HospitalInspections.org

Based on observation, testing, and interview, the provider failed to continuously maintain exits free of all obstructions for two of two exits from the operating room suite. Findings include:

1. Observation on 9/8/21 at 11:42 a.m. revealed the north exit door out of the operating room suite was equipped with electrical lock hardware that prevented egress. Testing of the door by applying force in the direction of the path of egress revealed it was locked and would not release. Further testing at that same time revealed that door would only open when the "handicap access" button twelve feet back into the suite was pressed

Interview at the time of the observation with the plant maintenance supervisor confirmed that condition. He stated that condition had existed since that space had been created.

2. Observation on 9/8/21 at 11:54 a.m. revealed the east exit door out of the operating room suite was equipped with electrical lock hardware that prevented egress. Testing of the door by applying force in the direction of the path of egress revealed it was locked and would not release. Further testing at that same time revealed that door would only open when the "handicap access" button twelve feet back into the suite was pressed

Interview at the time of the observation with the plant maintenance supervisor confirmed that condition. He stated that condition had existed since that space had been created.

Failure to provide egress doors as required increases the risk of death or injury due to fire.

The deficiency affected the entire suite.

Ref: 2012 NFPA 101 Section 19.2.1, 7.1.10.1

Based on observation, testing, and interview the provider failed to maintain the fire-resistive design of one randomly observed horizontal exit and building separation wall (outside chapel). Findings include:

1. Observation and testing on 9/8/21 at 12:20 p.m. revealed the two-hour, fire-rated separation wall outside the chapel had ninety-minute, fire-rated wood doors. Testing at that same time revealed the north leaf of those doors when released would strike the south leaf and prevented it from latching into the frame.
Fire doors must latch into their frames to maintain their fire resistive-rating.

Interview with the maintenance supervisor at that same time confirmed that condition.

The deficiency could affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to properly maintain one randomly observed fire extinguishers (I.T. room). Findings include:

1. Observation and interview at 11:30 a.m. on /26/19 revealed the extinguisher inside the I.T. room sitting on the floor had not received its monthly or annual inspections since 2015.

Interview with the environmental services director at the time of the observation confirmed that finding. He stated he was unaware there was a fire extinguisher in that location. He further stated he would add that extinguisher to the inspection list.

The deficiency has the potential to affect the entire smoke compartment.

Based on observation and interview, the provider failed to maintain one randomly observed enclosure (oxygen storage room) as required. Findings include:

1. Observation on 9/8/21 at 1:10 p.m. revealed the door to the oxygen storage room was equipped with a closer and did not latch into its frame. That door is required to latch into its frame to maintain the required enclosure.

Interview with the maintenance supervisor at the same time as the observation confirmed that finding.

The deficiency had the potential to affect 100% of the occupants of the smoke compartment.