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Based on observations and interview, the facility failed to ensure 1 of 12 corridors in the Forest Ridge building was provided with interior finishes with a flame spread rating of Class A or class B. LSC 39.3.3.2 requires interior wall and ceiling finish complying with 10.2.3 shall be class A or Class B in exits and in enclosed corridors furnishing access to exits, and Class A, Class B, or Class C in office areas. This deficient practice could affect any patient who would use the Service Hall exit for a secondary means of escape, located near the ground level main therapy room.

Findings include:

Based on observation on 04/30/14 at 1:40 p.m. with the director of maintenance, the ground level Service Hall corridor walls had wooden paneling on both sides of the corridor walls extending from the floor to four feet six inches above the floor. Based on an interview with the director of maintenance on 04/30/14 at 1:45 p.m., there was no documentation to indicate the flame spread rating of the wood paneling along both sides of the Service Hall corridor. The lack of flame spread rating evidence for the Service Hall corridor wood paneled walls was verified by the director of maintenance at the time of observation and at the exit conference on 04/30/14 at 2:45 p.m.

Based on observation and interview, the facility failed to ensure 2 of 2 areas in the Henry County Memorial Hospital building were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or meet an Exception. LSC 19-3.6.1 Exception No. 2: Waiting areas shall be permitted to be open to the corridor, provided that:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 sq ft (55.7 sq m); and
(b) Each area is protected by an electrically supervised, automatic smoke detection system installed in accordance with 12-3.4, or each area is arranged and located to permit direct supervision by the facility staff from a nursing station or similar space; and
(c) The area does not obstruct access to required exits.
This deficient practice could affect any number of patients using the men's and women's secondary waiting areas of the Imaging department as well as staff or visitors in the vicinity of these two areas.

Findings include:

Based on observation with the Chief Operating Officer and the Safety/Security Director at 9:55 a.m. on 04/30/14, the men's and women's secondary waiting areas of the Imaging department were open to the corridor and the corridor was protected by an electrically supervised automatic detection system but the individual spaces were not. Based on interview at the time of observation, the Chief Operating Officer and the Safety/Security Director acknowledged the waiting areas were not protected by automatic smoke detectors and the areas were not arranged and located to permit direct supervision by the facility staff from a nursing station or similar space.

Based on observation and interview, the facility failed to ensure 1 of 1 corridor doors for the cart wash room and 1 of 12 first floor rooms in the purchasing corridor in the Henry County Memorial Hospital building closed and latched into the door frames. This deficient practice could affect patients, staff and visitors.

Findings include:

Based on observation with the director of maintenance on 04/30/14 at 10:30 a.m., the cart wash room door would not latch positively into the door frame. Furthermore, based on observation during the tour with the electrician on 04/30/14 at 9:45 a.m., the door from the purchasing room into the first floor corridor was controlled by an electronic device that locked the door with controlled access and prevented the door from latching into the frame. This was acknowledged by the director of maintenance and the electrician at the time of observations.

Based on observation and interview, the facility failed to maintain the vertical opening protection of 1 of 9 exit stairwells in the Henry County Memorial Hospital building. LSC 8.2.5.2 requires enclosure of vertical openings including stairwells with fire barrier walls with a fire resistance rating of at least one hour. This deficient practice could affect any patient, staff and/or visitor using the stairwells.

Findings include:

Based on observation on 04/30/14 with the director of maintenance at 10:55 a.m., the ground floor stairwell # 3 door lacked a label indicating a fire resistance rating and it did not latch into the door frame. This door also had a hole in the upper right hand corner on the corridor side of the door. Based on interview during the observation, the director of maintenance acknowledged the stairwell door did not latch, and lacked a label indicated the fire resistance rating.

Based on observation and interview, the facility failed to ensure penetrations through 1 of 1 smoke barriers near the level 4 ER area in the Henry County Memorial Hospital building was protected to maintain the smoke resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect any patient as well as staff and visitors near the level 4 Emergency Room (ER) area if smoke from a fire were to infiltrate the protective barrier.

Findings include:

Based on observation with the Chief Operating Officer and the Safety/Security Director at 9:35 a.m. on 04/30/14, there was a two inch in diameter, orange conduit penetrating through the smoke barrier near the level 4 ER area with a one inch gap around the conduit that was not firestopped. Based on interview at the time of observation, the Chief Operating Officer and the Safety/Security Director acknowledged the conduit penetration had had not been firestopped.

