HospitalInspections.org

Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times in 1 of 3 smoke compartments. The findings were:

Observation on 03/09/16 at 10:30 AM revealed the corridor doors leading to the radiology department from the emergency room was labeled as and exit. Further observation revealed the doors were locked and could only be accessed by a key pad or employee badge. At the time of the observation the Facility Maintenance Director acknowledged the doors were locked.

Ref:
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.1

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are installed and continuously maintained per the requirements of NFPA 13 and NFPA 25 in 2 of 3 smoke compartments. The finding were:

1. Observation on 03/09/16 from 10:40 AM to 11:00 AM revealed missing escutcheon rings with a resulting gap around the sprinkler head in the surgery clean supply room, and the surgery decontamination room (SD147). At the time of the observations the Facility Maintenance Director acknowledged the missing escutcheon rings.

2. Observation on 03/09/16 at 10:20 AM revealed the sprinkler head located in the emergency room adjacent to the clean supply room had paint located on the sprinkler bulb. At the time of the observation the Facility Maintenance Manager acknowledged the sprinkler head.

Ref:
2000 NFPA 101, Sections 19.3.5.1, 9.7.1.1, and 9.7.5
1998 NFPA 25, Section 2-2.1.1
1999 NFPA 13, Section 3-2.7.2