HospitalInspections.org

Based on observation and interview, the facility failed to maintain doors in smoke barriers to be automatic closing. The smoke doors affected two of the six smoke compartments in the building. This deficient practice would not prevent the spread of fire and smoke and affect approximately 7 occupants within these two smoke compartments.

Findings include:

1. Observation on 08/17/22 at 1:07 P.M. revealed the smoke doors in the 100-wing corridor could not close completely when tested. The staff had placed a caution sign in front of the smoke doors which would not allow the doors to close.

2. During an interview on 08/17/22 at 1:07 P.M., Maintenance Staff A confirmed this observation that the doors did not close properly and advised that the sign was placed there because of the Isolation station setup in front of room 101.

Based on interview and documentation review, the facility failed to implement an annual testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility. These deficient practices failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke and affected all occupants in all smoke compartments. The facility capacity was 20, with a census of 4 on the day of survey.

Findings are:
Documentation review on 08/17/22 at 2:00 P.M. revealed that the facility failed to provide written documentation of annual inspections and testing of all fire rated doors throughout the facility.

During an interview on 08/17/22 at 2:00 P.M., Maintenance Staff A confirmed the lack of complete annual fire rated door inspection documentation.