Based on observation and interview, the facility failed to ensure 1 of 1 sets of smoke barrier doors near the dietary storage area in the Henry County Memorial Hospital building would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.6 requires doors in smoke barriers shall comply with LSC Section 8.3.4. LSC 8.3.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch. This deficient practice could affect patients as well as staff and visitors.

Finding include:

Based on observation with the director of maintenance at 10:45 a.m. on 04/30/1, the set of cross corridor doors outside dietary storage did not close completely, leaving a one inch gap between the doors. Based on interview, this observation was acknowledged by the director of maintenance.

Based on observation and interview, the facility failed to ensure the corridor door to 2 of 32 hazardous areas in the Henry County Memorial Hospital building, such as combustible storage areas over 50 square feet in size, were provided with smoke resistive doors equipped with self closing devices that would cause the doors to automatically close and latch into the door frames. This deficient practice could affect residents as well as staff and visitors in the corridor on the third floor adjacent to the Waters of New Castle Nursing Home wing and the second floor office area.

Findings include:

Based on observation during the tour with the electrician on 04/30/14 between 8:00 a.m. and 11:00 a.m.:
a. The third floor hazardous storage room (called Waters Storage room) which was approximately 12 feet by 15 feet had a door without a self closer.
b. The second floor hazardous storage room door had a louvered grate 24 inches by 18 inches in the bottom third of the door and the door did not have a self closer.
Based on the interview during the observations, the electrician acknowledged the aforementioned conditions.

1. Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 9 exits in the Henry County Memorial Hospital building was readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires that means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect any patient, staff or visitor using the first floor stairwell # 3 exit.

Findings include:

Based on observation with the director of maintenance on 04/30/14 at 11:00 a.m., the exit from the first floor stairwell # 3 to the exterior was provided with a concrete stoop outside the door, but the means of egress did not terminate at a public way. This was acknowledged by the director of maintenance at the time of observation.


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2. Based on observation and interview, the facility failed to ensure the exit corridor leading from Stairwell Exit # 6 to the exit in the Henry County Memorial Hospital building was cleared of hazardous storage. This deficiency practice could effect staff and visitors who would exit from the stairwell into the corridor and out to the public way.

Findings:

Based on observation and interview during the tour with the electrician on 04/30/14 between 08:00 a.m. and 11:00 a.m., the exit corridor out to the public access was being used to store fourteen 96 gallon waste containers. Based on the interview during the observation, the electrician acknowledged the aforementioned conditions. The containers at this time were all empty but upon interview with the director of maintenance at the exit conference, he stated that they could all be full at any given time before pickup.

Based on observation and interview, the facility failed to ensure 1 of 4 fire door sets on the first floor of the Henry County Hospital building was arranged to automatically close and latch. LSC 19.2.2.5 requires horizontal exits to be in accordance with 7.2.4 and 7.2.4.3.8 requires fire doors to be self closing or automatic closing in accordance with 7.2.1.8. In addition, NFPA 80, Standard for Fire Doors and Windows at 2-1.4.1 requires all closing mechanisms shall be adjusted to overcome fire resistance of the latch mechanism so positive latching is achieved on each door operation. This deficient practice could affect all patients using the first floor Surgery Hall.

Findings include:

Based on observation and interview on 04/30/14 at 10:45 a.m. with the electrician, the first floor Surgical Hall set of fire doors was released from their electromechanical holding devices and the fire doors failed to latch into the door frame. This was verified by the electrician at the time of observation.

Based on observation and interview, the facility failed to ensure 8 of 8 exit means of egress and 12 of 12 corridors in the Forest Ridge building were provided with emergency lighting. LSC Section 39.2.9.1 requires emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exist: (1) The building is two or more stories in height above the level of exit discharge. LSC 7.9.1.1 requires, for the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purpose of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way. This deficient practice affect all patients in the facility.

Findings include:

Based on observations during a tour of the facility with the director of maintenance on 04/30/14 from 12:55 p.m. to 2:30 p.m., the eight exit discharge paths which led to the parking lot, and the twelve corridors lacked emergency lighting. This was verified by the director of maintenance at the time of observations and acknowledged at the exit conference on 04/30/14 at 2:40 p.m.

Based on observation and interview, the facility failed to ensure 1 of 1 exit signs in the mammography unit of the Henry County Memorial Hospital building was continuously illuminated. This deficient practice had the potential to affect any patient or staff in the mammography unit.

