HospitalInspections.org

Based upon observations and staff interviews, during the Life Safety Survey, it was determined the facility did not ensure the integrity of the smoke barriers were maintained to form two separate and distinct compartments. A smoke barrier door that is not maintained smoke tight would, in the event of fire, allow fire, smoke and toxic gasses to migrate into adjacent smoke compartments prolonging exposure to the buildings occupants. This poses potential for adverse affects to health and safety.

The findings include:

During the tour of the facility with staff representatives on September 14, 2010, it was observed a number of self-closing fire doors in the OR areas had an impediments that prevented the doors from achieving closing function and adequate positive latching. The doors, upon testing, did not self close or achieve a positive latch due to frame misalignment and latching mechanism failure. Reference: NFPA 101 (2000 Edition): 19.2.2.2.6: "Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2."

1. Tested doors included: OR #3 and OR #4 (front corridor and sterile area egress) failed to latch when tested a 10:15 a.m. due to latching mechanism failure and frame misalignment.

2. OB OR's #1 and #2, to include the sterile corridor egress doors, failed to latch due to mechanism failure when tested at 2:00 p.m.

3. Nurse station third floor corridor fire door failed to close or latch when tested due to obstructions and mechanism failure.

Based upon observations and staff interviews, during the Life Safety Survey, it was determined the facility did not ensure the integrity of the smoke barriers were maintained to form two separate and distinct compartments. A smoke barrier door that is not maintained smoke tight would, in the event of fire, allow fire, smoke and toxic gasses to migrate into adjacent smoke compartments prolonging exposure to the buildings occupants. This poses potential for adverse affects to health and safety.

The findings include:

During the tour of the facility with staff representatives on September 14, 2010, it was observed a number of self-closing fire doors in the OR areas had an impediments that prevented the doors from achieving closing function and adequate positive latching. The doors, upon testing, did not self close or achieve a positive latch due to frame misalignment and latching mechanism failure. Reference: NFPA 101 (2000 Edition): 19.2.2.2.6: "Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2."

1. Tested doors included: OR #3 and OR #4 (front corridor and sterile area egress) failed to latch when tested a 10:15 a.m. due to latching mechanism failure and frame misalignment.

2. OB OR's #1 and #2, to include the sterile corridor egress doors, failed to latch due to mechanism failure when tested at 2:00 p.m.

3. Nurse station third floor corridor fire door failed to close or latch when tested due to obstructions and mechanism failure.