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Based on observation and interview the facility failed to ensure 1 of 8 separation fire doors were self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2.
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released, and the door leaf becomes self-closing. This deficient practice could affect 20 patients in the ER.

Findings include:

Based on observations with the Facilities Supervisor on 8/26/24 between 10:45 a.m. and 12:30 p.m., the ER separation fire door to the ER manager office was held open with a door wedge. Based on interview at the time of observation, the Facilities Supervisor agreed the door is in a separation fire barrier and was held open with a device that did not release with the fire alarm.

The findings were reviewed with the Facilities Supervisor during the exit conference.