Findings include:

Based on observation with the Safety/Security Director on 04/30/14 at 10:05 a.m., the exit sign on the inside of the mammography unit was not illuminated. Based on interview at the time of observation, the Safety/Security Director acknowledged the exit sign was not illuminated.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems in the Henry County Memorial Hospital building was continuously in proper operating condition. Note: LSC Chapter 4.6.12.1 is a general requirement and applies to all occupancies. LSC 4.6.12.1 requires that any device or any feature of a required fire detection and alarm system shall be continuously in proper operating condition. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect any patient, staff and visitor.

Findings include:

Based on observation on 04/30/14 with the Safety/Security Director from 9:30 a.m. to 10:15 a.m., the following were noted:
a. A smoke detector in the corridor outside exam room # 1 was one foot from an air vent. Based on interview at the time of observation, the Safety/Security Director acknowledged the smoke detector was one foot from an air vent.
b. An auxiliary fire alarm panel located near the oxygen storage area had "System Trouble" and "Circuit Trouble" lights on the fire alarm panel illuminated. Based on interview at the time of observation, the Safety/Security Director did not know why the lights were illuminated.

1. Based on observation and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems in the Henry County Memorial Hospital building was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13, Section 5-13.8.1 requires sprinklers shall be installed under combustible exterior roofs or canopies exceeding four feet in width.
This deficient practice could affect any patient as well as staff and visitors.

Findings include:

The canopy outside the first floor stairwell # 3 exit exceeded four feet in width and was constructed with a sheet of fiberglass attached to a wood frame. This canopy was not provided with sprinkler protection. Based on interview at the time of observation, the director of maintenance acknowledged the canopy was constructed of combustible material; exceeded four feet in width and lacked of sprinkler protection.

2. Based on observation and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems in the Henry County Memorial Hospital building was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. 5-13.11 states sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.
This deficient practice could affect any patient as well as staff and visitors.

Findings include:

Based on observations with the Safety/Security Director at 10:00 a.m. and with the director of maintenance from 10:35 a.m. to 11:00 a.m. on 04/30/14, the ground floor mechanical room with electrical panels and electrical equipment lacked sprinkler protection. The room was provided with a door with a solid wood core with no label indicating a fire resistance rating. The room contained two cardboard boxes and a small wood table. Based on interview at the time of observation, the director of maintenance acknowledged the room was enclosed by two hour fire rated walls but the door lacked the required fire resistance rating and combustible storage was not permitted.

3. Based on observation and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems in the Henry County Memorial Hospital building was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. This deficient practice could affect any patient as well as staff and visitors.

Findings include:

a. The privacy curtain in the EKG services room had a mesh top panel less than 70 percent open weave. Based on interview at the time of observation, the Safety/Security Director acknowledged the privacy curtain in the EKG services room had an inappropriate size mesh top panel.
b. The third floor gift shop storage room had an enclosed mechanical bulk head extending down 16 inches from the ceiling and extending from one side wall to the other side wall which prevented the sprinkler head from providing full protection to the 12 foot by 16 foot room. Based on the interview during the observation, the electrician acknowledged the aforementioned conditions.

Based on observation and interview, the facility failed to ensure 2 of 2 kitchen corridors and 1 of 8 kitchen rooms in the Henry County Memorial Hospital building were provided with sprinkler system piping free of nonsystem components in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems. NFPA 13, 6-1.1.5 requires sprinkler piping or hangers shall not be used to support nonsystem components. This deficient practice could affect any patients who use the main dining room, located adjacent to the kitchen.

Findings include:

Based on observations on 04/30/14 during a tour of the kitchen from 11:20 a.m. to 12:00 p.m. with the director of maintenance, the food storage room and food storage room corridor leading from the kitchen had twenty nine zip ties used to tie down a red fire alarm system electrical wire connected to a thirty six foot length of sprinkler pipe. Furthermore, the kitchen exit corridor leading to the dock had twenty one zip ties used to tie down a red fire alarm system electrical wire connected to the twelve foot length of sprinkler pipe. This was verified by the director of maintenance at the time of observations and acknowledged at the exit conference on 04/30/14 at 12:45 p.m.

