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Based on a follow up visit performed on 11/9/2016, tests to doors and observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee # 7 and 8), it was determined that some of the facility's doors protecting corridors on the fifth floor, fourth floor and third floor do not close completely (do not latch) at patient's doors, Medication room and Intravenous venous (IV) fluid room as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3

Findings include: Deficiency not corrected

During the tour for life safety from fire, patient's sleeping room doors and doors were tested on 11/9/16 from 8:00 am until 10:00 am and it was found that rooms #503, #508 and #515, Medication room from the fourth and third floor , IV fluid room fifth floor did not latch, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire.
Interview with employee #7 performed on 9/11/16 at 8:30 am reveals that the physical plant personnel performed weekly rounds to ensure that all the doors from all over the hospital latch.
However, at the moment of the follow up visit no evidence about the physical plant personnel maintenance round register log was presented and the deficiency still.

Based on a follow up visit performed on 11/9/2016, observations made during the survey for life safety from fire with the facility's Physical Structure Director (employee #7 )and Safety Officer (employee #8), it was determined that the smoke barrier door from the fourth floor cannot close automatically because it was being blocked by the maintenance cart and the other door had two big trash containers when released as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2.

Findings include: Deficiency not corrected

1. The smoke barrier doors on the fourth floor that separates the part of the patient's rooms from the hallway were observed on 11/09/16 at 9:45 am and provided evidence that they are left opened and they are blocked by one maintenance cart and two big trash containers. In case of a fire the doors are connected to the fire alarm; So that in case the alarm is activated the doors automatically close. Due to the above mentioned this cannot occur and this can permit smoke, fire and noxious gases to enter the hallway which is a means of egress from the floors above.

Based on a follow up visit, observations made during the survey for life safety from fire with the facility's Safety Officer (employee #8), it was determined that the facility failed to monitor the means of egress near the x-ray department and fifth floor and fourth floor to ensure that it is maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include: Deficiency not corrected

On 11/9/16 at 8:15 am a patient was observed in the hallway in front of the X-ray department in a stretcher. The patient was connected to an I.V solution and left in front of X-ray counter which reduced the width of this exit passage to less than three feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".
On 11/9/16 at 9:00 am it was observed in the fourth floor and fifth floor in front of the door from the escape stairs the Housekeeping cart blocking the emergency exit.
"Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on the follow up visit performed on 11/09/16, observations during the survey for Life safety from fire with the facility's Physical Structure Director (employee # 7) and Safety Officer (employee #8), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-U.

Findings include: Deficiency not corrected

Observations made on 11/9/16 at 9:20 am of the emergency department provided evidence that three small cylinders of oxygen were on the floor inside the Respiratory Therapy supply room in front of two pediatric cribs. The cylinders were not fastened to the wall or in stands to prevent them from falling. Oxygen cylinders must be secured in order to prevent them from falling and possible explosion.