HospitalInspections.org

Based on observation, testing, and interview, the provider failed to maintain the positive latching feature of the door located in the two-hour separation between the clinic and the hospital during the business hours from 8:00 a.m. to 5:00 p.m.
Findings include:

1. Observation, testing, and interview on 5/22/2025 at 2:45 p.mm with maintenance assistant Q of the two-hour separation between the hospital and the clinic revealed:
*The ninety-minute fire-rated door between the clinic and the hospital was equipped with an electronic strike door latch.
*During the business hours from 8:00 a.m. to 5:00 p.m. the door was programmed to release the electronic strike.
*When the electronic strike was released the latching feature of the door was disabled.
*Testing of the latching feature revealed the door could be pulled or pushed open without the need to turn the door handle proving the door was not positive latching.
*It was unknow if the electronic strike would latch upon initiation of the fire alarm system.

Follow up clarification regarding the latching of the electronic strike during initiation of the fire alarm system was requested by e-mail on 5/29/25 at 3:27 p.m.

Director of maintenance R responded to request for clarification on 5/30/25 at 4:24 p.m. and verified the electronic strike would not latch during the initiation of the fire alarm system and confirmed the door was not positive latching.

52836

This STANDARD is not met as evidenced by:
Based on observation and interview, the provider installed a lock on an egress/horizontal exit door in one randomly observed exit access corridor between the hospital and the clinic. Findings include:

1. Observation and interview on 5/22/2025 at 2:45 pm with maintenance assistant Q of a door between the hospital and the adjoining clinic, which serves as an egress/horizontal exit door for both occupancies, revealed the door has an electronic strike installed that is normally unlocked during the clinic's hours of operation and is otherwise locked. Testing revealed that the door, when locked, stays locked during a fire drill. This is a deficiency as all egress doors and horizontal exit doors are required to be unlocked at all times.

Interview with maintenance assistant Q confirmed the finding. He agreed it was a deficiency.

52836

This STANDARD is not met as evidenced by:
Based on observation and interview, the provider failed to maintain the fire and/or smoke barrier for three randomly observed door assemblies. Findings include:

1. Observation and interview on 5/22/2025 at 10:20 am with maintenance assistant Q of a door between the laundry and the soiled linen room revealed the door was fitted with a closer but was being held open by a wooden wedge. When the wedge was removed, the door would not close due to interference with the frame. Also, the door was deconstructing (delaminating). The condition of the door compromises the door assembly's ability to resist the passage of smoke as well as pathogens from the soiled linen room to the laundry.

2. Observation and interview on 5/22/2025 at 2:10 pm with maintenance assistant Q of an egress corridor double door assembly in the business center revealed the doors were unable to latch during testing due to interference with each other at the top interior edges. This compromises the door assembly's ability to resist fire spread and the passage of smoke.

3. Observation and interview on 5/22/2025 at 2:25 pm with maintenance assistant Q of an egress (north) corridor double door assembly near room 180 revealed the south leaf of the door assembly was unable to consistently latch during testing. This compromises the door assembly's ability to resist fire spread and the passage of smoke.

Interview with maintenance assistant Q at the time of each observation confirmed the findings. He agreed they would not resist the passage of smoke.

52836

This STANDARD is not met as evidenced by:
Based on observation and interview, the provider failed to maintain the fire and smoke barrier for one of four exit enclosures (stairway 10).
Findings include:

1. Observation and interview on 5/22/2025 at 10:30 am with maintenance assistant Q revealed a nonlatching door in the basement level of stairway 10, thus compromising the door assembly's ability to resist fire spread and the passage of smoke.

Interview with maintenance assistant Q confirmed the finding. He agreed it would not resist fire spread or the passage of smoke.

52836

This STANDARD is not met as evidenced by:
Based on observation and interview, the provider created a hazardous area via the accumulation of combustible items within the air handler 1 room in the basement. The provider failed to protect this hazardous area as required, affecting one of six smoke compartments and an exit corridor. Findings include:

1. Observation and interview on 5/22/2025 at 10:50 am with maintenance assistant Q revealed three groupings of mixed combustibles (e.g., cardboard, plastics, fiberglass, adhesives) being stored under large metal forced-air ducts measuring approximately 5' x 5' in cross-section. The bottom of the ducts were approximately 5' above the floor. The floor space occupied by the three combustibles groupings was approximately 5' x 50', 5' x 25', and 5' x 15' for a total area of approximately 450 square feet. This is larger than the 50 square feet of combustibles maximum for nonhazardous areas. Therefore, this area requires hazardous area protections. The area is sprinklered. However, the combustibles are shielded by the metal ducting immediately above, thus compromising the effectiveness of the sprinklers. Sprinklered hazardous areas must have smoke resisting partitions. However, the door to the air handler 1 room (from the fire alarm room) was propped open with a wedge. When tested, the door would not close on its own due to interference with a foam safety protector installed on the corner of a nearby metal duct fitting. The adjacent fire alarm room, into which the smoke from the hazardous area would enter in a fire event, had a compromised smoke resisting partition between it and the lay-in ceiling above the adjacent exit corridor (two rectangular holes in the wall measuring approximately 4" (inches) x 12" serving as pipe and cable conduits and one approximately 2" circular penetration containing a pipe without fire caulking near the fire alarm room ceiling). Random observation of ceiling tiles in the exit corridor lay-in ceiling near the fire alarm room door revealed three instances of broken tiles that would not resist the passage of smoke.

Interview with maintenance assistant Q confirmed the above findings.

52836

This STANDARD is not met as evidenced by:
Based on observation and interview, the provider failed to maintain the smoke barrier for one randomly observed patient sleeping room (140).
Findings include:

1. Observation and interview on 5/22/2025 at 3:20 pm with maintenance assistant Q revealed a gap at the top of the corridor door assembly for room 140 between the top of the door and the door frame stop (latch side) of approximately 1/4" (one-quarter inch) thus compromising the door assembly's ability to resist the passage of smoke.

Interview with maintenance assistant Q confirmed the finding. He agreed it would not resist the passage of smoke.

52836

This STANDARD is not met as evidenced by:
Based on observation and interview, the provider failed to protect medical gas storage as required in the oxygen cylinder storage room (sprinklered) affecting one of six smoke compartments. Findings include:

1. Observation and interview on 5/22/2025 at 1:30 pm with maintenance assistant Q revealed 13 full "E" size oxygen cylinders (approximately 312 cubic feet) colocated with a spray can of highly flammable glass cleaner, approximately 14 cardboard boxes and other combustibles within 5 feet of the cylinders, and a key-making machine with a grinding wheel which could generate sparks. Each of these observations represent deficiencies.

Interview with maintenance assistant Q confirmed the above findings.