HospitalInspections.org

Based on observation the rating of the paneling on the interior walls of the Human resources office room 295 and the facility Maintenance Directors office could not be determined. The penthouse for AHU #23 is exposed Styrofoam. This deficient practice could effect all occupants of the facility.

Findings include:

During the facility tour on 9-5-12 at approximately 2:00PM it was observed that the flame spread rating of the paneling on the interior wallls of the Human Resources office , room 295 and the maintenance directors office (located on the west end of the basement) could not be determined as required by LSC(00) 19.3.3.2. It was also observed that the interior walls of the penthouse for AHU #23 is exposed Styrofoam.

This deficient practice was confirmed by the facility Director of Maintenance (RW) at the time of exit.

Based on observations, and interview, the corridor was not separated from use areas as required by Sec. 19.3.6.2.1. This would include the alcove by room J256 and the gift shop located in the main west lobby.This deficient practice could affect all patients, staff and visitors in the event of a fire.

Findings include:

Based on observation during the facility tour on 9-5-12 at approximately 2:30PM it was observed that the wheelchair alcove by room J256 and the Gift Shop on the main level lobby, are use areas that are open to the corridor and are not protected by automatic smoke detectors connected to the facility fire alarm system.

This deficient practice was confirmed by Maintenance Director (RW) at the time of exit.

Based on observations, the below doors were held open improperly. This deficient practice could affect the safety of all patients, staff and visitors.

Finding include:

During the facility tour on 9-5-12 between 8:30-10:30AM it was observed that the doors listed below were held in the open position improperly, in accordance with LSC(00) Section 19-3.1. These doors are held open with magnetic hold opens, however they do not have a fire alarm connected smoke detector within 5 feet of the door(s).

A. Patient billing room, located on the main level.

B. The vending room, both doors.

C. The gift shop on the main level, lobby.


This deficient practice was confirmed by the facility Maintenance Director (RW) at the time of exit.

Based on observation and interview, several stairwell doors would not properly latch as required by LSC(00) section 19.3.2 This deficient practice could affect all occupants.

Findings include:

During the facility tour on 9-5-12 between 1:00-3:30PM it was observed that the below listed stairwell doors would not properly latch securely in the frames. They include door nujmbers 245, 209, & 291.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to provide means of egress in accordance with the following requirements of LSC(00), Section 7.2.1.5.4. The deficient practice could affect all occupants.

Findings include:

During the facility tour on 9-5-12 at approximately 8:30AM it was observed that 2 of 3 doors of the cafeteria conference room had locks on the egress side that require the use of a key to unlock.. The locking arrangement could prevent the doors from being opened from the inside.

On 9-5-12 at 1:00PM, it was observed that the east stairwell doo of the Birthing Area was equipped with a delayed egress device. However, the door was not properly signed to indicate that the door had a delayed egress device installed. Doors 245 and 209 were also secured improperly.

This deficient practice was verified by the Maintenance Director (RW) at the time of the exit.

Based on observation smoke detectors were located within 36 inches of HVAC deflectors in several locations. This deficient practice could effect all building occupants in the event of a fire emergency and cause delay of the fire alarm activation.

Findings include:

During the facility tour on 9-4-12 thru 9-6-12 it was observed in several locations, that there are fire alarm connected smoke detectors that are installed within 3 feet of both supply and/or return HV AC deflectors. This improper installation does not meet the requirements of NFPA 72(99).

This deficient practice was confirmed by Maintenance Director (RW) at the time of exit.

Based on observation, the facility has areas that lack the proper sprinkler protection required by NFPA 13. This deficient practice could affect all patients, staff and visitors.

Findings include:

During the facility tour on 9-4-12 thru 9-6-12 it was observed that automatic fire sprinkler protection was lacking in the following areas:

1. AHU penthouse #23.

2. The skylight in the main hospital lobby.

3. In the elevator pits that are scheduled to be renovated.

4. The installation of the sprinkler heads in the lobby by the gift shop does not meet the requirements of NFPA 13(99) Section A-1-4.6. The ceiling in this area does not meet the definition of a "smooth ceiling".

These deficient practices were observed by the facility Maintenance Director (RW) at the time of exit.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of the patients in an emergency situation.

Findings include:

During the facility tour on 9-5-12 it was observed, that the facility has charting tables that drop down from the wall, which are also known as "walleroos". When tested, 16 of the 19 "walleroos" would not retract into the closed position. They are located in the patient care areas.

This deficient practice was confirmed by the Maintenance Director (RW) at the time of exit.

Based on interview, and observation, the facility does not have an appropriate written policy addressing actions to be taken by staff in the event the sprinkler system is out of service. This deficient practice could affect all residents, staff and visitors.

Findings include:

Upon completion of the facility tour on 9-5-12 at 3:30PM, based on interview with the director of maintenance, it was discovered that the facility does not have an up-dated written policy on file addressing the actions required by staff in the event the required complete automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period, as required by LSC(00) section 9.7.6.1.

This deficient practice was confirmed by Maintenance Director (RW) at the time of exit.

Based on interview, and observation, the facility does not have an appropriate written policy to deal with periods of time that the complete automatic fire sprinkler system may be out of service. This deficient practice could affect all residents, staff and visitors.

Finding include:

Upon conclusion of the facility tour on 9-5-12 at 3:30PM, based on interview and observation with the director of maintenance, the facility does not have an up-dated written policy on file that would outline the actions required to be carried out in the event of a fire sprinkler system outage lasting more than 4 hours in a 24-hour period, as required by LSC(00, Section 9.7.6.1.

This deficient practice was confirmed by the Maintenance Director (RW) at the time of exit.

