HospitalInspections.org

K-018 Not Met.
While surveying the facility with the Safety Officer this Inspector observed the following patient room doors that due gaps will not resist the passage of smoke as required. ( Rooms 1-409,1-420,1-423,2-434.2-524., 1556,1549). Doors in each of all smoke compartments where surveyed for this condition.

K-043 Not Met.
While surveying the facility with the safety officer this Inspector observed the following violations of NFPA Life Safety Code 101 2000 Edition Section 19.2.2.2.2, and MSRA Title 25 Section 2452.
1. Lower Saco Unit SCU Main section Inspector observed that a door leading from the corridor to a seclusion patient room was equipped with ( 2) sliding deadbolt locks and a key operated lock. 1435 hrs local time,

2. Lower Saco Unit ( Forensic section) this Inspector observed the door from the corridor to the patient seclusion room was equipped with (2) sliding deadbolt locks and a key operated lock. 1450 hrs local time.

3. At 1505 hours local at verbal order of this Inspector the deadbolt locks were removed by facility maintenance staff.

4. After team meeting with DHHS staff and Visiting CMS Staff this Inspector was made aware of another condition they observed that effected the above seclusion room. At approximately 17 35 hrs local time this Inspector went back to the Lower Saco Unit (forensic section) and observed the door to the seclusion room that was locked with a key and asked the Law Enforcement Officer that was charged with monitoring the patient in the seclusion room to open the door. Prior to opening the door the officer inserted a steel rod in to the floor outside of the door that restricted the opening of the door to approximately 10 inches in width. This Inspector was told that using this restriction device on the door was the required practice when the door was opened.

5. Inspectors additional information for K tag 043.
ON April 10 , 2013 at approximately 0830 hrs this Inspector met with the facility personal to provide a Life Safety Code interpretation of the methods of securing a fire smoke barrier set of doors on the Lower Saco Unit (Forensic side) as a client was busting through the doors on occasion.
My observations were that a deadbolt had been installed on one leaf of the double doors egress doors to prevent the client from going through the doors.
I immediately advised the facility that the deadbolt lock was a violation of the Life Safety Code and not an approved method of locking the smoke fire barrier door.
Facility staff removed the deadbolt lock.

6. Potential Life Safety Impact statement.
The use of a non approved lock (deadbolt) on a door in a required means of egress could result in a patient or staff person not being able to egress the space in the event of an emergency such as fire,smoke, building collapse. The deadbolt lock does not require a key to lock the door and any one in the corridor could lock the door and not be an approved staff person.
The exceptions in NFPA Life Safety code 101 2000 Edition Section 19.2.2.2.2 ( a and b) both require a key to lock a patient room door from the corridor side.

This standard is not met as evidenced by
Based on observation the facility failed to maintain the horizontal exit. The evidence includes
On 10 May 2013 at the Clinical Services center in Portland the inspector observed the horizontal exit between the clinic and the exit corridor was not rated to one hour and did not have a 3/4 hour rated door.

This standard is not met as evidenced by
Based on observation the facility failed to display exit directional signs. The evidence includes
On 10 May at the Clinical Services Dental Facility the inspector observed that the two doors leading to the front lobby from each hallway did not have an exit sign that was illuminated.

This standard is not met as evidenced by
Based on interview and observation the facility failed to conduct required fire drills. The evidence includes
On 10 May 2013 the inspector observed that the facility was conducting only one drill per year at the Clinical Services center at 63 Pebble St. Portland, Maine. The facility only has one shift at this location but was not doing one drill per quarter. This was confirmed in interview with the facility safety compliance officer.

This standard is not met as evidenced by
Based on observation the facility failed to maintain exits free and clear at all times. The evidence includes
On 10 May 2013 at the Clinical Services Center in Portland the front door had a slide lock installed. The lock was not engaged during the inspection.