HospitalInspections.org

U9352

Doors protecting corridor openings are constructed to resist the passage of smoke. Doors are provided with positive latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted. Roller latches are prohibited. 18.3.6.3


This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to ensure all patient room doors are maintained to prevent the passage of smoke. This deficient practice would allow smoke to enter the patient rooms from the corridor in an emergency situation. The facility census was 10.

Findings included:

Observation during a tour of the facility conducted on the morning of 01/07/15, showed the following:

1. A gap of approximately one-forth inch (1/4") was observed between the double leaf doors to patient room 1714 at 9:37 AM.
2. A gap of approximately one-forth inch (1/4") was observed between the double leaf doors to patient room 1710 at 9:39 AM.
A gap of approximately one-forth inch (1/4") was observed between the double leaf doors to patient room 1722 at 9:54 AM.

Staff YY, Director of Facilities, confirmed at the time of each observation that a gap existed between the double leaf doors to those patient rooms.

Section 18.3.6.3.1 of the National Fire Protection Association (NFPA 101) states doors protecting corridor openings shall be constructed to resist the passage of smoke.

U9352

Width of aisles or corridors (clear and unobstructed) serving as exit access in hospitals and nursing homes is at least 8 feet. In limited care facilities and psychiatric hospitals, width of aisles or corridors is at least 6 feet. 18.2.3.3, 18.2.3.4






This STANDARD is not met as evidenced by: Based on observation and interview the facility failed to maintain all patient access corridors free of obstructions. This deficient practice affects all occupants in the facility. The facility census was 10.

Findings included:

1. A patient vital signs monitor was observed in the patient corridor plugged into a corridor electrical outlet for recharging by patient room 1716 at 9:42 AM.
2. A patient vital signs monitor was observed in the patient corridor plugged into a corridor electrical outlet for recharging by patient room 1720 at 9:47 AM.

Staff YY, Director of Facilities, confirmed at the time of each observation that medical equipment was not to be stored/recharged in the patient corridor.

Section 18.2.3.3 of the National Fire Protection Association (NFPA 101) states aisles, corridors, and ramps required for exit access in a hospital of nursing home shall be not less than 8 ft (2.4 m) in clear and unobstructed width.

U9352

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12, NFPA 13, NFPA 25,
9.7.5



This STANDARD is not met as evidenced by: Based on document review and interview the facility failed to conduct all required inspections of the sprinkler system throughout the year. This deficient practice affects all occupants in the facility. The facility census was 10.

Findings included:

Review of the facility sprinkler inspection documents, conducted on the afternoon of 01/06/15, showed an outside contractor had conducted an inspection of the sprinkler system on 12/09/14 and 09/12/14. There was no documentation showing quarterly inspections had been conducted between January of 2014 and August of 2014.

During an interview on 01/07/15 at 10:30 AM, Staff YY, Director of Facilities, stated there is no documentation of sprinkler inspections being conducted for the first two quarters of calendar year 2014.

Section 5.1 of the National Fire Protection Association (NFPA 25) states the minimum requirements for the routine quarterly inspections, testing, and maintenance of sprinkler systems.