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Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect patients, staff and visitors in 1 of 2 smoke compartments in the event of a fire not being contained to the hazardous room.

Findings include:

On 8/27/13 at approximately 11:50am, the Isolation Ante Room was observed to have a large amount of equipment stored within it. This room is not constructed with a 1-hour fire rated separation and also obstructs egress from the Isolation Room. This condition was noted with the Environmental Services Supervisor present.

On 8/27/13 at approximately 12:02pm, Supply Room 1113 was observed to not be equipped with a self-closing device on the door. The door is rated for 45 minutes and the room is 1-hour protected as a hazardous area. This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to maintained emergency lighting in accordance with the LSC section 18.2.9.1. This deficient practice could potentially affect patients and staff in the surgery area in the event of a generator failure.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility did not have documentation of the 30-second monthly testing of the battery operated emergency lighting in the operating rooms. This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility in the event of staff not knowing their roles in emergency response.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility Fire Safety Plan was noted as being very fragmented with various duties and documents for each department. The overall Fire Safety Plan had not been updated to the new building. This condition was noted with the Environmental Services Supervisor present.

Based on observation the facility failed to provide an approved fire alarm system in accordance with the LSC sections 18.3.4, 9.6. This deficient practice could potentially affect visitors and staff in the Main Entrance in the event of a fire not being contained by the 2-hour fire-rated occupancy separation.

Findings include:

On 8/27/13 at approximately 12:26pm, the following rooms were observed to have magnetic-type hold open devices for the doors without the required smoke detection for door release required by Section 7.2.1.8.2 of NFPA 101:
Financial Services 1248
Registration 1250
Registration 1251
This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to maintain the fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants in the facility in the failure of the alarm system to provide emergency forces notification.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility did not have documentation of the quarterly test of the off-premises transmission equipment in accordance with Section 7-3.2 of NFPA 72. This condition was noted with the Environmental Services Supervisor present.

Based on observation the facility failed to provide a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could potentially affect staff in the noted area in the event of a fire not being controlled by the sprinkler system.

Findings include:

On 8/27/13 at approximately 11:48am, no sprinkler protection was provided below the overhead garage door in Receiving. The door creates an obstruction greater than 4 feet in width when in the open postion in violation of Section 5-6.5.3.1 of NFPA 13. This condition was noted with the Environmental Services Supervisor present.

Based on observation and review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and tested in accordance with the LSC sections 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all patients, staff and visitors in the event of a malfunction of the sprinkler system due to improper maintenance.

Findings include:

On 8/27/13 at approximately 11:47am, the storage in Central Stores was observed to be within 18 inches of the sprinklers in violation of Section 5-6.5.2.1 of NFPA 13. This condition was noted with the Environmental Services Supervisor present.

On 8/27/13 at approximately 12:18pm, the storage in X-Ray Storage was observed to be within 18 inches of the sprinkler in violation of Section 5-6.5.2.1 of NFPA 13. This condition was noted with the Environmental Services Supervisor present.

On 8/27/13 between 10:20am and 11:20am during records review, the facility did not have documentation of the quarterly flow testing required by Section 2-3.3 of NFPA 25. This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility in the event of a generator failure due to improper maintenance.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility documentation of the monthly load testing of the generator provided no details of the load in relation to generator capacity to determine compliance with Section 6-4.2 of NFPA 110. This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility in the event of a failure of the sprinkler system without a fire watch in place.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility did not have a policy for when the sprinkler system is out of service for more than 4 hours in a 24-hour period. The current policy only references the fire alarm system. This condition was noted with the Environmental Services Supervisor present.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect patients, staff and visitors in 1 of 2 smoke compartments in the event of a fire not being contained to the hazardous room.

Findings include:

On 8/27/13 at approximately 11:50am, the Isolation Ante Room was observed to have a large amount of equipment stored within it. This room is not constructed with a 1-hour fire rated separation and also obstructs egress from the Isolation Room. This condition was noted with the Environmental Services Supervisor present.

On 8/27/13 at approximately 12:02pm, Supply Room 1113 was observed to not be equipped with a self-closing device on the door. The door is rated for 45 minutes and the room is 1-hour protected as a hazardous area. This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to maintained emergency lighting in accordance with the LSC section 18.2.9.1. This deficient practice could potentially affect patients and staff in the surgery area in the event of a generator failure.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility did not have documentation of the 30-second monthly testing of the battery operated emergency lighting in the operating rooms. This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility in the event of staff not knowing their roles in emergency response.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility Fire Safety Plan was noted as being very fragmented with various duties and documents for each department. The overall Fire Safety Plan had not been updated to the new building. This condition was noted with the Environmental Services Supervisor present.

Based on observation the facility failed to provide an approved fire alarm system in accordance with the LSC sections 18.3.4, 9.6. This deficient practice could potentially affect visitors and staff in the Main Entrance in the event of a fire not being contained by the 2-hour fire-rated occupancy separation.

Findings include:

On 8/27/13 at approximately 12:26pm, the following rooms were observed to have magnetic-type hold open devices for the doors without the required smoke detection for door release required by Section 7.2.1.8.2 of NFPA 101:
Financial Services 1248
Registration 1250
Registration 1251
This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to maintain the fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants in the facility in the failure of the alarm system to provide emergency forces notification.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility did not have documentation of the quarterly test of the off-premises transmission equipment in accordance with Section 7-3.2 of NFPA 72. This condition was noted with the Environmental Services Supervisor present.

Based on observation the facility failed to provide a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could potentially affect staff in the noted area in the event of a fire not being controlled by the sprinkler system.

Findings include:

On 8/27/13 at approximately 11:48am, no sprinkler protection was provided below the overhead garage door in Receiving. The door creates an obstruction greater than 4 feet in width when in the open postion in violation of Section 5-6.5.3.1 of NFPA 13. This condition was noted with the Environmental Services Supervisor present.

Based on observation and review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and tested in accordance with the LSC sections 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all patients, staff and visitors in the event of a malfunction of the sprinkler system due to improper maintenance.

Findings include:

On 8/27/13 at approximately 11:47am, the storage in Central Stores was observed to be within 18 inches of the sprinklers in violation of Section 5-6.5.2.1 of NFPA 13. This condition was noted with the Environmental Services Supervisor present.

On 8/27/13 at approximately 12:18pm, the storage in X-Ray Storage was observed to be within 18 inches of the sprinkler in violation of Section 5-6.5.2.1 of NFPA 13. This condition was noted with the Environmental Services Supervisor present.

On 8/27/13 between 10:20am and 11:20am during records review, the facility did not have documentation of the quarterly flow testing required by Section 2-3.3 of NFPA 25. This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility in the event of a generator failure due to improper maintenance.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility documentation of the monthly load testing of the generator provided no details of the load in relation to generator capacity to determine compliance with Section 6-4.2 of NFPA 110. This condition was noted with the Environmental Services Supervisor present.

Based on review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility in the event of a failure of the sprinkler system without a fire watch in place.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility did not have a policy for when the sprinkler system is out of service for more than 4 hours in a 24-hour period. The current policy only references the fire alarm system. This condition was noted with the Environmental Services Supervisor present.