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Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings provided with a means suitable for keeping the doors closed or in proper operating condition. This deficient practice could prevent the door from being quickly and easily closed and latched in the event of an emergency, could allow the passage of smoke, and could effect the patients in this room and all patients, visitors, and staff in the identified corridor.

The findings include:

During the survey on August 25, 2016 with the Vice President of Support Services, the Director of Facilities Engineering, and executive members of the building operations and medical staff, it was observed between 8:30 am and 2:30 pm that the corridor door to room # 1814 failed to latch properly when closed.

This deficiency was verified and acknowledged by all participants during the exit conference.

Based on observation of the physical environment, it was determined that the facility staff failed to provide base level protection by not ensuring that corridor smoke barrier doors function properly. Smoke barrier doors, walls, and partitions are designed to insulate means of egress from other areas of a building and to resist the passage of smoke in the event of an emergency and failure to do so could impact up to 25% of patients, visitors, and staff.

The findings include:

During the survey on August 25, 2016 with the Vice President of Support Services, the Director of Facilities Engineering, and executive members of the building operations and medical staff, it was observed between 8:30 am and 2:30 pm that:

1.) corridor smoke doors failed to operate and close properly in several locations, including, but not limited to - the doors by room #5533; the doors by room #2588; the doors #SDR 0207; the doors # SDR 0116;

2.) two sets of corridor doors in the behavioral unit had a large gap between the two panels when closed - it could not be determined if one or both sets of doors are actual smoke barriers.

This deficiency was verified and acknowledged by all participants during the exit conference.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that hazardous areas are separated from other spaces by smoke resisting ceilings, partitions, and doors. Partitions that are not smoke resisting, ceiling tiles that are missing, or doors to hazardous areas that are not self-closing could allow smoke to travel from hazardous areas of the facility to other sections in the event of an emergency and could effect up to 30% of the patients, visitors, and staff.

The findings include:

During the survey on August 25, 2016 with the Vice President of Support Services, the Director of Facilities Engineering, and executive members of the building operations and medical staff, it was observed between 8:30 am and 2:30 pm that one set of doors leading from the kitchen to a large storage room failed to close properly when activated - the door "coordinator" failed to operate properly - these doors were connected to the fire alarm system by magnetic locks.

This deficiency was verified and acknowledged by all participants during the exit conference.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not addressing the following miscellaneous safety issues. Failure to equip these appliances with remote shut-off switches could permit their accidental activation by patients and/or visitors without staff supervision.

The findings include:

During the survey on August 25, 2016 with the Vice President of Support Services, the Director of Facilities Engineering, and executive members of the building operations and medical staff, it was observed between 8:30 am and 2:30 pm that two therapy suites had oven/range units that were not equipped with remote shut-off switches.

This deficiency was verified and acknowledged by all participants during the exit conference.