HospitalInspections.org

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or five patient rooms, potentially affecting the staff, visitors and as many as 57 patient beds in a facility with a census of seven, four those patients in Swing Beds.

Findings include:

1. Observation on 9/14/10 at 11:30 A.M. doors to the following patient rooms failed to close and latch securely into the door frame as follows:
108-did not close into jamb and latch
109-dragged and closed with effort
105-dragged and did not close to latch
103-dragged and did not close to latch
102-dragged and closed with effort

During an interview on 9/14/10 at 11:55 A.M., the Maintenance Director said the humidity probably affected the doors. He said, every year there seems to be some kind of a problem with a door or two related to the humidity. He said he may have to plane a couple of the problem doors off to make them fit better into the frame.

Based on observations and interview, the facility failed to ensure a minimum 20-minute fire protection rating for two smoke barriers (a wall constructed to provide a fire barrier and resist the passage of smoke) on the first floor in accordance with 18.3.7.6 of the Life Safety Code requirements for new construction The deficient practice affects the separating corridor between existing and new construction and a total of four smoke compartments of the emergency, radiology and nuclear medicine departments and the access corridor to the east exit of a single story facility, affecting the staff, visitors and a patient census of seven, four those patients in Swing Beds.

Findings included:

1. Observations on 9/14/10 at 1:00 P.M. showed no astragals (a molding attached to one of two leafs of a double door that creates a smoke tight barrier) to prevent the spread of smoke from one compartment to another at the C100 North corridor where the existing structure is separated from an enclosed corridor connecting it to the new addition. The doors were on magnetic hold opens and closed to a gap greater than one eight inch.

2. Observations on 9/14/10 at 2:20 P.M. showed no astragal on a set of doors in a smoke barrier at the east end of the building (outside of emergency department and toward the helipad). The doors are part of a smoke control system serving protected egress from three separate smoke compartments. The doors were on magnetic hold opens and closed to a gap greater than one eight inch.

During an interview on 9/14/10 at 2:30 P.M., the Maintenance Director said the doors were added during the recently finished construction and he did not know why the installers did not put strips on those doors. He said the other smoke doors in the new construction had astragals. He said, due to changes in building settling and humidity, maintenance personnel do check all smoke doors throughout the facility on a regular basis to ensure they close without dragging or have too large of a gap between them. He observed the other pairs of smoke doors in the in new construction did have astragals and were smoke tight. He said they would get astragals on the two sets of doors immediately.

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or five patient rooms, potentially affecting the staff, visitors and as many as 57 patient beds in a facility with a census of seven, four those patients in Swing Beds.

Findings include:

1. Observation on 9/14/10 at 11:30 A.M. doors to the following patient rooms failed to close and latch securely into the door frame as follows:
108-did not close into jamb and latch
109-dragged and closed with effort
105-dragged and did not close to latch
103-dragged and did not close to latch
102-dragged and closed with effort

During an interview on 9/14/10 at 11:55 A.M., the Maintenance Director said the humidity probably affected the doors. He said, every year there seems to be some kind of a problem with a door or two related to the humidity. He said he may have to plane a couple of the problem doors off to make them fit better into the frame.

Based on observations and interview, the facility failed to ensure a minimum 20-minute fire protection rating for two smoke barriers (a wall constructed to provide a fire barrier and resist the passage of smoke) on the first floor in accordance with 18.3.7.6 of the Life Safety Code requirements for new construction The deficient practice affects the separating corridor between existing and new construction and a total of four smoke compartments of the emergency, radiology and nuclear medicine departments and the access corridor to the east exit of a single story facility, affecting the staff, visitors and a patient census of seven, four those patients in Swing Beds.

Findings included:

1. Observations on 9/14/10 at 1:00 P.M. showed no astragals (a molding attached to one of two leafs of a double door that creates a smoke tight barrier) to prevent the spread of smoke from one compartment to another at the C100 North corridor where the existing structure is separated from an enclosed corridor connecting it to the new addition. The doors were on magnetic hold opens and closed to a gap greater than one eight inch.

2. Observations on 9/14/10 at 2:20 P.M. showed no astragal on a set of doors in a smoke barrier at the east end of the building (outside of emergency department and toward the helipad). The doors are part of a smoke control system serving protected egress from three separate smoke compartments. The doors were on magnetic hold opens and closed to a gap greater than one eight inch.

During an interview on 9/14/10 at 2:30 P.M., the Maintenance Director said the doors were added during the recently finished construction and he did not know why the installers did not put strips on those doors. He said the other smoke doors in the new construction had astragals. He said, due to changes in building settling and humidity, maintenance personnel do check all smoke doors throughout the facility on a regular basis to ensure they close without dragging or have too large of a gap between them. He observed the other pairs of smoke doors in the in new construction did have astragals and were smoke tight. He said they would get astragals on the two sets of doors immediately.