HospitalInspections.org

Based on observation and interview the facility failed to ensure doors to all patient rooms closed and latched securely in the door frames. This deficient practice affects all patients within that smoke compartment. The facility census was 39 at the Bridgeton campus and 28 at the Richmond Heights campus.

Findings included:

Observation during a tour of the Richmond Heights campus, conducted on the afternoon of 01/08/14, showed the following patient room doors would not completely close and latch in the door frames to prevent the passage of smoke:

*Observation at 2:06 PM showed the door to patient room 306 would not close completely and latch in the door frame when tested.
*Observation at 2:08 PM showed the door to patient room 305 would not close completely and latch in the door frame when tested.
*Observation at 2:09 PM showed the door to patient room 303 would not close completely and latch in the door frame when tested.

Observation during a tour of the Bridgeton campus, conducted on the morning of 01/09/14, showed the following patient room door would not completely close and latch in the door frame to prevent the passage of smoke:

*Observation at 10:40 AM showed the door to patient room 230 would not close completely and latch in the door frame when tested.

Staff S, Plant Operations, confirmed at those times that the patient room doors would not completely close and latch in the door frames.

Section 18.3.6.3.2 of the National Fire Protection Association (NFPA 101) states doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

Based on observation and interview the facility failed to ensure one of two stairwells are enclosed with at least one hour fire resistive construction. This deficient practice affects all patients in one of two smoke compartments on the third floor. The facility census was 39 at the Bridgeton campus and 28 at the Richmond Heights campus.

Findings included:

Observation at 2:14 PM on 01/08/14, during a tour of the third floor unit at the Richmond Heights campus, showed the door to the third floor exit stairwell on the east side of the unit did not have a certified label designating the door as being fire resistive.

Staff S, Plant Operations, confirmed at that time the stairwell door was not labeled showing the door to be fire resistive.

Section 18.3.1.1 of the National Fire Protection Association (NFPA 101) states any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

Based on observation and interview the facility failed to maintain one of two patient corridor smoke barrier doors in good working order. This deficient practice affects all patients in those two smoke compartments. The facility census was 39 at the Bridgeton campus and 28 at the Richmond Heights campus.

Findings included:

Observation at 9:55 AM on 01/09/14 during a tour of the Bridgeton campus showed one of the two smoke barrier doors would not completely close when released from the fire alarm system automatic hold open device in the south corridor adjacent to patient room 330.

Staff S, Plant Operations, confirmed at that time only one of the two smoke barrier doors would completely close.

Section 1.3.7.6 of the National Fire Protection Association (NFPA 101) states doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

Based on document review and interview the facility failed to conduct weekly inspections of the emergency generator. This deficient practice affects all occupants in the facility. The facility census was 39 at the Bridgeton campus and 28 at the Richmond Heights campus.

Findings included:

Review of the facility generator testing documents, conducted on the afternoon of 01/07/14, showed there was no documentation indicating a weekly inspection of the emergency generator was being conducted by the facility staff at the Bridgeton campus.

During an interview on 01/07/14 at 3:51 PM, Staff S, Plant Operations, stated no one has been conducting and documenting a weekly inspection of the emergency generator.

Section 8.4.1 of the National Fire Protection Association (NFPA 110) states the emergency power supply system (EPSS) including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.