HospitalInspections.org

Based on observation and interview, the provider failed to maintain two randomly observed door locations (dirty linen storage and cross corridor smoke doors by the laboratory) as required. Findings include:

1. Observation on 8/4/22 at 12:45 p.m. revealed the dirty linen storage room was over 100 square feet and was used for storage of combustible items. The corridor door from that room was held open by a cart wedged in the door. The door closer could not overcome the wedge and protect the corridor.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency affected one of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of that smoke compartment.

2. Observation on 8/4/22 at 1:30 p.m. revealed the cross-corridor smoke doors by the laboratory were too swelled to close and would allow smoke to pass through. The doors could not protect the inhabitants of one smoke compartment from smoke in the other smoke compartment.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency affected one of numerous requirements for smoke compartments and had the potential to affect 100% of the occupants of both smoke compartments.