HospitalInspections.org

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect 10 occupants of the facility if smoke and fire is allowed to pass through a fire barrier.

Findings include:

-- On September 19, 2013, at approximately 12:45 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that a conduit penetrating the rated fire wall over the fire doors by room 214, was not completely sealed with a fire-stop system.
The deficiency was confirmed by the Maintenance Supervisor at the time of discovery.

Based on observation the facility failed to provide for doors hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 15 occupants of the facility if the doors failed to close and latch when released.

Findings include:

-- On September 19, 2013, at approximately 12:03 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the North leaf of the rated cross corridor doors located on 3-W did not latch when closed. This deficiency was confirmed at the time of disocovery by the Maintenance Supervisor.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 17 occupants of the facility if smoke is not contained to the smoke compartment.

Findings include:

A. On September 19, 2013, at approximately 11:50 AM, while conducting a walk through with the Maintenance Supervisor, it was observed that the glazing in the smoke barrier wall separating the corridor from OB did not have any marking indicating that it was fire-rated.

B. On September 19, 2013, at approximately 11:52 AM, while conducting a walk through with the Maintenance Supervisor, it was observed that a conduit penetrating the smoke barrier wall above the ceiling in the Nursery was not properly sealed with a fire-stop system.

C. On September 19, 2013, at approximately 1:16 PM. while conducting a walk through with the Maintenance Supervisor, it was observed that a conduit penetrating the smoke barrier wall over the smoke barrier doors to Physical Therapy was not properly sealed with a fire-stop system.

These deficiencies were confirmed at the time of discovery by the Maintenance Supervisor.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 15 occupants of the facility if hazard room failed to contain the smoke and fire.

Findings include:

A. On September 19, 2013, at approximately 12:48 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the Storage room at the 2-W fire doors by patient room 229 was not latching when allowed to close on the closer.

B. On September 19, 2013, at approximately 1:20 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the door hardware on the X-ray storage room on the 1st floor was not latching when allowed to close.

C. On September 19, 2013, at approximately 1:45 PM, while conducting a walk through with the Maintenance Supervisor, it was observed 2 open conduits penetrating the floor to floor separation from the Med Storage room in the east basement.These deficiencies were confirmed at the time of discovery by the Maintenance Supervisor.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect 1 occupants of the facility if door to closet closed and was unable to open again.

Findings include:

-- On September 19, 2013, at approximately 11:40 AM, while conducting a walk through with the Maintenance Supervisor, it was observed that the door hardware to the closet in the Doctor Consult room on the third floor did not latch properly and would not open from the inside of the closet in violation of Section 7.2.1.5.1.

Based on observation and/or review of records 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.

Findings include:

-- On September 19, 2013, between 10 AM and 11:30 AM, while reviewing records and conducting staff interviews, it was determined that the facility missed night shift fire drills for the 3rd and 4th quarter of 2012. This deficiency was confirmed at the time of discovery by the Maintenance Supervisor.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all occupants of the facility if the smoke detection failed to operate as designed.

Findings include:

-- On September 19, 2013, between 10 AM and 11:30 AM, while reviewing records and conducting staff interviews, it was determined that the facility did not have any records of sensitivity testing of the smoke detection within the last 2 years. This deficiency was confirmed by the Maintenance Supervisor at the time of discovery.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility if the fire sprinkler system failed due to the lack of proper maintenance.

Findings include:

A. On September 19, 2013, at approximately 1:00 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the sprinkler head located on the 2nd floor landing in the SW stairwell was obstructed by the ceiling mounted light per NFPA 13, 5-6.5.1.2, preventing coverage to the area under stairs to the 3rd floor.

B. On September 19, 2013, at approximately 1:15 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that according to NFPA 13, 5-6.5.2.1, that the storage in the X-ray store room can not be closer to the heads than 18 inches.

C. On September 19, 2013, at approximately 1:33 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the only sprinkler heads located in the mechanical room are further than 20 feet from the west wall of the room in violation of NFPA 13, 5-5.3.2.

D. On September 19, 2013, at approximately 1:40 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the sprinkler heads in the Med Storage room in the East basement were obstructed by the ductwork per NFPA 13, 5-6.5.1.2, preventing complete coverage of the room.

These deficiencies were confirmed by the Maintenance Supervisor at the time of discovery.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 20 occupants of the facility if the electrical wiring shorted out outside the electrical box.

Findings include:

-- On September 19, 2013, at approximately 1:20 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that an electrical device was hanging by its wires from the electrical box above the ceiling by the smoke barrier doors to Physical Therapy. This deficiency was confirmed at the time of discovery by the Maintenance Supervisor.

