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Based on observation, the facility failed to ensure doors to all patient rooms close and latch to prevent the potential spread of smoke or fire from or to the other 21 patient rooms, corridors or common areas. The patient census was 28 patients.

Findings include:

1. Observation on 3/1/10 at 1:38 P.M. through survey exit on 3/3/10 at 4:30 P.M. revealed a rubber wedge under entrance door of room 321 prevented door from being closed unassisted into the frame as it is designed to do via the attached gas or spring loaded device, or being pulled closed by staff in the event of a fire emergency when it may be necessary to prevent the harmful spread of smoke and endanger the occupant of the room who could not be easily moved.

The rubber wedge remained under or in front of the partially open entrance door throughout the survey, morning and afternoon on all three days, undisturbed by housekeeping or staff, who passed in and out of the room numerous times over the three day complaint survey.

Based on observation, the facility failed to ensure a clear access to a fire exit through corridors and cross passages in accordance with 19.2.3.3; the eight foot width of the corridor restricted to less than four feet by beds, gurneys, a hand cart and medical equipment, potentially endangering patients, staff and visitors in the 34 bed wing of a large acute care hospital. The patient census was 28 patients.

Findings include:

1. Observation on 3/1/10 at 1:20 P.M. through 1:38 P.M. revealed the northwest corridor vicinity of patient rooms 321 through 324 severely restricted by two mobile dialysis carts, a hand cart loaded with supplies, a bed, gurney, housekeeping cart and at least one ambulance crew with a collapsible stretcher processing a patient transfer. Near the west end of the corridor at room 321, a six foot-wide cross passage leading to the south corridor was restricted to 15 inches by an unoccupied patient bed, clean linen cart and a mechanical lift, further restricting the potential flow of patients exiting or being evacuated from the four rooms closest to the occluded north corridor.

Observation on 3/1/10 at 2:30 P.M. revealed all equipment had been removed from the corridor and placed in patient rooms, soiled utility room, and common shower room or into the two, six foot wide cross passage areas. One unoccupied patient bed was observed outside of the certified wing, in an open corridor area across from the staff elevators.