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PROVIDENCE MEDICAL CENTER
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and staff interview, the facility failed to provide smoke resistant enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke and gases to migrate into the exit corridors. Facility census was 6 and licensed for 21 at the time of the survey.
Finding are:
Observation and staff interview on 8-6-2024 at 10:45 AM, 11:45 AM and 12:00 PM revealed the following:
1. Open conduit penetrations were found in the 1-hour fire wall located inside of Electrical Room B123.
2. Open conduit penetrations were found in the 1-hour fire wall located inside of Electrical Room A135.
3. Open conduit penetrations were found in the 1-hour fire wall located inside of Electrical Room A260.
During interview on 8-6-2024 at 12:00 PM, Maintenance Staff A confirmed the open fire wall penetrations.
Corridor - Doors
Tag No.: K0363
Based on observation and staff interview, the facility failed to ensure that corridor doors would resist the passage of fire and smoke. This deficient practice would allow fire, smoke and gases to migrate into the adjoining exit corridors. Facility census was 6 and licensed for 21 at the time of the survey.
Finding are:
Observation and staff interview on 8-6-2024 at 11:15 AM revealed the following:
90-minute fire rated cross corridor door located nearest to room B131 failed to seal and latch when in the closed position.
During interview on 8-6-2024 at 11:15 AM, Maintenance Staff A confirmed the fire door failed to seal and latch.
Maintenance, Inspection and Testing - Doors
Tag No.: K0761
Based on record review and staff interview, the facility failed to ensure that fire rated doors are inspected and tested annually. This deficient practice would allow fire smoke and gases to migrate outside of the effected space. Facility census was 6 and licensed for 21 at the time of the survey.
Finding are:
Observation and staff interview on 8-6-2024 at 10:30 AM revealed the following:
Record review found that fire doors were not being inspected or tested annually.
During interview on 8-6-2024 at 10:30 AM, Maintenance Staff A confirmed fire door inspections were not being performed.