Based on observation the rating of the paneling on the interior walls of the Human resources office room 295 and the facility Maintenance Directors office could not be determined. The penthouse for AHU #23 is exposed Styrofoam. This deficient practice could effect all occupants of the facility.

Findings include:

During the facility tour on 9-5-12 at approximately 2:00PM it was observed that the flame spread rating of the paneling on the interior wallls of the Human Resources office , room 295 and the maintenance directors office (located on the west end of the basement) could not be determined as required by LSC(00) 19.3.3.2. It was also observed that the interior walls of the penthouse for AHU #23 is exposed Styrofoam.

This deficient practice was confirmed by the facility Director of Maintenance (RW) at the time of exit.

Based on observations, and interview, the corridor was not separated from use areas as required by Sec. 19.3.6.2.1. This would include the alcove by room J256 and the gift shop located in the main west lobby.This deficient practice could affect all patients, staff and visitors in the event of a fire.

Findings include:

Based on observation during the facility tour on 9-5-12 at approximately 2:30PM it was observed that the wheelchair alcove by room J256 and the Gift Shop on the main level lobby, are use areas that are open to the corridor and are not protected by automatic smoke detectors connected to the facility fire alarm system.

This deficient practice was confirmed by Maintenance Director (RW) at the time of exit.

Based on observations, the below doors were held open improperly. This deficient practice could affect the safety of all patients, staff and visitors.

Finding include:

During the facility tour on 9-5-12 between 8:30-10:30AM it was observed that the doors listed below were held in the open position improperly, in accordance with LSC(00) Section 19-3.1. These doors are held open with magnetic hold opens, however they do not have a fire alarm connected smoke detector within 5 feet of the door(s).

A. Patient billing room, located on the main level.

B. The vending room, both doors.

C. The gift shop on the main level, lobby.


This deficient practice was confirmed by the facility Maintenance Director (RW) at the time of exit.

Based on observation and interview, several stairwell doors would not properly latch as required by LSC(00) section 19.3.2 This deficient practice could affect all occupants.

Findings include:

During the facility tour on 9-5-12 between 1:00-3:30PM it was observed that the below listed stairwell doors would not properly latch securely in the frames. They include door nujmbers 245, 209, & 291.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to provide means of egress in accordance with the following requirements of LSC(00), Section 7.2.1.5.4. The deficient practice could affect all occupants.

Findings include:

During the facility tour on 9-5-12 at approximately 8:30AM it was observed that 2 of 3 doors of the cafeteria conference room had locks on the egress side that require the use of a key to unlock.. The locking arrangement could prevent the doors from being opened from the inside.

On 9-5-12 at 1:00PM, it was observed that the east stairwell doo of the Birthing Area was equipped with a delayed egress device. However, the door was not properly signed to indicate that the door had a delayed egress device installed. Doors 245 and 209 were also secured improperly.

This deficient practice was verified by the Maintenance Director (RW) at the time of the exit.

Based on observation smoke detectors were located within 36 inches of HVAC deflectors in several locations. This deficient practice could effect all building occupants in the event of a fire emergency and cause delay of the fire alarm activation.

Findings include:

During the facility tour on 9-4-12 thru 9-6-12 it was observed in several locations, that there are fire alarm connected smoke detectors that are installed within 3 feet of both supply and/or return HV AC deflectors. This improper installation does not meet the requirements of NFPA 72(99).

This deficient practice was confirmed by Maintenance Director (RW) at the time of exit.

Based on observation, the facility has areas that lack the proper sprinkler protection required by NFPA 13. This deficient practice could affect all patients, staff and visitors.

Findings include:

During the facility tour on 9-4-12 thru 9-6-12 it was observed that automatic fire sprinkler protection was lacking in the following areas:

1. AHU penthouse #23.

2. The skylight in the main hospital lobby.

3. In the elevator pits that are scheduled to be renovated.

4. The installation of the sprinkler heads in the lobby by the gift shop does not meet the requirements of NFPA 13(99) Section A-1-4.6. The ceiling in this area does not meet the definition of a "smooth ceiling".

These deficient practices were observed by the facility Maintenance Director (RW) at the time of exit.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of the patients in an emergency situation.

Findings include:

During the facility tour on 9-5-12 it was observed, that the facility has charting tables that drop down from the wall, which are also known as "walleroos". When tested, 16 of the 19 "walleroos" would not retract into the closed position. They are located in the patient care areas.

This deficient practice was confirmed by the Maintenance Director (RW) at the time of exit.

Based on interview, and observation, the facility does not have an appropriate written policy addressing actions to be taken by staff in the event the sprinkler system is out of service. This deficient practice could affect all residents, staff and visitors.

Findings include:

Upon completion of the facility tour on 9-5-12 at 3:30PM, based on interview with the director of maintenance, it was discovered that the facility does not have an up-dated written policy on file addressing the actions required by staff in the event the required complete automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period, as required by LSC(00) section 9.7.6.1.

This deficient practice was confirmed by Maintenance Director (RW) at the time of exit.

Based on interview, and observation, the facility does not have an appropriate written policy to deal with periods of time that the complete automatic fire sprinkler system may be out of service. This deficient practice could affect all residents, staff and visitors.

Finding include:

Upon conclusion of the facility tour on 9-5-12 at 3:30PM, based on interview and observation with the director of maintenance, the facility does not have an up-dated written policy on file that would outline the actions required to be carried out in the event of a fire sprinkler system outage lasting more than 4 hours in a 24-hour period, as required by LSC(00, Section 9.7.6.1.

This deficient practice was confirmed by the Maintenance Director (RW) at the time of exit.