HospitalInspections.org

Based on observation during the life safety survey completed on 10/20/2011, the hospital did not maintain the required fire rating protection for vertical openings and stairwell enclosures.

Findings:

1. The storage/raceway access room in the NE stairwell lacks a self-closing device.

2. The corridor door providing fire separation from the multi-story vertical mechanical shaft lacks a label indicating the door is at least a 90 minute rated fire door.

These observations were made in the presence of the chief clinical officer and building engineer.

Based on observation during the life safety survey completed on 10/20/2011, the hospital did not maintain the egress from stairwells to be readily accessible at all times.

Findings:

The central south stairwell at exit discharge lacks a paved walkway to a public way.

This observation was made in the presence of the chief clinical officer and building engineer.

Based on observation during the life safety survey completed on 10/20/2011, the hospital did not provide illuminated exit signs at all required locations.

Findings:

The east exit stairwell lacks an illuminated exit sign at the grade level exit discharge.

This observation was made in the presence of the chief nursing officer and building engineer.

Based on observation and a review of hospital emergency policies and procedures during the life safety survey completed on 10/20/2011, the hospital did not have updated accurate policies and procedures that describe emergency evacuation policies and fire policies for the new building and location.

Findings:

The hospital fire and emergency plans refer to the previous location of the hospital inside Salt Lake Regional Medical Center rather than the current location on the second floor of LDS Hospital.

This observation was made in the presence of the hospital chief clinical officer.

Based on observation during the life safety survey completed on 10/20/2011, the hospital did not provide integrated smoke detection in all required areas of the building per CMS regulations.

Findings:

The communications room which houses an auxiliary fire alarm panel is not protected by an integrated smoke detector.

This observation was made in the presence of the chief clinical officer and building engineer.

Based on observation and a review of hospital smoking policies and procedures during the life safety survey completed on 10/20/2011, the hospital did not have policies and procedures that address smoking by patients who may require staff supervision during smoking.

Findings:

Hospital smoking policies and procedures did not address smoking by patients who may be classified as not responsible to smoke without direct supervision.

This observation was made in the presence of the hospital chief clinical officer.

Based on observation during the life safety survey completed on 10/20/2011, the hospital did not maintain clearly identifiable egress routes from all stairwells.

Findings:

The One NE and Two NE stairwells lack control gates at the level of exit discharge to prevent egress to areas below the level of exit discharge.

These observations were made in the presence of the chief clinical officer and building engineer.

Based on observation during the life safety survey completed on 10/20/2011, the hospital did not maintain electrical equipment in a safe manner in accordance with NFPA 70, The National Electrical Code.

Findings:

The double cover electrical panels located in corridors were observed to be not locked thereby allowing possible access to energized unprotected bus bars and circuits.

This observation was made in the presence of the chief nursing officer and building engineer.

Based on observation and a review of hospital emergency policies and procedures during the life safety survey completed on 10/20/2011, the hospital did not have updated accurate policies and procedures that describe fire watch procedures in the event of a failure or interruption of fire sprinkler system.

Findings:

There were no fire watch policies addressing facility response to the interruption or failure of the fire sprinkler system.

This observation was made in the presence of the hospital chief clinical officer.

Based on observation and a review of hospital emergency policies and procedures during the life safety survey completed on 10/20/2011, the hospital did not have updated accurate policies and procedures that describe fire watch procedures in the event of a failure or interruption of fire alarm system.

Findings:

There were no fire watch policies addressing facility response to the interruption or failure of the fire alarm system.

This observation was made in the presence of the hospital chief clinical officer.