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Based on observations and interview, the facility failed to ensure items stored in 1 of 3 exit stairways would not interfere with egress. LSC 7.2.2.5.3.2 states open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress. This deficient practice affects all patients, staff, or visitors that would use stairway 323 in an event of an emergency.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 at 1:14 p.m., the open space under exit stairwell 323 on the ground floor was used to store tables and chairs. Based on interview at the time of observation, the Facilities Director and the Environmental Care Coordinator acknowledged exit stairway 323 was used for storage.

Based on observation and interview, the facility failed to ensure 1 of 2 fire door sets in the basement was arranged to automatically close and latch. LSC 7.2.4.3.10 requires all fire door assemblies in horizontal exit shall be self-closing or automatic-closing. In addition NFPA-80 2010 edition, 6.1.4.3.1 states the fire door shall latch upon closing. This deficient practice was not in a patient care area but could affect all staff in the basement.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 at 1:26 p.m., the fire door set by outside storage failed to latch into the frame. Based on interview at the time of observation, this was acknowledged and confirmed these were fire doors by the Facilities Director and the Environmental Care Coordinator.

Based on observation and interview, the facility failed to ensure the failure of any single lighting fixture would not leave the area an illumination level of less than 0.2 foot candle (2.2 lux) of 1 of 1 kitchen exits in accordance with 7.8.1.4. This deficient practice could affect all kitchen staff exiting the kitchen.

Finding include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 at 2:35 p.m., the exterior exit discharge from the back kitchen exit was equipped with a single light fixture with a single bulb. Based on interview at the time of observation, this was acknowledged by the Facilities Director and the Environmental Care Coordinator.

Based on observation and interview, the facility failed to ensure continuity of egress lighting for 5 of 16 emergency exits. LSC 7.9.1.1 Emergency lighting for the means of egress shall be provided. 7.9.2.3 The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting. This deficient practice could affect all patients, staff and visitors using the facilities exits in event of a power frailer.

Finding include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 between 12:00 p.m. and 3:00 p.m. and on 11/02/16 between 9:00 a.m. and 11:30 a.m., the exit discharge sidewalks from exit #1, #2, #12, #15, and #16 had lighting fixtures down the sidewalks to the common way, but none of the fixtures were provided with back up emergency power. Based on interview at the time of observations, the Facilities Director and the Environmental Care Coordinator confirmed that aforementioned emergency lights were not on the generator.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained. LSC 39.3.4.2 refers to 9.6. LSC 9.6.1.5 states to ensure operational integrity, the fire alarm system shall have an approved maintenance program accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. NFPA 72, 14.3.1 requires 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 "Visual Inspection Frequencies" requires alarm initiating devices, alarm notification appliances, batteries, and initiating devices to be tested at least annually. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on records review with the Facilities Director and the Environmental Care Coordinator on 11/01/16 at 10:14 a.m. no record of an annual fire alarm inspection was available for review. Based on interview at the time of observation, the Facilities Director and the Environmental Care Coordinator stated the owner of the Medical Office Building where the sleep center is located did not have the latest inspection paper work.

Based on observation and interview, the facility failed to ensure 1 of 1 laundry rooms were separated from other spaces by smoke resisting partitions and doors. This deficient practice was not in a patient care area but could affect any staff in the basement.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 at 1:14 p.m., behind the fuel dryer access in the laundry room was an unsealed half inch penetration around a pipe. Based on an interview at the time of observation, the Facilities Director and the Environmental Care Coordinator acknowledged the penetration and provided the measurement.

Based on observation and interview, the facility failed to ensure complete automatic sprinkler system was provided for 1 of 1 laundry rooms in accordance with NFPA 13-2010, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice was not in a patient care area but could affect any staff in the basement.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 at 1:14 p.m., the rear dryer access in the laundry room lacked sprinkler coverage. Based on an interview at the time of observation, the Facilities Director and the Environmental Care Coordinator acknowledged there was no sprinkler head behind the dryers.

Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers for the automatic sprinkler system in accordance with NFPA 25, 2011 Edition 5.4.1.4 which requires a supply of spare sprinklers (never fewer than six) shall be maintained on premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. 5.4.1.4.1 The sprinklers shall correspond to the types and temperature ratings of the sprinkler on the property. 5.4.1.4.2 The sprinklers shall be kept in a cabinet located where the temperature in which are subjected will at no time exceed 100 degrees F. This deficient practice could affect all occupants if the sprinkler system had to be shut down because a proper sprinkler wasn't available as a replacement.

Findings include:

Based on observations at the sprinkler riser with the Facilities Director and the Environmental Care Coordinator on 11/01/16 at 1:44 p.m., there were no sidewall or pendant sprinklers in the spare sprinkler cabinet. Based on observation during the tour between 12:00 p.m. and 3:00 p.m., there were sidewall, upright, pendant and concealed sprinkler heads throughout the facility. Based on interview at the time of observation, the Facilities Director and the Environmental Care Coordinator confirmed there were two of the four types of spare sprinkler heads missing.

Based on observation and interview, the facility failed to maintain 1 of 1 K Class portable fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition. NFPA 10, 5.5.5 requires fire extinguishers provided for the protection of cooking appliances use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 5.5.5.3 requires a placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. This deficient practice could affect all patients, visitors, and staff using the main dining room.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 at 2:33 p.m., the kitchen K Class fire extinguisher lacked a placard. Based on an interview at the time of observation, the Facilities Director and the Environmental Care Coordinator confirmed the kitchen K Class fire extinguisher lacked a placard identifying its use as secondary backup to the kitchen automatic fire suppression system.

