HospitalInspections.org

Based on observation during the afternoon of September 8, 2010, the corridor doors for two examination rooms at the second floor out-patient clinic had roller type latching hardware. CMS regulations require these doors have positive latching hardware.

Based on observation during the afternoon of September 8, 2010, the following doors to exit stairways were not in compliance with the Life Safety Code:

(a) The second floor door to exit stair #5 did not latch automatically when closed by the door closer.

(b) The first floor door to the exit stair adjacent to the central plant was held open because the bottom of the door was binding against the floor.

Based on observation during the afternoon of September 8, 2010, the designated exit doors between the emergency waiting area and the exit vestibule required the use of a key to open when locked. The Life Safety Code requires designated exit doors be able to be opened from inside the building without the use of a key when locked.

Based on observation during the afternoon of September 8, 2020, the fire sprinkler system did not comply with NFPA 13 because of the following:

(a) The sprinkler branch line in room 3M02 (on the third floor) did not have a fire sprinkler installed in it. (The orfice where the sprinkler should be installed was capped off.) NFPA 13 requires room 3M02 be protected by the fire sprinkler system.

(b) The tops of the rolling medical x-ray storage files were approximately 6 inches below the ceiling mounted fire sprinklers. NFPA 13 requires there be minimum 18 inches of clearance between the fire sprinklers and the tops of these storage cabinets.