Based on observation and interview, the facility failed to ensure the means of egress for 1 of 2 exits for the swimming pool in the Forest Ridge building was free of all obstructions which could interfere with their full instant use. This deficient practice could affect all patients who use the swimming pool and would use the north swimming pool exit during an evacuation.

Findings include:

Based on observation on 04/30/14 at 1:20 p.m. with the director of maintenance, the north swimming pool exit corridor had a desk, two chairs, and a table stored in the the center of the north exit corridor which obstructed the use of the north exit corridor. This was verified by the director of maintenance at the time of observation and acknowledged at the exit conference on 04/30/14 at 2:45 p.m.

Based on observation and interview, the facility failed to ensure soiled linen containers in 1 of 12 first floor corridors in the Henry County Memorial Hospital building did not exceed 32 gallons. This deficiency practice could effect all staff and visitors who would use the first floor corridor near stairwell exit # 6.

Findings include:

Based on observation during the tour with the electrician on 04/30/14 at 9:45 a.m., there were fourteen, 96 gallon soiled waste containers stored in the corridor in front of the exit door # 6 stairwell. This was verified by the electrician at the time of observation.

1. Based on observation and interview, the facility failed to ensure 2 of 2 emergency generators with over 100 horsepower in the Henry County Memorial Hospital building were equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine, and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation on 04/30/14 at 11:05 a.m. with the director of maintenance, each of the two generators in their respective generator enclosures was equipped with a manual stop switch, but not at a remote location. Based on an interview at the time of observation, the director of maintenance acknowledged each of the generator engines provide more than 100 horsepower and lack remote manual stop stations.

2. Based on observation and interview, the facility failed to provide adequate emergency task lighting in and around the 1 of 2 generator sets in the Henry County Memorial Hospital building in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation on 04/30/14 at 11:05 a.m. with the director of maintenance, a battery powered emergency light was not located in the generator enclosure for the 480 V Caterpillar generator. Based on an interview at the time of observation, the director of maintenance acknowledged the 480 V Caterpillar generator enclosure lacked emergency task lighting inside the enclosure.

Based on record review and interview, the facility failed to provide a written policy for the protection for 68 of 68 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period at the Henry County Memorial Hospital building in accordance with LSC, Section 9.7.6.1. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-2 requires an appointed sprinkler impairment coordinator. NFPA 25, 11-5 requires a preplanned program to include evacuation or an approved fire watch and 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified and 11-5(f) requires notification of supervisors in the area in addition to those already mentioned and lastly 11-7 requires notification of everyone again when the system is restored. This deficient practice could affect all patients in the facility.

Findings include:

Based on record review and interview on 04/30/14 at 9:45 a.m. with the director of maintenance, the facility did not have a written policy in the event the automatic sprinkler system has to be placed out of service for four hours or more in a twenty four hour period. The only documentation provided was a flow chart for fire alarm system procedures. The lack of a written policy in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period was verified by the director of maintenance at the time of record review and acknowledged at the exit conference on 04/30/14 at 12:45 p.m.

Based on record review and interview, the facility failed to provide a written policy for the protection for 68 of 68 patients in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period for the Henry County Memorial Hospital building in accordance with LSC, Section 9.6.1.8. LSC 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all patients in the facility.

Findings include:

Based on record review and interview on 04/30/14 at 9:30 a.m. with the director of maintenance, the facility did not have a written policy in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period. The only documentation provided was a flow chart for fire alarm system procedures. The lack of a written policy in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period was verified by the director of maintenance at the time of record review and acknowledged at the exit conference on 04/30/14 at 12:45 p.m.

Based on observation and interview, the facility failed to ensure 1 of 10 sprinkled elevator equipment rooms in the Henry County Memorial Hospital building was provided with an automatic means for disconnecting the main line power supply. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon, or prior to, the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect all patients on the first floor through the fourth floor who use elevator # 4.

Findings include:

Based on observation of the first floor elevator equipment room # 4 on 04/30/14 at 10:40 a.m. with the director of maintenance, the elevator equipment room for elevator # 4 was provided with sprinkler coverage. Based on an interview and observation of the main elevator electrical equipment on 04/30/14 at 10:55 a.m. with the director of maintenance and the electrician, there was no indication in the elevator equipment room a shunt trip was provided for the elevator equipment. This was verified by the director of maintenance and electrician at the time of observation of the elevator equipment room for elevator # 4 and at the exit conference on 04/30/14 at 12:45 p.m.

