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Based on observation and staff interview the facility is not ensuring that corridor doors latch properly. This deficient practice of not ensuring that corridor doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting 0 patients and all occupants in 2 of 8 smoke zones on the 1st floor. This facility has a capacity of 373 and a census of 118.

Findings Include:

During the tour conducted on 12/3/2013 and 12/4/13, between 9:00 A.M. and 5:00 P.M. the following is observed:

1.) At 10:12 A.M. on 12/4/13 it is discovered that one of the two rated doors does not positively latch that seperate X-ray from the Medical Records Corridor.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting 0 patients and all occupants in 1 of 8 smoke zones on the 1st floor. This facility has a capacity of 373 and a census of 118.

Findings Include:

During the tour conducted on 12/3/2013 and 12/4/13, between 9:00 A.M. and 5:00 P.M. the following is observed:

1.) At 10:20 A.M. on 12/4/13 it is discovered that one of the double exit doors does not open unless the other door is open first near Nuclear Medicine.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview the facility failed to provide emergency lighting as required. The deficient practice could leave the Medication Preparation Room without illumination during a disruption of normal power or in the event of an emergency. This deficiency affects 0 patients and all occupants in 1 of 5 smoke zones on the 3rd floor. This facility has a capacity of 373 and a census of 118.

Findings Include:

During the tour conducted on 12/3/2013 and 12/4/13, between 9:00 A.M. and 5:00 P.M. the following is observed:

1.) At 2:54 on 12/3/13 it is discovered that the emergency lighting can be turned off by a manually operated wall switch in Medication Preparation room 3619 on the 3rd floor.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

Based on observation and staff interview the facility is not ensuring that corridor doors latch properly. This deficient practice of not ensuring that corridor doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting 0 patients and all occupants in 2 of 8 smoke zones on the 1st floor. This facility has a capacity of 373 and a census of 118.

Findings Include:

During the tour conducted on 12/3/2013 and 12/4/13, between 9:00 A.M. and 5:00 P.M. the following is observed:

1.) At 10:12 A.M. on 12/4/13 it is discovered that one of the two rated doors does not positively latch that seperate X-ray from the Medical Records Corridor.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting 0 patients and all occupants in 1 of 8 smoke zones on the 1st floor. This facility has a capacity of 373 and a census of 118.

Findings Include:

During the tour conducted on 12/3/2013 and 12/4/13, between 9:00 A.M. and 5:00 P.M. the following is observed:

1.) At 10:20 A.M. on 12/4/13 it is discovered that one of the double exit doors does not open unless the other door is open first near Nuclear Medicine.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview the facility failed to provide emergency lighting as required. The deficient practice could leave the Medication Preparation Room without illumination during a disruption of normal power or in the event of an emergency. This deficiency affects 0 patients and all occupants in 1 of 5 smoke zones on the 3rd floor. This facility has a capacity of 373 and a census of 118.

Findings Include:

During the tour conducted on 12/3/2013 and 12/4/13, between 9:00 A.M. and 5:00 P.M. the following is observed:

1.) At 2:54 on 12/3/13 it is discovered that the emergency lighting can be turned off by a manually operated wall switch in Medication Preparation room 3619 on the 3rd floor.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2