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TYLER HOLMES MEMORIAL HOSPITAL CAH
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observations, the facility failed to protect hazardous area in accordance with NFPA 101 section 19.3.2.1. This deficient practice had potential of affecting the entire facility on the day of facility survey.
Findings include:
On 09/27/22 at 10:20 AM, observation revealed Lab and Medical Record Rooms were identified as hazardous areas (storage areas) and were incapable of resisting the passage of smoke throughout the facility. The doors to the HIM Director's Office, Lab Room, and Medical Record Room lacked automatic door closers.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.
Corridor - Doors
Tag No.: K0363
Based on observations, the facility failed to protect corridor openings in accordance with NFPA 101 section 19.3.6.3.5. This deficient practice had potential of affecting the entire facility on the day of facility survey.
Findings include:
On 09/27/22 at 10:55 AM, observation revealed the following corridors doors could not close properly and were incapable of resisting the passage of smoke throughout the facility:
Lab Room
Emergency Room Utility Room (Mop bucket room)
Room 15
Kitchen
Ultrasound Room
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.