Based on observations and interview, the facility failed to ensure 1 of 12 corridors in the Forest Ridge building was provided with interior finishes with a flame spread rating of Class A or class B. LSC 39.3.3.2 requires interior wall and ceiling finish complying with 10.2.3 shall be class A or Class B in exits and in enclosed corridors furnishing access to exits, and Class A, Class B, or Class C in office areas. This deficient practice could affect any patient who would use the Service Hall exit for a secondary means of escape, located near the ground level main therapy room.

Findings include:

Based on observation on 04/30/14 at 1:40 p.m. with the director of maintenance, the ground level Service Hall corridor walls had wooden paneling on both sides of the corridor walls extending from the floor to four feet six inches above the floor. Based on an interview with the director of maintenance on 04/30/14 at 1:45 p.m., there was no documentation to indicate the flame spread rating of the wood paneling along both sides of the Service Hall corridor. The lack of flame spread rating evidence for the Service Hall corridor wood paneled walls was verified by the director of maintenance at the time of observation and at the exit conference on 04/30/14 at 2:45 p.m.

Based on observation and interview, the facility failed to ensure 2 of 2 areas in the Henry County Memorial Hospital building were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or meet an Exception. LSC 19-3.6.1 Exception No. 2: Waiting areas shall be permitted to be open to the corridor, provided that:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 sq ft (55.7 sq m); and
(b) Each area is protected by an electrically supervised, automatic smoke detection system installed in accordance with 12-3.4, or each area is arranged and located to permit direct supervision by the facility staff from a nursing station or similar space; and
(c) The area does not obstruct access to required exits.
This deficient practice could affect any number of patients using the men's and women's secondary waiting areas of the Imaging department as well as staff or visitors in the vicinity of these two areas.

Findings include:

Based on observation with the Chief Operating Officer and the Safety/Security Director at 9:55 a.m. on 04/30/14, the men's and women's secondary waiting areas of the Imaging department were open to the corridor and the corridor was protected by an electrically supervised automatic detection system but the individual spaces were not. Based on interview at the time of observation, the Chief Operating Officer and the Safety/Security Director acknowledged the waiting areas were not protected by automatic smoke detectors and the areas were not arranged and located to permit direct supervision by the facility staff from a nursing station or similar space.

Based on observation and interview, the facility failed to ensure 1 of 1 corridor doors for the cart wash room and 1 of 12 first floor rooms in the purchasing corridor in the Henry County Memorial Hospital building closed and latched into the door frames. This deficient practice could affect patients, staff and visitors.

Findings include:

Based on observation with the director of maintenance on 04/30/14 at 10:30 a.m., the cart wash room door would not latch positively into the door frame. Furthermore, based on observation during the tour with the electrician on 04/30/14 at 9:45 a.m., the door from the purchasing room into the first floor corridor was controlled by an electronic device that locked the door with controlled access and prevented the door from latching into the frame. This was acknowledged by the director of maintenance and the electrician at the time of observations.

Based on observation and interview, the facility failed to maintain the vertical opening protection of 1 of 9 exit stairwells in the Henry County Memorial Hospital building. LSC 8.2.5.2 requires enclosure of vertical openings including stairwells with fire barrier walls with a fire resistance rating of at least one hour. This deficient practice could affect any patient, staff and/or visitor using the stairwells.

Findings include:

Based on observation on 04/30/14 with the director of maintenance at 10:55 a.m., the ground floor stairwell # 3 door lacked a label indicating a fire resistance rating and it did not latch into the door frame. This door also had a hole in the upper right hand corner on the corridor side of the door. Based on interview during the observation, the director of maintenance acknowledged the stairwell door did not latch, and lacked a label indicated the fire resistance rating.

Based on observation and interview, the facility failed to ensure penetrations through 1 of 1 smoke barriers near the level 4 ER area in the Henry County Memorial Hospital building was protected to maintain the smoke resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect any patient as well as staff and visitors near the level 4 Emergency Room (ER) area if smoke from a fire were to infiltrate the protective barrier.

Findings include:

Based on observation with the Chief Operating Officer and the Safety/Security Director at 9:35 a.m. on 04/30/14, there was a two inch in diameter, orange conduit penetrating through the smoke barrier near the level 4 ER area with a one inch gap around the conduit that was not firestopped. Based on interview at the time of observation, the Chief Operating Officer and the Safety/Security Director acknowledged the conduit penetration had had not been firestopped.

