HospitalInspections.org

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

- On May 2, 2011 at approximately 10:30 AM, observed that the "EXIT" sign at the 1st floor of stairway #5 was not illuminated.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect 25 occupants of the facility. Findings include:

- On May 3, 2011 at approximately 1:45 PM, observed combustible materials stored in room 3414. The room is about 188 sq. ft. and is not constructed to provide a 1 hour fire separation.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11. This deficient practice could potentially affect 40 occupants of the facility. Findings include:

- On May 2, 2011 at approximately 1:15 PM, observed sprinkler piping penetrating stairway #4, above the door that is not fire stopped.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 19.2.2.3, 19.2.2.4. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

- On May 2, 2011 at approximately 10:20 AM, observed on the 1st floor of stairway #5 no effective means of preventing occupants from going below the level of exit discharge. A chain had been installed to block the way, but someone had taken the chain from one side and hung it on the opposite side of the stairway, not putting it back as required. A chain was also noted in east stairway, but the chain was in place.

- On May 3, 2011 at approximately 1:25 PM, observed the 2nd floor west stairway exits into the 1st floor lobby of the building, which becomes an exit passageway. The exit passageway is not sprinkler protected does not have the same fire resistance rating of the stairway. 7.2.6.3

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 35 occupants of the facility. Findings include:

- On May 2, 2011 between the hours of 11:20 AM and 12:10 PM, observed linen carts and blood pressure equipment charging in the egress corridor at the southwest area of the 3rd floor.

- On May 2, 2011 between the hours of 12:10 PM and 12:40 PM, observed corridor wall chart racks for the following rooms did not self close when released from use: 3346, 3343, 3339, 3338.

- On May 2, 2011 at approximately 2:00 PM, observed the exterior exit door in stairway #1 is rusted and difficult to open.

- On May 3, 2011 at approximately 10:15 AM, observed the corridor wall chart box for room 2335 does not self close when released from use.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8. This deficient practice could potentially affect 40 occupants of the facility. Findings include:

- On May 2, 2011 at approximately 1:30 PM, observed lights are burned out in stairway #4, between the 1st and 2nd floors.

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 90 occupants of the facility. Findings include:

- On May 3, 2011 by review of records, observed that the facility has not performed a sensitivity test for the smoke detectors.

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 62 occupants of the facility. Findings include:

- On May 2, 2011 at approximately 10:15 AM, observed the building fire department connections are missing the protective caps.

- On May 3, 2011 at approximately 12:15 PM by review of records, observed the fire sprinkler system is passed due for annual inspection and testing.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 35 occupants of the facility. Findings include:

- On May 2, 2011 at approximately 1:45 PM, observed an oxygen cylinder free standing in the corridor next a cylinder stand across from room 3348.