HospitalInspections.org

Based on the Fire & Life Safety tour with the Director of Plant Operations on 08/21/2018, the facility failed to maintain safe and reliable exit egress. All exit doors must be maintained in proper operational condition. Reliable egress is essential to the safety of all persons within the facility in an emergency situation.

The findings included:

During the Fire & Life Safety document review with the Director of Plant Operations on 08/21/2018, the entrance/exit horizontal sliding doors to the hospital were observed not being maintained.
1. Horizontal sliding doors at the ambulance entrance/exit
2. Horizontal sliding doors at the dining area
3. Horizontal sliding doors at the front entrance/exit

Theses doors required an excessive amount of force (more than 15 lbf) to operate the breakaway feature. Horizontal sliding doors must break away with 15lbf per NFPA 101 7.2.

Based on observations made during the Fire & Life Safety tour, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) Smoke Compartments to become involved in a Fire/Smoke situation. This could allow fire, smoke and fire gasses to enter the compartment, which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency.

The findings included:

During the Fire & Life Safety tour of the facility with the Director of Plant Operations on 08/21/2018,the surveyor observed that several 1 hour rated Fire/Smoke doors were not closing or opening properly:
1. Glass sliding doors at the ambulance entrance/exit, were blocked with a bed and cart preventing the doors from opening completely
2. Double doors at the loading dock, not releasing after the 15 second hold
3. Glass sliding doors in the dining area, dragging on the floor preventing them from opening completely
4. Glass sliding doors in the front lobby, dragging on the floor preventing them from opening completely
The Director of Plant Operations was present during the observations, and confirmed the findings.

NFPA 101, (2012 edition,) Chapter 19, 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on the Fire & Life Safety document review with the Director of Plant Operations on 08/21/2018, the facility failed to provide and maintain maintenance, inspection & testing of fire doors. This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

The findings included:

During the Fire & Life Safety document review with the Director of Plant Operations on 08/21/2018, this surveyor observed that the facility failed to provide records of fire door Maintenance, Inspection & Testing.
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
The Director of Plant Operations was present during the observation, and confirmed the findings.

19.7.6, 8.3.3.1 (LSC), NFPA 80 (2010 edition) 5.2, 5.2.3