Based on observation and interview, the facility failed to ensure 1 of 1 sets of smoke barrier doors near the dietary storage area in the Henry County Memorial Hospital building would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.6 requires doors in smoke barriers shall comply with LSC Section 8.3.4. LSC 8.3.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch. This deficient practice could affect patients as well as staff and visitors.

Finding include:

Based on observation with the director of maintenance at 10:45 a.m. on 04/30/1, the set of cross corridor doors outside dietary storage did not close completely, leaving a one inch gap between the doors. Based on interview, this observation was acknowledged by the director of maintenance.

Based on observation and interview, the facility failed to ensure the corridor door to 2 of 32 hazardous areas in the Henry County Memorial Hospital building, such as combustible storage areas over 50 square feet in size, were provided with smoke resistive doors equipped with self closing devices that would cause the doors to automatically close and latch into the door frames. This deficient practice could affect residents as well as staff and visitors in the corridor on the third floor adjacent to the Waters of New Castle Nursing Home wing and the second floor office area.

Findings include:

Based on observation during the tour with the electrician on 04/30/14 between 8:00 a.m. and 11:00 a.m.:
a. The third floor hazardous storage room (called Waters Storage room) which was approximately 12 feet by 15 feet had a door without a self closer.
b. The second floor hazardous storage room door had a louvered grate 24 inches by 18 inches in the bottom third of the door and the door did not have a self closer.
Based on the interview during the observations, the electrician acknowledged the aforementioned conditions.

1. Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 9 exits in the Henry County Memorial Hospital building was readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires that means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect any patient, staff or visitor using the first floor stairwell # 3 exit.

Findings include:

Based on observation with the director of maintenance on 04/30/14 at 11:00 a.m., the exit from the first floor stairwell # 3 to the exterior was provided with a concrete stoop outside the door, but the means of egress did not terminate at a public way. This was acknowledged by the director of maintenance at the time of observation.


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2. Based on observation and interview, the facility failed to ensure the exit corridor leading from Stairwell Exit # 6 to the exit in the Henry County Memorial Hospital building was cleared of hazardous storage. This deficiency practice could effect staff and visitors who would exit from the stairwell into the corridor and out to the public way.

Findings:

Based on observation and interview during the tour with the electrician on 04/30/14 between 08:00 a.m. and 11:00 a.m., the exit corridor out to the public access was being used to store fourteen 96 gallon waste containers. Based on the interview during the observation, the electrician acknowledged the aforementioned conditions. The containers at this time were all empty but upon interview with the director of maintenance at the exit conference, he stated that they could all be full at any given time before pickup.

Based on observation and interview, the facility failed to ensure 1 of 4 fire door sets on the first floor of the Henry County Hospital building was arranged to automatically close and latch. LSC 19.2.2.5 requires horizontal exits to be in accordance with 7.2.4 and 7.2.4.3.8 requires fire doors to be self closing or automatic closing in accordance with 7.2.1.8. In addition, NFPA 80, Standard for Fire Doors and Windows at 2-1.4.1 requires all closing mechanisms shall be adjusted to overcome fire resistance of the latch mechanism so positive latching is achieved on each door operation. This deficient practice could affect all patients using the first floor Surgery Hall.

Findings include:

Based on observation and interview on 04/30/14 at 10:45 a.m. with the electrician, the first floor Surgical Hall set of fire doors was released from their electromechanical holding devices and the fire doors failed to latch into the door frame. This was verified by the electrician at the time of observation.

Based on observation and interview, the facility failed to ensure 8 of 8 exit means of egress and 12 of 12 corridors in the Forest Ridge building were provided with emergency lighting. LSC Section 39.2.9.1 requires emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exist: (1) The building is two or more stories in height above the level of exit discharge. LSC 7.9.1.1 requires, for the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purpose of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way. This deficient practice affect all patients in the facility.

Findings include:

Based on observations during a tour of the facility with the director of maintenance on 04/30/14 from 12:55 p.m. to 2:30 p.m., the eight exit discharge paths which led to the parking lot, and the twelve corridors lacked emergency lighting. This was verified by the director of maintenance at the time of observations and acknowledged at the exit conference on 04/30/14 at 2:40 p.m.

Based on observation and interview, the facility failed to ensure 1 of 1 exit signs in the mammography unit of the Henry County Memorial Hospital building was continuously illuminated. This deficient practice had the potential to affect any patient or staff in the mammography unit.

