HospitalInspections.org

Based on observation and interview, the facility failed to ensure 2 of 4 self closing doors to hazardous areas such as a kitchen were held open only by devices which would allow the doors to close upon activation of the fire alarm system. This deficient practice affects visitors, staff and 10 or more patients.

Findings include:

Based on observation with the maintenance engineer on 08/15/14 at 11:45 a.m., two self closing doors between the food service area and the kitchen stood wide open. Both doors were equipped self closers, but when the doors were pushed wide open, a feature of the self closers prevented the doors from closing without being pulled closed. The maintenance engineer acknowledged at the time of observation, the doors would not automatically close when opened fully.

This deficiency was cited on 05/15/14. The facility failed to implement a systemic plan of correction to prevent recurrence.

Based on observation and interview, the facility failed to provide automatic door closers on 5 of 12 doors providing access to hazardous areas such as a kitchen and hazardous materials storage room. Sprinklered hazardous areas are required to be equipped with self closing doors or with doors that close automatically upon activation of the fire alarm system. Furthermore, doors to hazardous areas are required to latch in the door frame when closed to keep the door tightly closed. This deficient practice could affect visitors, staff and 10 or more patients in the center second floor smoke compartment and first floor dining room.

Findings include:

a. Based on observation with the maintenance engineer on 08/15/14 at 11:45 a.m., a rolling steel door which protected the three by four foot opening between the kitchen and dining room was not self closing. The maintenance engineer acknowledged at the time of observation, the door had to be manually closed to provide separation between the two spaces.
b. Based on observation with the maintenance engineer on 08/15/14 at 11:55 p.m., four kitchen access doors equipped with self closers each had no automatic positive latch. Instead the doors were equipped with deadbolt latches which required a key to secure them in their door frames. The maintenance engineer acknowledged at the time of observations, the doors could not latch automatically to secure them in the door frames.

This deficiency was cited on 05/15/14. The facility failed to implement a systemic plan of correction to prevent recurrence.