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Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 10 of 15 doors in the Behavioral Medicine Unit of the facility as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects the 10 patients in this unit of the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, " Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.
And
Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, "Existing Health Care Occupancy, " 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted. Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During facility tour on February 25, 2014 between 2:30 p.m. and 3:30 p.m. it was observed that the door to the patient rooms in Behavioral Medicine Unit have four holes around the new door knobs. These holes would allow smoke to between the room and the corridor.

Based on observation the facility failed to provide door to smoke barriers that close fully in accordance with National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects 1 of 1 smoke barrier, 2 of 2 smoke compartments and the 18 patients in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101:19.2.2.2.6 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. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During a tour of the facility on February 25, 2014 between 2:00 p.m. and 4:00 p.m. it was observed that the smoke barrier doors in the Emergency Room did not close all the way. When the fire alarm system is activated the magnetic holding device did release the doors, but the doors did not close fully.

Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 10 of 15 doors in the Behavioral Medicine Unit of the facility as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects the 10 patients in this unit of the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, " Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.
And
Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, "Existing Health Care Occupancy, " 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted. Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During facility tour on February 25, 2014 between 2:30 p.m. and 3:30 p.m. it was observed that the door to the patient rooms in Behavioral Medicine Unit have four holes around the new door knobs. These holes would allow smoke to between the room and the corridor.

Based on observation the facility failed to provide door to smoke barriers that close fully in accordance with National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects 1 of 1 smoke barrier, 2 of 2 smoke compartments and the 18 patients in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101:19.2.2.2.6 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. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During a tour of the facility on February 25, 2014 between 2:00 p.m. and 4:00 p.m. it was observed that the smoke barrier doors in the Emergency Room did not close all the way. When the fire alarm system is activated the magnetic holding device did release the doors, but the doors did not close fully.