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Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained.

Findings include:

On 05/07/2019 at 1:30pm while in the company of the DPO, it was observed that a pair of cross corridor doors were not provided with the required signage to comply with 7.2.1.6.1.1(4) in accordance with Delayed Egress locking devices. Location observed: Corridor C1002 adjacent to Work Area A-150
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Based on observation, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice could affect patients, staff and visitors and may compromise the prompt care and movement if during a fire/smoke emergency a longer route would be required to exit.

Finding includes:

On 05/07/2019 at 11:15am while accompanied by the DPO a corridor was observed in which access is provided through rooms other than Lobbys which does not comply with 19.2.5.4 and 7.5.1.2.
Location observed: Corridor in B Wing contains a designated exit which leads into the Emergency Department suite.

Based on observation, document review and staff interview, emergency lighting is not tested and maintained. This deficient practice could affect patients, staff and visitors if failure to test and maintain the installed emergency lighting system can result in failure of the system to perform when needed during loss of normal power.

Finding includes:

On 05/07/2019 at 2:00pm, while in the company of the DPO during document review battery powered emergency lighting annual testing for the 1.5 hour duration was not conducted and recorded to comply with 7.9.3.1.1 (3).

Based upon observation, sprinklered hazardous areas are not separated by a minimum of smoke resisting construction. this deficient practice could affect patiens, staff and visitors if a failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

Finding includes:

On 05/07/2019 at 9:50am while accompanied by the DPO a room/area not designated as hazardous is used as storage for plastic wrapped equipment and combustibles. The area is open to a means of egress corridor. Location observed: B Wing former Physical Therapy. This condition does not comply with 19.3.2.1.2 and 8.4.2 (3).

Based on observation not all exit access corridors are separated from use areas. This deficiency could affect any patients, staff, or visitors in the immediate area if smoke were to enter the egress corridor.

The finding is:

On 05/07/2019 at 1:15pm while accompanied by the DPO a patient treatment area was observed separated from the corridor by a privacy curtain. This condition does not comply with 19.3.6.1.1 a). Location observed: corridor adjacent to the Emergency Department, area is referred to as "Patient Triage".