HospitalInspections.org

Based on observation and staff interview conducted on 6/5/24, it was determined that the facility failed to ensure the hospital is maintained for the safety of patients in accordance with the 2012 edition of the National Fire Protection's Life Safety Code (A0710).

Findings include:

Cross Reference 42 CFR 482.41(b)(1)(12)(3) - Life Safety from Fire

Based on observations and staff interview conducted on 6/5/24, it was determined that the facility failed to ensure doors protecting corridors and hazardous areas are maintained to resist the transfer of smoke or fire in accordance with the 2012 edition of the National Fire Protection's Life Safety Code.

Findings include:

Reference: National Fire Protection Association's Life Safety Code, 2012 edition, 101:8.5.4.3 "Latching hardware shall be required on doors in smoke barriers . . ."

Reference: National Fire Protection Association's Standard for Fire Doors and Other Opening Protective's, 2013 edition, 80:5.2.3.5.2 "(1) Labels are clearly visible and legible."

Reference: National Fire Protection Association's Life Safety Code, 2012 edition, 101:8.5.4.1 "Doors in smoke barriers shall close the opening . . . "

Reference: National Fire Protection Association's Life Safety Code, 2012 edition, 101:19.3.6.3.10 "Doors shall not be held open by devices other than those that release when the door is pushed or pulled."

During a tour of Floor-A on 6/5/24 at 11:30 AM in the presence of Staff (S)9, the Manager of Access Control, the 90-minute fire rated doors separating the Cargo Elevator Lobby from the Corridor was missing latching hardware. S9 confirmed this finding at the time of observation.

During a tour of Floor-A at 11:57 AM in the presence of S9, the fire rated door outside room A132 does not self-close and latch. The fire rating for this door was unknown due to the label being painted over. S9 confirmed this finding at the time of observation.

During a tour of Floor-C at 12:24 PM in the presence of S9, the ¾ hour smoke barrier doors near Room C234 did not close completely. S9 confirmed this finding at the time of observation.

During a tour of Floor-C at 12:30 PM in the presence of S9, the ¾ hour fire rated door outside Room C360 is held open by a scrap piece of metal wedged between the bottom of the door and the floor. S9 confirmed this finding at the time of observation.

During a tour of Floor-E at 12:48 PM in the presence of S9, the double doors separating the Operating Room Suite from the Corridor were splitting apart down the middle edge of the door and not fully closing. S9 confirmed this finding at the time of observation.

During a tour of Floor-F at 12:56 PM in the presence of S9, the Cross-Corridor ¾ hour fire rated doors separating Inpatient Unit Blue from the Corridor did not close fully from the open position. S9 confirmed this finding at the time of observation.

During a tour of Floor-F at 1:10 PM in the presence of S9, the two (2) ¾ hour fire rated door between the Corridor and FICN Unit were held open by air pressure from the air conditioner unit pushing air through the corridor creating wind which is preventing the cross-corridor doors from fully closing. S9 confirmed this finding at the time of observation.

During a tour of Floor-H at 1:18 PM in the presence of S9, the ¾ hour fire rated door between inpatient unit Blue H and the public corridor near the elevators did not fully close and latch. S9 confirmed this finding at the time of observation.

During a tour of Floor-A at 11:48 AM in the presence of S9, the Loading Dock doors separating the loading dock from the main hospital corridor do not close and positively latch. S9 confirmed this finding at the time of observation.

During a tour of Floor-B at 12:02 PM in the presence of S9, the 90-minute fire rated door separating the Kitchen from the Corridor does not positively latch. S9 confirmed this finding at the time of observation.