HospitalInspections.org

Based on observation and interview, the provider failed to provide egress doors as required at one location (hospital to nursing home corridor). Findings include:

1. Observation on 4/23/24 at 1:15 p.m. revealed the cross-corridor egress doors in the two-hour fire-rated wall between the hospital and the former nursing home was equipped with magnetic lock hardware. Interview with the maintenance supervisor at the time of the above observation revealed the magnetic locks were activated by one of three 'active shooter' panic buttons located at the hospital nurses' station, the clinic reception desk, and computer room. He added the locks were automatically activated to lock at 5:00 p.m. daily. A key fob would be required to pass through either door. The doors were both marked as required EXITs with illuminated signs. The magnetic locks when activated nightly would prevent egress from any individual without a key fob.

Interview with the maintenance supervisor at the time of the above observation confirmed that condition. He stated he was new in the position in the last six months and that there had not been any testing of the magnetic locking doors to verify that operation.

Failure to provide egress doors as required increases the risk of death or injury due to fire.

Ref: 2012 NFPA 101 Section 19.2.2.2.4(3), 7.2.1.6.2(3)(a)

Based on observation, testing, and interview, the provider failed to maintain a separation one of one randomly observed stair enclosure to the second floor and lower level (corridor door was not closing to latch). Findings include:

1. Observation on 4/23/24 at 10:40 a.m. revealed the ninety-minute fire-rated door at the nurses station to the stair enclosure to the second floor and basement was equipped with spring hinges. Testing of the door at the time of the above observation revealed the door would not close to latch with the spring hinges. Interview with the maintenance supervisor at the time of the above observation confirmed that condition.

The deficiency had the potential to affect 100% of the smoke enclosure occupants.

Based on observation and interview, the provider failed to maintain corridor smoke monitoring of that area for one randomly observed area (south end of the patient wing) as required. Findings include:

1. Observation on 4/23/24 at 10:50 a.m. revealed the south end of the patient wing was separated at the former palliative care area by a pair of cross-corridor doors. The area was open to the required EXIT but was not equipped with any smoke detection device.

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

The deficiency had the potential to affect 100% of the occupants of that smoke compartment.

A. Based on observation and interview, the provider failed to maintain impediment-free closing for one randomly observed corridor door (room 108) as required. Findings include:

1. Observation on 4/23/24 at 10:55 a.m. revealed the corridor door to patient room 108 was blocked by a Bowman dispenser (holding single-use gloves of various sizes). The room was being used to store unused walkers and wheelchairs and was full. There was no room to move the Bowman dispenser into the room. The corridor door would not be able to be closed without moving the dispenser unit.

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

The deficiency had the potential to affect 100% of the occupants of the smoke compartment.

B. Based on observation and interview, the provider failed to maintain positive latching hardware for one randomly observed corridor door (room 110 shower room) as required. Findings include:

1. Observation on 4/23/24 at 11:00 a.m. revealed the patient room 110 had two corridor doors. One door was to the provider-used main room and one door was from the shower area to the corridor. The shower area corridor door was equipped with a deadbolt which was not a positive-latching device. The room would not be separated from the corridor unless the door was closed and then the deadbolt turned into the strike plate.

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

The deficiency had the potential to affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to maintain combustion (fresh) air in one randomly observed laundry area. Findings include:

1. Observation of the two Huebsch 165,000 btu input commercial propane gas-fired dryers in the laundry room on 4/23/24 at 10:30 a.m. revealed the following:
a. There was no dedicated combustion (fresh) air ductwork provided for the operation of the two propane gas-fired commercial clothes dryers.
b. A manually operated window is not acceptable for use as a combustion (fresh) air source for fuel-fired equipment.
c. The corridor door to the laundry room may not be used as a source of combustion air for the dryers. This door is to be closed at all times to maintain fire separation of the laundry room.

Interview with the maintenance supervisor at the time of the above observations confirmed those findings.

The deficiency affected one of several requirements for fuel-fired devices.

Based on observation and interview, the facility failed to ensure combustible items and oxygen concentrators were not stored within five feet of the oxygen cylinders in the storage room. Findings include:

1. Observation on 4/23/24 at 11:15 a.m. revealed combustible materials and four oxygen concentrators were found to be stored adjacent to and within five feet of oxygen cylinders in the oxygen storage room. The minimum five feet of separation between combustibles and oxygen storage was not maintained as required in this area.

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

The finding violated one of several requirements for the storage of oxygen.