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Based upon observation, egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

On 5/25/21 at 2:20pm while in the company of the SO it was observed that magnetic locking devices were employed at the double egress corridor door marked with an exit sign from the PT suite and not in full compliance with 19.2.2.2.4. The door from the suite was locked without Delayed Egress in accordance with 7.2.1.6.1. Only card reader release was provided and release by fire alarm activation was not confirmed by testing of the fire alarm system.

Based upon observation, doors required to be self-closing are held open by nonapproved means. Failure to maintain the door in the closed position or employ an approved hold-open device can compromise the safety of the means of egress for which the door separation is intended in the event of a fire/smoke condition within the space.

Findings include:

On 5/25/21 at 2:35pm while in the company of the SO it was observed that the (Hazardous Area) Purchasing Storeroom corridor door was being held open by a wedge not in compliance with 7.2.1.8.2. A magnetic hold-open device was installed, but reported by staff not to be working.

Based on document review, exit signs are not inspected, tested, and maintained on a monthly basis. This deficient practice could affect patients, staff, and visitors in the building because failure of the signs to be properly maintained can result in occupants inability to be directed to available exits during an emergency evacuation.

Findings include:

On 5/25/21 at 11:30am, during record document review, it was indicated by the SO that records were not available for the inspection and maintenance of exit signs. The maintenance, inspection & testing of exit signs as required by NFPA 101 - 2012, 7.10.9.1 is not being performed. The SO & CEO confirmed that a written record of such inspections have not been kept within the last year.

Based upon observation, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to compromise the use of the adjacent corridor for exiting.

Findings include:

A. On 5/25/21 it was observed while in the company of the SO that sprinklered rooms deemed to be Hazardous Areas containing combustibles were not provided with self-closing positive latching doors to comply with 19.3.2.1.3 and 19.3.6.3.5. Locations observed include:

1. At 2:40pm the 1-hour separated Laundry room corridor door was observed not to self-close and latch.

2. At 2:55pm the Nitros Oxide manifold room door was not self-closing to provide 1-hour rated separation of the manifold room from the mechanical room to comply with NFPA 99-2012, 5.1.3.3.2(4).

3. At 3:15pm the Central Sterile Supply (Hazardous Area) door from the Surgical corridor did not self-close to a latched condition to comply with 19.3.2.1.3 and 19.3.6.3.5.

4. At 3:15pm the Surgery Dept. Janitor room containing shelving and storage of combustible paper supplies was observed not to be self-closing to comply with 19.3.2.1.3 and 19.3.6.3.5.

Based upon observation, door assemblies employed as forming a portion of the smoke barrier are not maintained in accordance with Code requirements. Failure to maintain fire rated door assemblies can result in failure of the door to perform properly during a fire/smoke event to provide adequate separtion of areas for safe refuge for staff, visitors and patients.

Findings include:

On 5/25/21 at 2:00pm while in the company of the SO it was observed that the 3/4-hour rated smoke barrier cross corridor doors near room 101 did not self close to a latched condition to comply with NFPA 80. The vertical rod latching device retracts to release the latch but does not retract to allow the door to fully close and relatch.

Based on document review, fire drills are not being conducted in accordance with Code requirements. Failure to conduct fire drills to properly train staff can result in inappropriate or inadequate response to an actual fire event.

Findings include:

A. On 5/25/21 at 12:15pm, during record document review, it was indicated by the fire drill records that sufficient training of staff may not have occured. The following conditions were reflected by the fire drill records:

1. The drill records revealed the following drills were conducted:

1/26/20 at 6:00pm for (fiscal) 3rd quarter, 2nd shift
2/17/20 at 11:00pm for (fiscal) 3rd quarter, 3rd shift
3/14/20 at 6:00am for (fiscal) 3rd quarter, 1st shift
9/30/20 at (time not recorded) for (fiscal) 2nd quarter, 1st shift
9/30/20 at 8:45pm for (fiscal) 2nd quarter, 2nd shift
3/22/21 at 2:30pm for (fiscal) 3rd quarter, 1st shift
3/22/21 at 10:00pm for (fiscal) 3rd quarter, 2nd shift

The master form for recording the date & times for the drills indicates a three-shift day. However, drills are being conducted to coincide with a two-shift day. Recorded drill times could not confirm that personnel in all three shifts were being covered by the two-shift drill schedule.

2. The typical schedule of fire drills being conducted once per quarter per shift has been disrupted by the COVID waiver. Only drills conducted in September 2020 and March 2021 were available for review. No Drills for (fiscal) 4th quarter 2020 & 1st quarter 2021 were conducted.

3. The drills conducted on 3/22/21 at 2:30pm & 10:00pm were both conducted as "silent" drills because response indicated "N/A" for alarm activation, door controls and monitoring service receiving signal. "Silent" or coded drills are only permitted for the time between 9:00pm and 6:00am in accordance with 19.7.1.7.

4. The 9/30/20 drill indicated training to be required. The response document failed to list the time of the drill and the drilled personnel indicated a lack of knowledge: "No one responded. One person asked: 'what all are we supposed to do down here?' No one got a fire extinguisher." No documentation was available to resolve the deficient response.

Based on document review, fire door assemblies are not inspected, tested, and maintained on an annual basis. This deficient practice could affect patients, staff, and visitors in the building because the doors may fail to operate when needed if they are not periodically inspected, tested, and maintained.

Findings include:

On 5/25/21 at 11:15am, during record document review, it was indicated by the SO that records were not available for the inspection and maintenance of fire door assemblies. The maintenance, inspection & testing of fire doors as required by NFPA 101 - 2012, 7.2.1.15 and NFPA 80 - 2010, 5.2.1 is not being performed. The SO & CEO confirmed that no such inspections have been conducted within the last year.