HospitalInspections.org

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for five randomly observed corridor doors (the single door separating the lobby from the patient rooms, the pair of doors separating the patient rooms from the pre-operation and post-operation suite, and the pair of doors separating the patient rooms from the operating suite) would not latch into the frames. Findings include:

1. Observation at 10:00 a.m. on 9/13/16 revealed the corridor door separating the main lobby from the patient rooms would not latch into the frame when allowed to operate with the self-closer or when shut manually. Interview with the maintenance supervisor at the time of the observation confirmed those findings. He stated the door operated properly during the previous quarterly door checks.

2. Observation at 10:30 a.m. on 9/13/16 revealed the double cross-corridor doors used to separate the pre-operation and post-operation suite as well as the double cross-corridor doors used to separate the operating suite would not latch into the frames. Interview with the maintenance supervisor at the time of the observation confirmed those findings. He stated the door operated properly during the previous quarterly door checks.

The above issues could affect all staff and patients within the hospital due to fire and smoke.

Based on record review, observation, and interview, the provider failed to verify the required maintenance of the sprinkler system (quarterly flow and tamper inspections and five year internal inspection) had been performed. Findings include:

1. Review of the provider's sprinkler maintenance records revealed no documentation the quarterly flow or tamper switches had been tested in accordance with NFPA 25. Further review indicted the last five year internal obstruction inspection of the sprinkler system had been performed in April 2010 in accordance with NFPA 25. Observation at 11:10 a.m. on 9/13/16 revealed there was not a tag on the fire sprinkler risers indicating a flow or tamper test had ever been completed, and the last tag for five year obstruction inspection was dated April 2010.

Interview with the administrator at 11:30 a.m. on 9/13/16 revealed he assumed the monitoring company was completing the required testing for the system.

The deficiency affected two of numerous requirements for fire sprinkler system maintenance.