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Tag No.: K0018
S&C-07-18, CMS MEMORANDUM (APRIL 20th, 2007)
In smoke compartments not sprinklered, 1/4 inch gap is permitted. In smoke compartment sprinklered, 1/2" gap is permitted.
Based on observations and interview the facility failed to ensure that 6 doors, protecting egress corridors could resist the passage of smoke.
Findings include:
Observations during tour on 10/29/14 between 7:30 a.m. and 11:30 a.m. with Staff B (Director of Plant Operations/Maintenance) revealed the following 6 doors that have a gap in excess of the maximum 1/2" allowed to prevent the passage of smoke.
1. The entry door to the Central Nursing Station has a 5/8" gap.
2. Door # 1-196 has a 7/8" gap.
3. 1st floor Exam room door # 2 has a 3/4" gap.
4. 1st floor Cardiology Suite door has a 3/4" gap.
5. 1st floor Family Conference room door has a 5/8" gap.
6. 1st floor Central Sterile room door has a 5/8" gap.
Interview with Staff B at the time of observations, confirmed the findings and locations.
Tag No.: K0021
Based on observations and interviews the facility failed to ensure that 4 doors located within the Smoke Barrier separations are equipped with an automatic door closing device.
Findings include:
Observations during tour on 10/29/14 between 7:30 a.m. and 11:30 a.m. with Staff B (Director of Plant Operations/Maintenance) revealed the following locations of 4 doorways that pass through the required Smoke Barrier separations and are not equipped with an automatic closing device.
1. 1st floor Orthopedics room door.
2. 2nd floor Library/Conference room door.
3. 3rd floor Endoscope room door.
4. 3rd floor Staff area room door.
Interview with Staff B at the time of observations confirmed the findings and locations.
Tag No.: K0076
4-3.1.1.1 NFPA 99, HEALTH CARE FACILITIES
Cylinder and Container Management: Cylinders in service and in Storage shall be individually secured and located to prevent falling or being knocked over.
4-3.5.2.1(b) NFPA 99, HEALTH CARE FACILITIES Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
Based on observations and interview the facility failed to ensure that Medical Gas cylinders are properly secured.
Findings include:
Observations during tour on 10/28/14 at approximately 3:30 p.m. with Staff B (Director of Plant Operations/Maintenance) revealed that approximately 12 medical gas cylinders in the exterior storage area containing Oxygen, Nitrogen, Argon and N.O.S are chained together as a group and not individually secured.
Interview with Staff B at the time of observation confirmed the findings.