HospitalInspections.org

Based upon observations and staff interviews on 05/04/2022 between approximately 1145 to 1315 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff and/or visitors to the toxic products of combustion.

The findings include:

Cross Corridor Fire Door on west end of connecting corridor failed to latch when tested.

NFPA 101 (2012) 19.2.2.2.7

These findings were discussed and acknowledged by the facility staff during survey and reviewed at the exit conference.

Based on observation and staff interview on 05/04/2022 between approximately 1145 to 1315 hours the facility has failed to maintain openings in corridor walls and doors and only have allowed openings. This could lead to the rapid spread of fire and smoke throughout the facility.

The findings include:

Louvers were observed in the following door:

1. IT closet by stairwell door (east wing).

NFPA 101 (2012) 19.3.6.4.1

The above was discussed and acknowledged by the facility staff.