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect 10 occupants of the facility if smoke and fire is allowed to pass through a fire barrier.

Findings include:

-- On September 19, 2013, at approximately 12:45 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that a conduit penetrating the rated fire wall over the fire doors by room 214, was not completely sealed with a fire-stop system.
The deficiency was confirmed by the Maintenance Supervisor at the time of discovery.

Based on observation the facility failed to provide for doors hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 15 occupants of the facility if the doors failed to close and latch when released.

Findings include:

-- On September 19, 2013, at approximately 12:03 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the North leaf of the rated cross corridor doors located on 3-W did not latch when closed. This deficiency was confirmed at the time of disocovery by the Maintenance Supervisor.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 17 occupants of the facility if smoke is not contained to the smoke compartment.

Findings include:

A. On September 19, 2013, at approximately 11:50 AM, while conducting a walk through with the Maintenance Supervisor, it was observed that the glazing in the smoke barrier wall separating the corridor from OB did not have any marking indicating that it was fire-rated.

B. On September 19, 2013, at approximately 11:52 AM, while conducting a walk through with the Maintenance Supervisor, it was observed that a conduit penetrating the smoke barrier wall above the ceiling in the Nursery was not properly sealed with a fire-stop system.

C. On September 19, 2013, at approximately 1:16 PM. while conducting a walk through with the Maintenance Supervisor, it was observed that a conduit penetrating the smoke barrier wall over the smoke barrier doors to Physical Therapy was not properly sealed with a fire-stop system.

These deficiencies were confirmed at the time of discovery by the Maintenance Supervisor.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 15 occupants of the facility if hazard room failed to contain the smoke and fire.

Findings include:

A. On September 19, 2013, at approximately 12:48 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the Storage room at the 2-W fire doors by patient room 229 was not latching when allowed to close on the closer.

B. On September 19, 2013, at approximately 1:20 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the door hardware on the X-ray storage room on the 1st floor was not latching when allowed to close.

C. On September 19, 2013, at approximately 1:45 PM, while conducting a walk through with the Maintenance Supervisor, it was observed 2 open conduits penetrating the floor to floor separation from the Med Storage room in the east basement.These deficiencies were confirmed at the time of discovery by the Maintenance Supervisor.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect 1 occupants of the facility if door to closet closed and was unable to open again.

Findings include:

-- On September 19, 2013, at approximately 11:40 AM, while conducting a walk through with the Maintenance Supervisor, it was observed that the door hardware to the closet in the Doctor Consult room on the third floor did not latch properly and would not open from the inside of the closet in violation of Section 7.2.1.5.1.

Based on observation and/or review of records 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.

Findings include:

-- On September 19, 2013, between 10 AM and 11:30 AM, while reviewing records and conducting staff interviews, it was determined that the facility missed night shift fire drills for the 3rd and 4th quarter of 2012. This deficiency was confirmed at the time of discovery by the Maintenance Supervisor.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all occupants of the facility if the smoke detection failed to operate as designed.

Findings include:

-- On September 19, 2013, between 10 AM and 11:30 AM, while reviewing records and conducting staff interviews, it was determined that the facility did not have any records of sensitivity testing of the smoke detection within the last 2 years. This deficiency was confirmed by the Maintenance Supervisor at the time of discovery.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility if the fire sprinkler system failed due to the lack of proper maintenance.

Findings include:

A. On September 19, 2013, at approximately 1:00 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the sprinkler head located on the 2nd floor landing in the SW stairwell was obstructed by the ceiling mounted light per NFPA 13, 5-6.5.1.2, preventing coverage to the area under stairs to the 3rd floor.

B. On September 19, 2013, at approximately 1:15 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that according to NFPA 13, 5-6.5.2.1, that the storage in the X-ray store room can not be closer to the heads than 18 inches.

C. On September 19, 2013, at approximately 1:33 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the only sprinkler heads located in the mechanical room are further than 20 feet from the west wall of the room in violation of NFPA 13, 5-5.3.2.

D. On September 19, 2013, at approximately 1:40 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the sprinkler heads in the Med Storage room in the East basement were obstructed by the ductwork per NFPA 13, 5-6.5.1.2, preventing complete coverage of the room.

These deficiencies were confirmed by the Maintenance Supervisor at the time of discovery.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 20 occupants of the facility if the electrical wiring shorted out outside the electrical box.

Findings include:

-- On September 19, 2013, at approximately 1:20 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that an electrical device was hanging by its wires from the electrical box above the ceiling by the smoke barrier doors to Physical Therapy. This deficiency was confirmed at the time of discovery by the Maintenance Supervisor.