HospitalInspections.org

Based on observation and staff interview on 6/5/24, it was determined that the facility failed to ensure hazardous areas are protected to resist the passage of smoke or fire.

Findings include:

During a tour of Floor-A at 11:48 AM in the presence of Staff (S)9, the Manager of Access Control, it was observed that 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.

During an interview at 12:33 PM, S9 stated, "I have the parts to fix most of these doors. I am just waiting on the go ahead to shut down areas to do the work."

Based on observations and staff Interview on 6/5/24, it was determined that the facility failed to ensure doors protecting corridors are maintained to resist the transfer of smoke or fire.

Findings include:

During a tour of Floor-A 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 is 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 will 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 preventing these doors from resisting the passage of smoke. 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 did not fully close and latch. S9 confirmed this finding at the time of observation.

During an interview at 12:33 PM, S9 stated, "I have the parts to fix most of these doors. I am just waiting on the go ahead to shut down areas to do the work."