Findings include:

Based on observation with the Safety/Security Director on 04/30/14 at 10:05 a.m., the exit sign on the inside of the mammography unit was not illuminated. Based on interview at the time of observation, the Safety/Security Director acknowledged the exit sign was not illuminated.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems in the Henry County Memorial Hospital building was continuously in proper operating condition. Note: LSC Chapter 4.6.12.1 is a general requirement and applies to all occupancies. LSC 4.6.12.1 requires that any device or any feature of a required fire detection and alarm system shall be continuously in proper operating condition. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect any patient, staff and visitor.

Findings include:

Based on observation on 04/30/14 with the Safety/Security Director from 9:30 a.m. to 10:15 a.m., the following were noted:
a. A smoke detector in the corridor outside exam room # 1 was one foot from an air vent. Based on interview at the time of observation, the Safety/Security Director acknowledged the smoke detector was one foot from an air vent.
b. An auxiliary fire alarm panel located near the oxygen storage area had "System Trouble" and "Circuit Trouble" lights on the fire alarm panel illuminated. Based on interview at the time of observation, the Safety/Security Director did not know why the lights were illuminated.

1. Based on observation and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems in the Henry County Memorial Hospital building was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13, Section 5-13.8.1 requires sprinklers shall be installed under combustible exterior roofs or canopies exceeding four feet in width.
This deficient practice could affect any patient as well as staff and visitors.

Findings include:

The canopy outside the first floor stairwell # 3 exit exceeded four feet in width and was constructed with a sheet of fiberglass attached to a wood frame. This canopy was not provided with sprinkler protection. Based on interview at the time of observation, the director of maintenance acknowledged the canopy was constructed of combustible material; exceeded four feet in width and lacked of sprinkler protection.

2. Based on observation and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems in the Henry County Memorial Hospital building was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. 5-13.11 states sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.
This deficient practice could affect any patient as well as staff and visitors.

Findings include:

Based on observations with the Safety/Security Director at 10:00 a.m. and with the director of maintenance from 10:35 a.m. to 11:00 a.m. on 04/30/14, the ground floor mechanical room with electrical panels and electrical equipment lacked sprinkler protection. The room was provided with a door with a solid wood core with no label indicating a fire resistance rating. The room contained two cardboard boxes and a small wood table. Based on interview at the time of observation, the director of maintenance acknowledged the room was enclosed by two hour fire rated walls but the door lacked the required fire resistance rating and combustible storage was not permitted.

3. Based on observation and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems in the Henry County Memorial Hospital building was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. This deficient practice could affect any patient as well as staff and visitors.

Findings include:

a. The privacy curtain in the EKG services room had a mesh top panel less than 70 percent open weave. Based on interview at the time of observation, the Safety/Security Director acknowledged the privacy curtain in the EKG services room had an inappropriate size mesh top panel.
b. The third floor gift shop storage room had an enclosed mechanical bulk head extending down 16 inches from the ceiling and extending from one side wall to the other side wall which prevented the sprinkler head from providing full protection to the 12 foot by 16 foot room. Based on the interview during the observation, the electrician acknowledged the aforementioned conditions.

Based on observation and interview, the facility failed to ensure 2 of 2 kitchen corridors and 1 of 8 kitchen rooms in the Henry County Memorial Hospital building were provided with sprinkler system piping free of nonsystem components in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems. NFPA 13, 6-1.1.5 requires sprinkler piping or hangers shall not be used to support nonsystem components. This deficient practice could affect any patients who use the main dining room, located adjacent to the kitchen.

Findings include:

Based on observations on 04/30/14 during a tour of the kitchen from 11:20 a.m. to 12:00 p.m. with the director of maintenance, the food storage room and food storage room corridor leading from the kitchen had twenty nine zip ties used to tie down a red fire alarm system electrical wire connected to a thirty six foot length of sprinkler pipe. Furthermore, the kitchen exit corridor leading to the dock had twenty one zip ties used to tie down a red fire alarm system electrical wire connected to the twelve foot length of sprinkler pipe. This was verified by the director of maintenance at the time of observations and acknowledged at the exit conference on 04/30/14 at 12:45 p.m.

