HospitalInspections.org

Based on observation and staff interview, the facility failed to separate a hazardous area with a smoke resistive door. This condition would allow smoke to migrate into the exit corridor.

Findings are:
Observation on 8/10/21, at 1:59 pm revealed the Soiled Linen room door by ER did not positively latch when self-closed.

In an interview on 8/10/21, at 1:59 pm, Safety staff acknowledged the door did not positively latch.

Based on observation and staff interview, the facility failed to meet all criteria for a space to be open to the exit corridor. This condition would allow smoke to develop in the open space without early detection, and enter the exit corridor.

Findings are:
Observation on 8/10/21, at 2:13 pm revealed smoke detection was not installed in the Sub-Waiting Room, which was open to the exit corridor.

In an interview on 8/10/21, at 2:13 pm, Safety A acknowledged the space lacked smoke detection, and that the space was not continuously supervised by staff.

18.3.6.1 Corridor Separation. Corridors shall be separated
from all other areas by partitions complying with 18.3.6.2
through 18.3.6.5 (see also 18.2.5.4), unless otherwise permitted
by one of the following:
(2) Waiting areas shall be permitted to be open to the corridor,
provided that all of the following criteria are met:
(a) The aggregate waiting area in each smoke compartment
does not exceed 600 ft2 (55.7 m2).
(b) Each area is protected by an electrically supervised
automatic smoke detection system in accordance
with 18.3.4, or each area is arranged and located to
allow direct supervision by the facility staff from a
nursing station or similar space.
(c) The area does not obstruct access to required exits.

Based on observation and staff interview, the facility failed to use electrical wiring in a way that would not create a fire hazard. This condition had the potential to cause a fire.

Findings are:
Observation on 8/10/21, at 2:26 pm revealed power strips were daisy chained together in the Operations Director's Office, and not plugged directly into hardwired outlets.

In an interview on 8/10/21, at 2:26 pm, Safety A acknowledged the findings.

UL Standard: Relocatable power taps are not intended to be piggybacked or daisy chained. UL 1363 User Guide for Relocatable Power Taps