HospitalInspections.org

Based on observation the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly sealed penetrations.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 12:20 PM observed that above the smoke barrier doors at the Patient Area there were 4 conduits with wiring that had unsealed ends that were not sealed with a fire stopping material.

Based on observation the facility failed to provide exit and directional signs in accordance with the LSC section 18.2.10.1. This deficient practice could affect all building occupants in the event of an emergency where the rapid evacuation of the facility is necessary, but is delayed due to improperly marked exits.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 11:40 AM observed that the Physical Therapy NE exit door is not marked with an " Exit " sign.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 18.7.1.2. This deficient practice could potentially affect all occupants of the facility in the event of a fire emergency where the established fire safety plan is not used to protect the occupants of the facility.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 1:00 PM observed that upon activation of a smoke detector for the purpose of conducting an unannounced fire drill, no staff person in the immediate vicinity of the nurse ' s station checked the fire alarm panel to determine the location of the alarm system activation, resulting in no location being announced as outlined in the emergency plan.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could affect all building occupants in the event of a delay in occupant notification due to improperly maintained fire alarm system components.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 11:50 PM observed that in the X-Ray Storage Room there was a ceiling mounted smoke detector located within 3 feet of an HVAC duct opening.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could affect all building occupants in the event of a fire where the early suppression of the fire does not occur due to the improperly maintained fire sprinkler system.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 11:50 AM observed that in the X-Ray Storage Room there was storage located within 18 " of the sprinkler head deflector.

Based on observation the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly sealed penetrations.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 12:20 PM observed that above the smoke barrier doors at the Patient Area there were 4 conduits with wiring that had unsealed ends that were not sealed with a fire stopping material.

Based on observation the facility failed to provide exit and directional signs in accordance with the LSC section 18.2.10.1. This deficient practice could affect all building occupants in the event of an emergency where the rapid evacuation of the facility is necessary, but is delayed due to improperly marked exits.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 11:40 AM observed that the Physical Therapy NE exit door is not marked with an " Exit " sign.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 18.7.1.2. This deficient practice could potentially affect all occupants of the facility in the event of a fire emergency where the established fire safety plan is not used to protect the occupants of the facility.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 1:00 PM observed that upon activation of a smoke detector for the purpose of conducting an unannounced fire drill, no staff person in the immediate vicinity of the nurse ' s station checked the fire alarm panel to determine the location of the alarm system activation, resulting in no location being announced as outlined in the emergency plan.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could affect all building occupants in the event of a delay in occupant notification due to improperly maintained fire alarm system components.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 11:50 PM observed that in the X-Ray Storage Room there was a ceiling mounted smoke detector located within 3 feet of an HVAC duct opening.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could affect all building occupants in the event of a fire where the early suppression of the fire does not occur due to the improperly maintained fire sprinkler system.

Findings include:

On 08/31/10, the following observations were made:

- At approximately 11:50 AM observed that in the X-Ray Storage Room there was storage located within 18 " of the sprinkler head deflector.