HospitalInspections.org

Based on observation and interview, the facility failed to ensure that corridor doors to hazardous areas were maintained and equipped with door-closing devices as required. This deficient practice affected three of ten smoke compartments, staff, and other occupants of the building.

The findings include:

During the Life Safety Code survey on 05/23/13 at 2:25 PM, with the Director of Maintenance (DOM), four corridor doors in the Radiology area were observed to not close correctly and would hang in the open position. These doors are required to close and latch on their own accord and remain closed.

An interview with the DOM on 05/23/13 at 2:25 PM revealed the doors were heavy and difficult to fix.

On 05/23/13 at 2:45 PM, hazardous area corridor doors to the Pharmacy were observed not to have self-closing devices as required. An interview with the DOM on 05/23/13 at 2:45 PM revealed she was not aware which doors were required to have self-closing devices. The facility was also issued a deficiency on 11/10/10 due to the failure to have door-closing devices on the Pharmacy doors.

In addition, during the survey on 05/23/13, a Kitchen door was observed not to have a door-closing device.

The findings were revealed to the Administrator during exit.

Reference: NFPA 101 (2000 Edition).

19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview, the facility failed to maintain an exit according to NFPA standards. This deficient practice affected one of ten smoke compartments, staff, and other occupants of the building.

The findings include:

During the Life Safety Code survey on 05/23/13 at 3:05 PM, with the Director of Maintenance (DOM) a cross-corridor door leading to the former Obstetrical (OB) clinic was observed to be locked with latches at the top of the doors. Storage was observed in the corridor of the clinic. These doors must remain unlocked due to egress requirements and storage is not allowed in the corridor. An interview with the DOM on 05/23/13 at 3:05 PM revealed the clinic was no longer in use and the area was being used for storage. The DOM was unaware the doors must remain unlocked and the clinic corridor cannot contain storage.

The findings were revealed to the Administrator during exit.

Reference: NFPA 101 (2000 Edition).

19.2.5.9*
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.2.1.5.1
Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Based on observation and interview, the facility failed to ensure that corridor doors to hazardous areas were maintained and equipped with door-closing devices as required. This deficient practice affected three of ten smoke compartments, staff, and other occupants of the building.

The findings include:

During the Life Safety Code survey on 05/23/13 at 2:25 PM, with the Director of Maintenance (DOM), four corridor doors in the Radiology area were observed to not close correctly and would hang in the open position. These doors are required to close and latch on their own accord and remain closed.

An interview with the DOM on 05/23/13 at 2:25 PM revealed the doors were heavy and difficult to fix.

On 05/23/13 at 2:45 PM, hazardous area corridor doors to the Pharmacy were observed not to have self-closing devices as required. An interview with the DOM on 05/23/13 at 2:45 PM revealed she was not aware which doors were required to have self-closing devices. The facility was also issued a deficiency on 11/10/10 due to the failure to have door-closing devices on the Pharmacy doors.

In addition, during the survey on 05/23/13, a Kitchen door was observed not to have a door-closing device.

The findings were revealed to the Administrator during exit.

Reference: NFPA 101 (2000 Edition).

19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview, the facility failed to maintain an exit according to NFPA standards. This deficient practice affected one of ten smoke compartments, staff, and other occupants of the building.

The findings include:

During the Life Safety Code survey on 05/23/13 at 3:05 PM, with the Director of Maintenance (DOM) a cross-corridor door leading to the former Obstetrical (OB) clinic was observed to be locked with latches at the top of the doors. Storage was observed in the corridor of the clinic. These doors must remain unlocked due to egress requirements and storage is not allowed in the corridor. An interview with the DOM on 05/23/13 at 3:05 PM revealed the clinic was no longer in use and the area was being used for storage. The DOM was unaware the doors must remain unlocked and the clinic corridor cannot contain storage.

The findings were revealed to the Administrator during exit.

Reference: NFPA 101 (2000 Edition).

19.2.5.9*
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.2.1.5.1
Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.