HospitalInspections.org

Based on observation and interview the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect occupants of the facility by permitting smoke and fire to travel between smoke compartment exposing occupants to the products of combustion.

Findings include:

1. On 11/06/14 at approximately 11:05 AM during an inspection of smoke barrier doors with the maintenance supervisor, the following observation was made:

-The cross corridor smoke barrier doors between x-ray and ER department did not self close to within an 1/8 th of an inch gap.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview the facility failed to provide for egress in accordance with the LSC sections 19.2.4.1, 19.2.4.2. This deficient practice could potentially affect occupants of the facility by contributing to a delay in the ability to evacuate the facility, exposing occupants to an increased risk of exposure to a hazardous condition.

Findings include:

1. On 11/06/14 at approximately 11:45 AM during an inspection of exits with the maintenance supervisor, the following observation was made:

-The facilities basement only has one exit.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect occupants of the facility by contributing to a delay in exiting the facility, increasing the occupant's exposure to a hazardous condition.

Findings include:

1. On 11/06/14 at approximately 11:10 AM during an inspection of exits with the maintenance supervisor, the following observation was made:

-The shower room door located across from room 124 has door hardware that locks against egress.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on review of records and interview the facility failed to provide written documentation regarding fire drills in accordance with the 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 which may lead to a delay in response to an emergency, exposing occupants to a hazardous condition.

Findings include:

1. On 11/06/14 at approximately 10:00 AM during a review of the facilities fire drill records (untitled) and dated: 01/29/14, 06/13/14, 07/30/14, and 11/20/13 with the maintenance supervisor, the following discovery was made:

-The untitled fire drill records for 3rd shift revealed that the drills are not being held at unexpected times under varying conditions. The fire drills were held on 01/29/14 @ 11:15 PM, 06/13/14 @ 11:30 PM, 07/30/14 @ 11:15 PM, and 11/20/13 @ 11:05 PM.

This deficiency was confirmed by interview with the maintenance supervisor at the time of discovery.

Based on observation and interview the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect occupants of the facility by permitting smoke and fire to travel between smoke compartment exposing occupants to the products of combustion.

Findings include:

1. On 11/06/14 at approximately 11:05 AM during an inspection of smoke barrier doors with the maintenance supervisor, the following observation was made:

-The cross corridor smoke barrier doors between x-ray and ER department did not self close to within an 1/8 th of an inch gap.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview the facility failed to provide for egress in accordance with the LSC sections 19.2.4.1, 19.2.4.2. This deficient practice could potentially affect occupants of the facility by contributing to a delay in the ability to evacuate the facility, exposing occupants to an increased risk of exposure to a hazardous condition.

Findings include:

1. On 11/06/14 at approximately 11:45 AM during an inspection of exits with the maintenance supervisor, the following observation was made:

-The facilities basement only has one exit.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on observation and interview the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect occupants of the facility by contributing to a delay in exiting the facility, increasing the occupant's exposure to a hazardous condition.

Findings include:

1. On 11/06/14 at approximately 11:10 AM during an inspection of exits with the maintenance supervisor, the following observation was made:

-The shower room door located across from room 124 has door hardware that locks against egress.

This deficiency was confirmed by interview with the maintenance supervisor at the time of observation.

Based on review of records and interview the facility failed to provide written documentation regarding fire drills in accordance with the 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 which may lead to a delay in response to an emergency, exposing occupants to a hazardous condition.

Findings include:

1. On 11/06/14 at approximately 10:00 AM during a review of the facilities fire drill records (untitled) and dated: 01/29/14, 06/13/14, 07/30/14, and 11/20/13 with the maintenance supervisor, the following discovery was made:

-The untitled fire drill records for 3rd shift revealed that the drills are not being held at unexpected times under varying conditions. The fire drills were held on 01/29/14 @ 11:15 PM, 06/13/14 @ 11:30 PM, 07/30/14 @ 11:15 PM, and 11/20/13 @ 11:05 PM.

This deficiency was confirmed by interview with the maintenance supervisor at the time of discovery.