Based on observation and interview, the facility failed to ensure the means of egress for 1 of 2 exits for the swimming pool in the Forest Ridge building was free of all obstructions which could interfere with their full instant use. This deficient practice could affect all patients who use the swimming pool and would use the north swimming pool exit during an evacuation.

Findings include:

Based on observation on 04/30/14 at 1:20 p.m. with the director of maintenance, the north swimming pool exit corridor had a desk, two chairs, and a table stored in the the center of the north exit corridor which obstructed the use of the north exit corridor. This was verified by the director of maintenance at the time of observation and acknowledged at the exit conference on 04/30/14 at 2:45 p.m.

Based on observation and interview, the facility failed to ensure soiled linen containers in 1 of 12 first floor corridors in the Henry County Memorial Hospital building did not exceed 32 gallons. This deficiency practice could effect all staff and visitors who would use the first floor corridor near stairwell exit # 6.

Findings include:

Based on observation during the tour with the electrician on 04/30/14 at 9:45 a.m., there were fourteen, 96 gallon soiled waste containers stored in the corridor in front of the exit door # 6 stairwell. This was verified by the electrician at the time of observation.

1. Based on observation and interview, the facility failed to ensure 2 of 2 emergency generators with over 100 horsepower in the Henry County Memorial Hospital building were equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine, and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation on 04/30/14 at 11:05 a.m. with the director of maintenance, each of the two generators in their respective generator enclosures was equipped with a manual stop switch, but not at a remote location. Based on an interview at the time of observation, the director of maintenance acknowledged each of the generator engines provide more than 100 horsepower and lack remote manual stop stations.

2. Based on observation and interview, the facility failed to provide adequate emergency task lighting in and around the 1 of 2 generator sets in the Henry County Memorial Hospital building in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation on 04/30/14 at 11:05 a.m. with the director of maintenance, a battery powered emergency light was not located in the generator enclosure for the 480 V Caterpillar generator. Based on an interview at the time of observation, the director of maintenance acknowledged the 480 V Caterpillar generator enclosure lacked emergency task lighting inside the enclosure.

Based on record review and interview, the facility failed to provide a written policy for the protection for 68 of 68 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period at the Henry County Memorial Hospital building in accordance with LSC, Section 9.7.6.1. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-2 requires an appointed sprinkler impairment coordinator. NFPA 25, 11-5 requires a preplanned program to include evacuation or an approved fire watch and 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified and 11-5(f) requires notification of supervisors in the area in addition to those already mentioned and lastly 11-7 requires notification of everyone again when the system is restored. This deficient practice could affect all patients in the facility.

Findings include:

Based on record review and interview on 04/30/14 at 9:45 a.m. with the director of maintenance, the facility did not have a written policy in the event the automatic sprinkler system has to be placed out of service for four hours or more in a twenty four hour period. The only documentation provided was a flow chart for fire alarm system procedures. The lack of a written policy in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period was verified by the director of maintenance at the time of record review and acknowledged at the exit conference on 04/30/14 at 12:45 p.m.

Based on record review and interview, the facility failed to provide a written policy for the protection for 68 of 68 patients in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period for the Henry County Memorial Hospital building in accordance with LSC, Section 9.6.1.8. LSC 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all patients in the facility.

Findings include:

Based on record review and interview on 04/30/14 at 9:30 a.m. with the director of maintenance, the facility did not have a written policy in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period. The only documentation provided was a flow chart for fire alarm system procedures. The lack of a written policy in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period was verified by the director of maintenance at the time of record review and acknowledged at the exit conference on 04/30/14 at 12:45 p.m.

Based on observation and interview, the facility failed to ensure 1 of 10 sprinkled elevator equipment rooms in the Henry County Memorial Hospital building was provided with an automatic means for disconnecting the main line power supply. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon, or prior to, the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect all patients on the first floor through the fourth floor who use elevator # 4.

Findings include:

Based on observation of the first floor elevator equipment room # 4 on 04/30/14 at 10:40 a.m. with the director of maintenance, the elevator equipment room for elevator # 4 was provided with sprinkler coverage. Based on an interview and observation of the main elevator electrical equipment on 04/30/14 at 10:55 a.m. with the director of maintenance and the electrician, there was no indication in the elevator equipment room a shunt trip was provided for the elevator equipment. This was verified by the director of maintenance and electrician at the time of observation of the elevator equipment room for elevator # 4 and at the exit conference on 04/30/14 at 12:45 p.m.