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Based on observation and interview, the facility failed to ensure 1 of 1 nonconforming business occupancy buildings were separated from health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. This deficient practice affects all occupants of the building.

Findings include:

Based on observations during a tour of the facility on 12/10/19 at 3:20 p.m. with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, and the Safety Coordinator:
The hospital, a two story building of Type II (111) construction was connected to a two story medical office building of Type V (111) construction by a breezeway of Type V (000) construction. The Hospital lacked a fire barrier separation having a least a two hour fire resistance rating. Based on interview at the time of observation, the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager confirmed the lack of a two fire barrier separation and indicated the hospital had a variance when the hospital was constructed and installed additional sprinklers where the two hour fire barrier would be.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all building occupants.

Findings include:

During record review on 12/10/19 at 11:14 a.m., with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, Safety Coordinator, Vice President of Patient Services, Police Captain, SVP Support Manager, and the Director of Emergency Preparedness, an annual visual/functional fire alarm inspection conducted on 10/17/19 was provided but documentation regarding a visual semi-annual fire alarm system inspection conducted six months prior to the annual was not provided. Based on interview at the time of record review, the Corporate Director of Facilities, Technical Operations Manager, and Facilities Manager stated a visual semi-annual inspection of the fire-alarm system was not completed.

Based on record review and interview, the facility failed to ensure 9 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice could affect all building occupants.

Findings include:

During record review on 12/10/19 at 11:14 a.m., with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, Safety Coordinator, Vice President of Patient Services, Police Captain, SVP Support Manager, and the Director of Emergency Preparedness, after February 2019 the fire drill forms did not indicated transmission of signal to the monitoring company. Based on interview at the time of record review, the Police Captain stated the drill form was changed at the beginning of the year and did not include a space to record the transmission of the alarm signal to the monitoring company.

Based on observation and interview; the facility failure to ensure 1 of 1 portable space heaters were not used in areas accessible to patient. This deficient practice could affect all building occupants due to all patients, visitors, and staff can use the main entrance.

Findings include:

Based on observations during a tour of the facility on 12/10/19 at 3:00 p.m. with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, and the Safety Coordinator, a portable fire place containing a space heater was used in a patient area. In the main entrance waiting area there was a moveable electric fire place with a heater. When tested, the heater did turn on and produced heat. Based on interview at the time of observation, the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, stated there is a working electric fire place with a heater in an area accessible to patients.

Based on observation, record review and interview, the facility failed to ensure the hospital grade electrical receptacles in 25 of 25 patient sleeping rooms and in 2 of 2 operating rooms were tested after initial installation, replacement, or servicing of the device. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.1 where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. Section 6.3.3.2 states Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). This deficient practice could affect all building occupants.

Findings include:

Based on observations during a tour of the facility on 12/10/19 between 1:00 p.m. and 3:40 p.m. with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, and the Safety Coordinator, the facility's 25 patient care rooms contained over 10 hospital grade electrical receptacles, and the two operating rooms were general anesthesia is administered contained around 20 hospital grade electrical receptacles.
During record review on 12/10/19 at 11:14 a.m., with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, Safety Coordinator, Vice President of Patient Services, Police Captain, SVP Support Manager, and the Director of Emergency Preparedness, no documentation was available to show electrical receptacles in the patient care rooms and in the operating rooms were tested after initial installation, replacement, or servicing of the device. Based on interview at the time of the observation and records review, the Corporate Director of Facilities, Technical Operations Manager, and Facilities Manager confirmed all of the electrical receptacles in the patient care rooms and in the operating rooms were hospital-grade and stated it is unknown if initial testing per NFPA 99, Receptacle Testing requirements was conducted