 between approximately 10:00 AM & 1:00 PM during an inspection of the fire alarm system with the maintenance supervisor, the following observations were made:

1. Observed smoke detector outside of Emergency Room # 10 to be located with-in three feet of an HVAC opening.
2. Observed smoke detector in ICU Clean Utility Room to be located with-in three feet of an HVAC opening.
3. Observed smoke detector outside of second floor staff elevators to be located with-in three feet of an HVAC opening.
4. Observed smoke detector in 2N old Kitchen to be located with-in three feet of an HVAC opening.

These deficiencies were confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, the facility failed to provide chutes that are in accordance with the LSC sections 9.5, 9.7, 8.4. This deficient practice could potentially affect occupants of the facility by contributing to the spread of fire due to improperly installed and maintained chutes, exposing occupants to fire and the products of combustion.

Findings include:

1. On 04/09/15 at approximately 12:15 PM during an inspection of chutes with the maintenance supervisor, the following observation was made:

Observed the 6th floor linen chute door not self-close to a positive latch.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect occupants of the facility by contributing to the development and spread of fire, exposing occupants to fire and the products of combustion.

Findings include:

On 04/09/15 at approximately 1:00 PM during an inspection of oxygen storage with the maintenance supervisor, the following observation was made:

1. Observed Surgery Gas Storage Room to have four unsecured cylinders.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview, the facility failed to maintain the emergency generators in accordance with NFPA 99 & NFPA 110. This deficient practice could potentially affect occupants of the facility contributing to the failure of emergency systems in the event of a power failure, delaying notification to occupants and emergency services, and evacuation of the building.

Findings include:

On 04/09/15 at approximately 1:40 PM during an inspection of the emergency generators with the maintenance supervisor, the following discoveries were made:

1. Emergency generators # 2 & # 3 do not have remote stop buttons.

2. The three emergency generators are equipped with maintenance free batteries. Maintenance free batteries are not permitted in Type 1 EES.

These deficiencies were confirmed with the maintenance supervisor at the time of discovery.