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DEWITT HOSPITAL & NURSING HOME, INC
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and interview, it was determined the facility failed to provide the door to one (storage room in the Emergency Department) of five hazardous areas observed with a mechanism or system to self-close. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:
A. While on tour of the facility with the Maintenance Engineer on 08/15/2017 at 10:15 AM, observation showed the door to storage room across from Exam Rooms #2 and #3 in the Emergency Department was not equipped with a mechanism or system to self-close.
B. During the tour, the Maintenance Engineer verified the door did not have the ability to self-close.
Referenced code: NFPA 101, 2012 edition; Section 8.4.3.5