HospitalInspections.org

Based on observation the facility failed to provide free egress from all required exits that is in accordance with 19.2.2.2.5 for 4 of 6 exit doors. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice has the potential to affect the 24 patients in the facility.

NFPA 101: 19.2.2.2.5 Doors located in the means of egress that are permitted to be locked under other provisions of
this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times.

When special locking devices, such as magnetic locks, are permitted one of the three options is required in order to allow free egress for staff and visitors. The three options are:
The access code for the keypad is posted at the device, or,
The key to the override switch is posted at the device, or.
Staff carries a key to the override switch at all times.

The Fire Marshal ' s office permits Magnetic locks on exit doors if they unlock upon activation of the fire alarm and loss of power with no automatic re-locking capabilities, key overrides at each door that is not in view of the nurse station, with all staff having a key, and a remote release at a nurses station.

Findings:

Testing of the fire alarm system on May 19, 2014 at 3:30 p.m. revealed that the three magnetic locks in the patient area relocked when the fire alarm system was reset. These doors did automatically unlock when the fire alarm was activated. There are key overrides at each door and a remote release at the nurse station.

Based on observation and review of documentation, the facility failed to provide a current fire alarm inspection as per NFPA 72 and NFPA 101 for 1 of 1 system. This deficiency affects all 24 patients in the facility.

Findings:

An observation was made on May 19, 2014 at 3:30 p.m. of the fire alarm system. Review of the annual inspection report (dated 4-9-13) revealed that the facility failed to have a current annual inspection done for the fire alarm system, within the last twelve months. Interview with the administrator during the survey process and at the exit interview verified that no additional documentation of a current fire alarm system inspection was available.