Based on observation and interview, the facility failed to ensure there were no impediments to the closing of 4 of 9 meeting or store room doors on first floor entry smoke compartment. This deficient practice could affect all patients, visitors, and staff.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 between 12:00 p.m. and 3:00 p.m. the corridor door to the following rooms were propped open with a door wedge:
a) The gift shop store room.
b) The Prayer Room.
c) The Learning Center
d) Meeting room #3
Based on interview at the time of observation, this was acknowledged by the Facilities Director and the Environmental Care Coordinator.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 8 of 14 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. NFPA 101 2012 edition 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC 8.5. 8.5.2.2 States smoke barriers required by this code shall be continuous from outside wall to outside wall, from floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6.2 Requires penetrations for cable, conduit, pipe, or wire...of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. This deficient practice affects all patients, staff, and visitors of the hospital.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/02/16 between 9:50 a.m. and 12:00 p.m. the following smoke barrier walls had unsealed penetrations:
a) Above the ceiling tiles of the smoke barrier wall by OB there was an unsealed one inch penetration at the end of an open conduit.
b) Above the ceiling tiles of the smoke barrier wall by 220 there were two unsealed one inch penetrations at the end of an open conduit.
c) Above the ceiling tiles of the smoke barrier wall by 204 there were two unsealed one inch penetrations at the end of an open conduit.
d) Above the ceiling tiles of the curved Won-door smoke barrier wall there were a total of six unsealed penetrations measuring from one inch to six inches in size.
e) Above the ceiling tiles of the smoke barrier wall by ER there were two unsealed inch and a half holes and an unsealed six inch by six inch hole.
f) Above the ceiling tiles of the smoke barrier wall by the woman ' s center there was an unsealed one inch penetration at the end of an open conduit and an unsealed six inch crack.
g) Above the ceiling tiles of the smoke barrier wall by the rear main elevators there were six unsealed one inch holes and two unsealed three by three inch holes.
h) Above the ceiling tiles of the first floor Won-door smoke barrier wall was an unsealed two inch penetration at the end of an open conduit and two unsealed gaps along two support beams.
Based on interview at the time of observation, the Facilities Director and the Environmental Care Coordinator acknowledged and provided the measurements of the penetrations.

Based on observation and interview, the facility failed to ensure 1 of 16 sets of smoke barrier doors in the hospital would restrict the movement of smoke for at least 20 minutes. NFPA 101 2012 19.3.7.8 requires doors in smoke barriers shall comply with LSC Section 8.5.4. LSC 8.5.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch. This deficient practice could affect 10 patients, staff, and visitors in the ER.

Finding include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/02/16 at 11:00 a.m. the smoke barrier doors entering the ER had a one half inch gap between the doors when closed. Based on an interview at the time of observation, the Facilities Director and the Environmental Care Coordinator acknowledge the gap in the smoke doors.

Based on observation and interview, the facility failed to ensure 2 of 2 receptacles near a wet location was provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70 2011 edition, 517.20 (A) defines wet locations as patient care areas subjected to wet conditions while patients are present. These include standing fluids on the floor shall be provide with special protection against electric shock by one of the following means:
(1) Power distribution systems that inherently limits the possible ground fault current due to first fault to a low value, without interrupting the power supply.
(2) Power distribution systems in which the power supply is interrupted if the ground fault current does. This deficient practice could affect up to four patients in the lab and assessment room.

Findings include:

Based on observations during a tour of the facility with the Facilities Director on 11/02/16 between 11:27 a.m. and 11:30 a.m. in assessment room #4 and the lab room there was a power receptacle within six inches of a sink faucet. Based on interview the Facilities Director acknowledged the receptacles were not provided with GFCI protection.

Based on observation and interview, the facility failed to ensure there were battery-powered lighting for 3 of 3 anesthesia areas. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provide within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect three patients, and staff during surgery.

Findings include:

Based on observations during a tour of the facility with the Environmental Care Coordinator on 11/02/16 between 9:00 a.m. and 11:00 a.m., operating rooms one, two, and three did not have battery-powered lighting. Based on interview at the time of observation, the Environmental Care Coordinator acknowledged all three operating room that used deep sedation and general anesthesia did not have backup battery-powered lighting.

Based on observation and interview, the facility failed to ensure there were ground-fault circuit interrupters (GFCI) for 3 of 3 wet procedure locations in the O.R. This deficient practice could affect three patients, and staff during surgery.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/02/16 between 9:00 a.m. and 10:00 a.m. the following O.R. rooms did not have all electrical outlets GFCI protected:
a) O.R. #1 had a 220 volt (v) outlet and one 110v outlet.
b) O.R. #2 had a 220v outlet and one 110v outlet.
c) O.R. #3 had a 220v outlet and one 110v outlet.
The 110v outlets were providing power to anesthesia equipment that were sitting on the ground. Based on interview at the time of observation, the Environmental Care Coordinator acknowledged the 220v outlets confirmed there were not GFCI protected. Facilities Director stated the 110v outlets were not GFCI protected because the equipment plugged into them would trip a GFCI outlet and the equipment takes 15 minutes to restart. Also, the Facilities Director stated there was not a risk assessment conducted to show that the 110v outlets could be unprotected by a GFCI.

Based on observation and interview, the facility failed to ensure 4 of 4 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA-70/2011, 400.8 states unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. This deficient practice could affect up to 10 patients in the Imaging Center, Lab, and staff in the basement.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 between 12:00 p.m. and 3:00 p.m., the following high current draw equipment was plugged into and supplied power by an extension cord or extension cord power strip:
a) A microwave and coffee pot in the environmental services office.
b) A microwave in the I.T. office.
c) A microwave in the laboratory breakroom.
d) A microwave and a coffee in the imaging breakroom.
Based on interview at the time of observations, the power strips and/or extension cords were acknowledged by the Facilities Director and the Environmental Care Coordinator.