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Based on observation and interview, it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with LSC Sections 19.1.2.1 and 19.1.1.4.2. This deficient practice could potentially affect all occupants of the facility in the event of a fire in the adjoining building.

Findings Include:
On 3/31/15 at approximately 11:47am, the north leaf of the 90-minute fire-rated door that separates the hospital from the Medical Office Building and Administration was observed to not close to a positive latch when tested as required by 8.2.3.2.1.
In an interview at approximately 11:47am on 3/31/15, Eng #1 and Maint #1 confirmed that the door did not close to a positive latch.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with LSC Section 19.3.2.1. This deficient practice could potentially affect 3 staff of the facility in the event of a fire not being contained to the hazardous area.

Findings Include:
On 3/31/15 at approximately 12:04pm, the Cardio Storage Room door was observed to be held open with a wooden wedge under the door in violation of Section 8.2.3.2.1.
In an interview at approximately 12:02pm on 3/31/15, Eng #1 and Maint #1 confirmed that the room was used for storage and the door was held open with the wedge.

Based on observation and interview, the facility failed to provide emergency lighting in accordance with LSC Sections 19.2.9.1 and 7.9. This deficient practice could potentially affect 2 occupants of the facility in the event of a power outage during a surgical procedure.

Findings Include:
In an interview at approximately 11:00am on 3/31/15, Eng #1 was questioned if there were battery-powered emergency lights in the operating rooms. Eng #1 stated that no battery-powered emergency lights were provided for the operating room and procedure room where patients are under anesthesia and only emergency lights powered by the on-site generator were installed.
On 3/31/15 at approximately 12:15pm, there were no battery-powered emergency lights observed in the operating room or procedure room as required by NFPA 99, Section 3-3.2.1.2(5)(e).

Based on observation and interview, the facility failed to provide exit and directional signs in accordance with LSC Sections 19.2.10.1 and 7.10. This deficient practice could potentially affect 10 occupants of the facility in the event of an evacuation emergency.

Findings Include:
On 3/31/15 at approximately 12:06pm, the exit sign across the corridor from the Nurse Station was observed to not be illuminated as required by Section 7.10.
In an interview at approximately 12:06pm on 3/31/15, Eng #1 and Maint #1 confirmed that the internal bulbs were not working in the exit sign.

Based on review of records and interview, the facility failed to ensure that fire drills were conducted in accordance with 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:
On 3/31/15 between 10:30am and 11:20am during records review, the facility Fire Drill Documentation did include a fire drill documented as occurring during the 3rd Shift in the 3rd Quarter of 2014 as required by 19.7.1.2.
In an interview at approximately 11:00am on 3/31/15, Eng #1 confirmed that the documentation did not show a drill conducted during the 3rd Shift in the 3rd Quarter of 2014.

Based on review of records and interview, the facility failed to provide written documentation regarding fire drills in accordance with LSC Section 18.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings Include:
On 3/31/15 between 10:30am and 11:20am during records review, the facility Fire Drill Documentation did include a fire drill documented as occurring during the 3rd Shift in the 3rd Quarter of 2014 as required by 18.7.1.2.
In an interview at approximately 11:00am on 3/31/15, Eng #1 confirmed that the documentation did not show a drill conducted during the 3rd Shift in the 3rd Quarter of 2014.

Based on observation and interview, it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with LSC Sections 19.1.2.1 and 19.1.1.4.2. This deficient practice could potentially affect all occupants of the facility in the event of a fire in the adjoining building.

Findings Include:
On 3/31/15 at approximately 11:47am, the north leaf of the 90-minute fire-rated door that separates the hospital from the Medical Office Building and Administration was observed to not close to a positive latch when tested as required by 8.2.3.2.1.
In an interview at approximately 11:47am on 3/31/15, Eng #1 and Maint #1 confirmed that the door did not close to a positive latch.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with LSC Section 19.3.2.1. This deficient practice could potentially affect 3 staff of the facility in the event of a fire not being contained to the hazardous area.

Findings Include:
On 3/31/15 at approximately 12:04pm, the Cardio Storage Room door was observed to be held open with a wooden wedge under the door in violation of Section 8.2.3.2.1.
In an interview at approximately 12:02pm on 3/31/15, Eng #1 and Maint #1 confirmed that the room was used for storage and the door was held open with the wedge.

Based on observation and interview, the facility failed to provide emergency lighting in accordance with LSC Sections 19.2.9.1 and 7.9. This deficient practice could potentially affect 2 occupants of the facility in the event of a power outage during a surgical procedure.

Findings Include:
In an interview at approximately 11:00am on 3/31/15, Eng #1 was questioned if there were battery-powered emergency lights in the operating rooms. Eng #1 stated that no battery-powered emergency lights were provided for the operating room and procedure room where patients are under anesthesia and only emergency lights powered by the on-site generator were installed.
On 3/31/15 at approximately 12:15pm, there were no battery-powered emergency lights observed in the operating room or procedure room as required by NFPA 99, Section 3-3.2.1.2(5)(e).

Based on observation and interview, the facility failed to provide exit and directional signs in accordance with LSC Sections 19.2.10.1 and 7.10. This deficient practice could potentially affect 10 occupants of the facility in the event of an evacuation emergency.

Findings Include:
On 3/31/15 at approximately 12:06pm, the exit sign across the corridor from the Nurse Station was observed to not be illuminated as required by Section 7.10.
In an interview at approximately 12:06pm on 3/31/15, Eng #1 and Maint #1 confirmed that the internal bulbs were not working in the exit sign.

Based on review of records and interview, the facility failed to ensure that fire drills were conducted in accordance with 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:
On 3/31/15 between 10:30am and 11:20am during records review, the facility Fire Drill Documentation did include a fire drill documented as occurring during the 3rd Shift in the 3rd Quarter of 2014 as required by 19.7.1.2.
In an interview at approximately 11:00am on 3/31/15, Eng #1 confirmed that the documentation did not show a drill conducted during the 3rd Shift in the 3rd Quarter of 2014.

Based on review of records and interview, the facility failed to provide written documentation regarding fire drills in accordance with LSC Section 18.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings Include:
On 3/31/15 between 10:30am and 11:20am during records review, the facility Fire Drill Documentation did include a fire drill documented as occurring during the 3rd Shift in the 3rd Quarter of 2014 as required by 18.7.1.2.
In an interview at approximately 11:00am on 3/31/15, Eng #1 confirmed that the documentation did not show a drill conducted during the 3rd Shift in the 3rd Quarter of 2014.

Based on review of records and interview, the facility failed to ensure that the fire alarm system was installed, tested, and maintained in accordance with LSC Section 9.6.1.4 and NFPA 72. This deficient practice could potentially affect all occupants of the facility in the event of a failure of the fire alarm system due to a lack of maintenance.

Findings Include:
On 3/31/15 between 10:30am and 11:20am during records review, the Fire Alarm Inspection documentation by Superiorland Electronics dated 6/24/14 did not include the list of inspection and test results for all fire alarm devices. The documentation listed only the inspection and test results for the smoke detectors in violation of NFPA 72, Section 7-5.2.2.
In an interview at approximately 11:15am on 3/31/15, Eng #1 confirmed that the inspection documentation did not include device inspection and test results for devices other than smoke detectors.