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Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 1 hazardous area rooms were provided with a self-closing device which would cause the door to automatically close and latch into the door frame. LSC 39.3.2.2 states hazard contents areas, as classified in Section 6.2, shall meet all of the following criteria:
(1) The area shall be separated from other parts of the building by fire barriers having a minimum 1-hour fire resistance rating, with all openings therein protected by self-closing fire door assemblies having a minimum 3.4-hour fire protection
rating. This deficient practice could affect 5 patients in the Psychiatry center

Findings include:

Based on observation with the Facility's Director on 06/14/22 at 11:00 a.m., the corridor door to the main storeroom which contained fuel-fired equipment was not provided with an automatic or self-closing device. Based on interview at the time of observation, the Facility's Director agreed the room was a hazardous area due to the fuel-fired equipment, and the door was not self-closing.

This finding was reviewed with the Safety Manager and Facility's Director during the exit conference.

Based on observation and interview, the facility failed to ensure 4 of 4 sliding ER corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke. This deficient practice could affect 4 patients in the ER.

Findings include:

Based on observation with the Facility's Director on 06/13/22 at 2:03 p.m., the sliding corridor doors to ER rooms 1, 2, 3, and 4 did not latch into the frame when evaluated. Based on interview at the time of observation, the Facility's Director stated the ER doors would not latch into the door frame because the latches were broken.

This finding was reviewed with the Safety Manager and Facility's Director during the exit conference.

Based on observation and interview, the facility failed ensure 1 of 3 electrical branches were not comingled. NFPA 99, 2012 edition 6.5.2.2.2.1 states the life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code
(3) Alarm and alerting systems, including the following:
(a) Fire alarms.
(b) Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 5.
(4) Communications systems, where used for issuing instructions during emergency conditions.
(5) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of a minimum of 5 ft-candles.
(6) Task illumination and select receptacles at the generator set location.
(7) Elevator cab lighting, control, communications, and signal systems.
6.5.2.2.2.2 states no functions, other than those listed in 6.5.2.2.2.1(1) through (7), shall be connected to the life safety.
This deficient practice could affect all occupants.

Finding include:

Based on observation with the Facility's Director on 06/13/22 at 12:30 p.m. in the basement there was an electric panel identified as an equipment branch from the generator. The breaker for the fire alarm panel was located on this equipment panel instead of a life safety panel. Based on interview at the time of observation, the Facility's Director agreed the breaker for the fire alarm panel was located on an equipment panel and needs to be moved to a life safety panel.

This finding was reviewed with the Safety Manager and Facility's Director during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 1 flexible cord power strips in patient care locations met the required UL rating of 1363A or 60601-1. This deficient practice can affect 1 patient in the Ortho treatment room.

Findings include:

Based on observations during a tour of the facility with the Facility's Director on 06/14/22 at 10:16 a.m., a power strip was in use in the Ortho treatment room where patient care was provided that did not meet 1363A or 60601-1. Based on interview at the time of observation, the Maintenance Director agreed a power strip was in use in a patient care area and did not meet 1363A or 60601-1.

This finding was reviewed with the Safety Manager and Facility's Director during the exit conference.