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Based on observation, interview, and record review, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA 101). The facility failed to ensure that patient doors were not propped open, and were kept free of impediments.

Findings include:

Observations conducted in the facility on 6/21/17 from 3:00 pm to 4:00 pm revealed the following:

- Room 231 (PCU): The patient room door was propped open with a dirty linen cart.
- Room 209 (CVU): The patient room door was propped open with a dirty linen cart.

In an interview conducted on 6/21/17, at the time of discovery, the facility Director of the Intensive Care Unit (ICU) revealed that nursing staff were propping the doors to the patient rooms open so they could view confused patients in those areas. She further stated that the patient room doors were self-closing, and that she was unaware that patient doors could not be propped open.

Record review of the facility General Safety Policy, effective 10/2016, revealed the following:

- E.) Environmental Tours: "As part of the facility Safety program, each facility safety officer coordinates the performance of safety/environmental tours of the facility. They are to identify and evaluate information concerning safe practices and behaviors including staff knowledge the report those back to the facility safety committee."

According to NFPA 101, issued January 14, 2000: NFPA 101 restricts the use of hold-open devices on patient rooms to those that release when the door is pushed or pulled. Doors should not be blocked by furniture, door stops, hooks, or plunger type hold-opens.