HospitalInspections.org

Based on observation, on March 15, 2011 at approximately 1:00pm onward, doors to patient rooms in third floor CCU corridor walls are equipped with bi-fold inactive door leaf. The doors require greater than a single hand motion to close and latch doors in an emergency. The inactive door leaf is not equipped with self-closing hardware and self-latching hardware.

1. This facility utilizes Special Locking (Magnetic) devices through out in various locations (Delayed egress, Access Control, and NC Special Locking):

The facility is not equipped through-out (100%) with an automatic, supervised fire suppression system (Sprinkler) or an automatic, supervised smoke detection section or a combination there-of.


2. Based on observation, on March 15, 2011 at approximately 1:00pm onward, the facility is equipped with incomplete electromagnetic locking arrangements on cross corridor doors throughout as follows:

a. ED - corridor behind emergency department is equipped with incomplete access-controlled egress hardware. There is no sensor to unlock the door in the direction of egress. On March 16, 2011 at approximately 9:15am the locking system did not release with activation of the building fire alarm system - this action constitutes an immediate jeopardy to the health and safety of all occupants requiring egress in the subject area. The hospital administration was notified at approximately 1:00pm after conferral with health care survey team and supervisory authority. The immediate jeopardy was abated by hospital engineering staff at approximately 9:30am by removing noncompliant locking devices from subject doors.

b. second floor near elevators - the facility utilizes delayed egress locks and NC special locking arrangements with remote switches in the same egress path.

c. CCU unit located on third floor - lack of master release switch located at nurse's station outside of CCU Unit, and switches adjacent to doors are greater than three feet from cross corridor doors.

d. first floor near physician call room - special locking arrangement does not comply with delayed egress, access controlled or NC special locking arrangement requirements. Locks release with the activation of a push switch, fire alarm activation, and loss of power.

B. Based on observation, on March 15, 2011 at approximately 1:00pm onward, the exit discharge across fourth floor roof is incomplete. The discharge path is not bound by guardrails from the patient care area to the stair accessible from the roof.

C. Based on observation, on March 15, 2011 at approximately 1:00pm onward, there is a steel chain secured across the handrails of stair serving fourth floor exit across roof. The chain obstructs stair egress path from the fourth level - located inside stair at third floor CCU area.