HospitalInspections.org

Based on observation and interview, it was determined the facility failed to ensure exits were maintained according to National Fire Protection Agency (NFPA) standards. This deficient practice affected one (1) of five (5) smoke compartments, staff, visitors, and patients.

The findings include:

During the Life Safety Code tour, on 04/24/19 at 9:30 AM, with the Director of Maintenance (DOM), the exit door from the Medical/Surgery North to the Helipad/Parking Lot area, which serves as an emergency exit, had a homemade sign affixed that read:

DOOR ALARM
IS ACTIVE .....
DON'T USE THIS
DOOR AS AN EXIT!

The door also had an illuminated EXIT sign over the door along with a red and white sign on the door that read:

EMERGENCY
EXIT ONLY

Conflicting signs arranged in this manner can cause confusion and delay in case of an evacuation.

Interview with the DOM, on 04/24/19 at 9:30 AM, revealed he was unaware the homemade sign had been placed on the door however: he was aware of the regulation requiring exits to be arranged and marked in a clear manner. He corrected the deficiency upon discovery.

The findings were revealed to the Administrator on exit.

Reference: NFPA 101 2012 edition

7.10.1.2 Exits.
7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner.