HospitalInspections.org

This standard is not met as evidenced by
Based on observation the facility failed to maintain doors that protect the corridor from smoke by positively latching. The evidence includes
On 08 Jan 2013 the inspector observed that door 1030 was a double door that had manual latches on the non hardware side of the doors. These latches were not engaged and did not operate smoothly indicating they had been used. The doors pulled open freely when they were shut.

This standard is not met as evidenced by:
Based on observation the facility failed to maintain the one hour fire rating of stair enclosures. The evidence includes.
On 09 Jan 2013 the inspector observed that in stair D above the door leading to the emergency generator room a piece of the CMU wall has fallen out.

This standard is not met as evidenced by
Based on observation the facility failed to provide complete sprinkler coverage for all area's. The evidence includes.
On 08 Jan 2013 the inspector observed the landing leading down to the lower level at stair A floor B did not have sprinkler coverage on the lower level side of the door.

This standard is not met as evidenced by
Based on observation the facility failed to maintain corridors free and clear at all times. The evidence includes
On 08 January 2013 the inspector observed several charting stations that did not automatically retract back into the wall, causing them to extend out into the corridor after use.

This standard is not met as evidenced by
Based on observation the facility failed to provide free egress to several rooms. The evidence includes
On 09 Jan 2-13 the inspector observed that rooms 2056 and 2034 had dead bolt locks on the doors and no keys were available to any staff members that were with the survey party. Staff or patients may have been unable to exit the room if the locks were activated.