HospitalInspections.org

Based on observation and interview, the facility failed to ensure that means of egress signage was properly displayed according to National Fire Protection Agency (NFPA) standards. This deficient practice affected one (1) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Observation and interview on 06/11/14 at 9:40 AM with the Administrator revealed a set of cross-corridor doors at the back of the Emergency Department entrance that were magnetically locked and could not be used for exiting purposes. An illuminated exit sign was above these doors. The facility was cited on 04/03/14 for this exit not being accessible. The facility's plan of correction dated 05/04/14 stated the exit sign would be taken down and signage that indicated the doors were not an exit would be placed on the doors no later than 06/07/14. An interview with the Administrator on 06/11/14 at 9:40 AM revealed the Director of Maintenance stated the doors released when the fire alarm system was activated and there was no need to do anything to the doors.

Passing through these doors, another set of cross-corridor doors was observed not to be part of an exit. Doors that are not part of an exit, and may be mistaken for exits, must have signage stating the doors are not exits. Two illuminated exit signs in close proximity to each other between these two sets of cross-corridor doors may add to the confusion for people not aware of the buildings exits. The facility was cited on 04/03/14 for the failure to ensure the cross-corridor doors had signage that the doors were not an exit and for the potentially confusing exit signage. The facility's plan of correction dated 06/04/14 stated the facility would ensure signage was placed on the cross-corridor doors to indicate the doors were not an exit and that one of the exit signs would be taken down.

An interview with the Administrator on 06/11/14 at 9:45 AM revealed the cross-corridor doors was an exit if you were coming from the other direction. The Administrator also stated one of the exit signs in this area should have been taken down.