HospitalInspections.org

Based on observation and interview, the provider failed to maintain a protected path of egress at two randomly observed locations (second floor stairwell one and northwest exit). Findings include:

1. Observation on 7/15/24 at 1:50 p.m. revealed the second floor corridor in front of stairwell one had a Hoyer lift and a portable x-ray machine kept in the corridor at the stairwell door location. The access to the egress door could be reduced by the equipment kept in that location.

2. Observation on 7/15/24 at 3:45 p.m. revealed the egress corridor at the northwest exit one had seven plastic totes measuring 24 inches by 30 inches by 18 inches tall in the path of egress from the ground floor and in the elevator ground floor discharge location. Further observation revealed a sign was posted indicating how to handle items delivered to the building at that location.

3. Interview with the environmental services manager at the time of the observation confirmed that condition.

The deficiency had the potential to affect 100% of the smoke compartment occupants.

Based on observation, testing, and interview, the provider failed to maintain six separate hazardous areas (storage rooms) as required. Findings include:

1. Observation and testing on 7/15/24 at 2:20 p.m. revealed room 309, the soiled utility room corridor door, would not close and latch with the operation of the closer.

2. Observation and testing on 7/15/24 at 3:00 p.m. revealed the 1-1/2 hour fire-rated door to the generator room in the lower level would not close and latch with the operation of the closer.

3. Observation and testing on 7/15/24 at 3:15 p.m. revealed the lower level material storage room (storage room 2) was over 100 square feet in area with a quantity of combustible items. The corridor door was equipped with spring hinges, but the door would not close and latch upon the action of the spring hinges.

4. Observation and testing on 7/15/24 at 3:20 p.m. revealed the lower level hospitality room (storage room 1) was over 100 square feet in area with a quantity of combustible items. The corridor door was equipped with spring hinges, but the door would not close and latch upon the action of the spring hinges.

5. Observation and testing on 7/15/24 at 3:25 p.m. revealed the lower level storage room 3 was over 100 square feet in area with a quantity of combustible items. The corridor door was equipped with spring hinges, but the door would not close and latch upon the action of the spring hinges.

6. Observation and testing on 7/15/24 at 3:30 p.m. revealed the lower level storage room 4 was over 100 square feet in area with a quantity of combustible items. The corridor door was equipped with spring hinges, but the door would not close and latch upon the action of the spring hinges.

7. Interview with the director of plant operations at the times of the observations confirmed those findings.

The deficiency affected one of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of the smoke compartment.

Based on observation, testing, and interview, the provider failed to maintain two separate hazardous areas (storage rooms) as required. Findings include:

1. Observation and testing on 7/15/24 at 4:15 p.m. revealed the housekeeping room was over 100 square feet in area with quantities of combustibles in storage. The room had two corridor doors equipped with spring hinges.
The corridor doors would not close and latch with the operation of the spring hinges.

2. Observation and testing on 7/15/24 at 4:15 p.m. revealed the storage room was over 100 square feet in area with quantities of combustibles. The room had a corridor door equipped with a closer.
The corridor door would not close and latch with the operation of the closer.

3. Interview with the director of plant operations at the times of the observations confirmed those findings.

The deficiency affected one of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of the smoke compartment.