HospitalInspections.org

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.

Findings include:

On 08/25/10, at approximately 10:00 A.M., during an inspection of smoke barrier walls with the maintenance director, the following observation was made:

1. Observed two large holes through the smoke barrier wall in room # E31.

Based on review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1.

Findings include:

On 08/25/10, at approximately 2:00 P.M., during review of records with the maintenance director, the following observations were made:

1. The facility fire watch policy that was provided to the surveyor did not state that it was the sole duties of the person conducting the fire watch.

2. The facility fire watch policy that was provided to the surveyor did not state that the fire watch rounds would be constant rounds as required. The policy stated that the rounds would be completed hourly.

Based on 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.

Findings include:

On 08/25/10, at approximately 2:30 P.M., during review of records with the maintenance director, the following observation was made:

1. Sprinkler water flow testing is being completed semi-annually instead of quarterly as required.

Based on review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99.

Findings include:

On 08/25/10, at approximately 3:00 P.M., during review of records with the maintenance director, the following observation was made:

1. No record of weekly visual inspections for the weeks of June 13, 2010 & June 20, 2010.