HospitalInspections.org

Based upon observation and interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could potentially affect 5 staff of the facility at the time of a potential incident to be injured if the exit door failed to operate as designed during a fire emergency. Findings include:

1. On 05/02/18 at 1:23 PM it was observed that the exit door in the basement next to the elevator failed to self-close and positively latch when tested.
In an interview on 05/02/18 at 1:24 PM, Staff E verified that the exit door in the basement next to the elevator failed to self-close and positively latch when tested.

Based upon observation and interview, the facility failed to ensure that stairways and smokeproof enclosures used as exits are in accordance with 7.2 as required by 19.2.2.3 and 19.2.2.4.7.2. This deficient practice could potentially affect 5 staff at the time of a potential incident to be injured if the stairway was compromised during a fire emergency. Findings include:

1. On 05/02/18 at 1:12 PM it was observed that there was storage under the stairway in the classroom in the basement.
In an interview on 05/02/18 at 1:13 PM, Staff E verified that there was storage under the stairway in the classroom in the basement.

Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could potentially affect 2 patients, all of the staff and any visitors present at the time of a potential incident to be injured if the fire barriers failed to operate as designed during a fire emergency. Findings include:

1. On 05/02/18 at 12:09 PM it was observed that there was a penetration in the wall of the old phone room.
In an interview on 05/02/18 at 12:10 PM, Staff E verified that there was a penetration in the wall of the old phone room.

2. On 05/02/18 at 12:19 PM it was observed that there was a penetration in the wall of the Housekeeping Storage Room.
In an interview on 05/02/18 at 12:20 PM, Staff E verified that there was a penetration in the wall of the Housekeeping Storage Room.

3. On 05/02/18 at 1:49 PM it was observed that a former office space is now being used as the Operating Room (OR) Storage Room. The hollow core door needs to be replaced and a door closing unit needs to be installed.
In an interview on 05/02/18 at 1:50 PM, Staff E verified that a former office space is now being used as the OR Storage Room.

Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could potentially affect 2 patients and 10 staff at the time of a potential incident to be injured if the sprinkler system failed to operate as designed during a fire emergency. Findings include:

1. On 05/02/18 at 1:42 PM it was observed that the sprinkler head in the OR Supply Closet was being obstructed by the top shelf of the shelving unit.
In an interview on 05/02/18 at 1:43 PM, Staff E verified that the sprinkler head in the OR Supply Closet was being obstructed by the top shelf of the shelving unit.