HospitalInspections.org

Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice had the potential to affect 10 of 16 residents.

4 of 7 egress doors are deficient

Findings:

During the facility tour on 5/30/2018, between the hours of 8:45 am to 2:30 pm it was observed the magnetic door locks located at the front Exit door, rear corridor Exit door near patient sleeping room 214, the rear outside gate and the interior cross corridor double door located between the office area and the nursing station re-lock after a loss of power without being manually reset from a remote control location.

Louisiana State Fire Marshal Health Care Special Locking Memo 2009-05 dated 10/1/2009 states, "A. UNLOCKING (EMERGENCY RELEASE) shall be accomplished by the following:
1. Loss of power to any part of the system that controls locks or the emergency releasing mechanisms; and
2. Activation of the fire alarm system; and
3. Remote release at approved, constantly attended location(s). Furnish a floor plan showing the location of required exits, all locked doors - (existing and new), nurses' station(s), control station(s) and remote release location(s).
(NOTE: The remote control functions must be identified at the remote release location(s) with permanent legible signage and responsible staff must be trained on system control and emergency operations); and,
4. A means of manual mechanical unlocking must be provided at each door that is not in direct view of the remote release location. Doors must be keyed alike and keys must be carried by the staff responsible for patient evacuation whenever the locking system is operational and in use.
(Keypads, card readers, and other electrical devices are not acceptable as means of mechanically unlocking doors during emergency conditions.)
B. "AUTOMATIC" RE-LOCKING, after an emergency release as described above, shall be PROHIBITED. A specific human action dedicated for re-locking doors must be provided at the remote control location or at each lock location".

Interview with the Administrator revealed the facility was not aware that the magnetic locks re-locking after a loss of power without being manually reset at a remote control location is prohibited in order to exit from the building.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier. The penetrating item must be properly filled with a material (intumescent) that is capable of maintaining the fire resistance rating in accordance with ASTM E-814 or UL1479 designed for wall cable, wire type penetrations of the smoke barrier. Unprotected penetrations would permit the movement of smoke / fire from one compartment to the other in the facility. The deficient practice had the potential to effect 10 of 16 residents.
1 of 2 smoke barriers were deficient.

Findings:

During the facility tour on 5/30/2018 between the hours of 8:45 am to 2:30 pm it was observed the patient sleeping rooms wing smoke barrier is lacking the proper intumescent fire stopping material for a four inch penetration located at the lower center of the smoke barrier.

NFPA 101: 8.3.5.1 states, "Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly".

Interview with the Administrator revealed the facility was not aware that the smoke barrier had a duct penetration that was not sealed