HospitalInspections.org

Based on observation and interview, the facility failed to maintain the delayed egress hardware, this deficient practice would cause confusion and delay egress. The facility had a census of 36 on the day of survey.

Findings are:
Observations on 12-10-18 at 11:10 am revealed, the delayed egress on the stair door next to Room 139 failed to engage within 3 seconds and only operated when constant pressure was applied to the hardware.

During an interview on 12-10-18 at 11:10 am, Administrative Staff A confirmed the delayed egress hardware failed to operate as designed.

Based on observation and interview, the facility failed to separate the physical therapy treatment area from the exit corridor. This deficient practice would allow smoke to spread into the exit corridor. The facility had a census of 36 on the day of survey.

Findings are:
Observation on 12-10-18 at 10:35 am revealed, facility was conducting therapy in Day Room across from Room 117 and no walls were provided to separate the Therapy area from the egress corridor.

During an interview on 12-10-18 at 10:35 am, Administrative Staff A confirmed that therapy was being conducted in Day Room, which failed to be separated from the egress corridor.

19.3.6.1
Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4), unless otherwise permitted
by one of the following:
(1) Smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met:
(a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observation and interview, the facility failed to assure that corridor doors were provided with latching devices. This deficient practice would allow smoke, fire and gasses to spread into the egress corridor. The facility had a census of 36 on the day of survey.

Findings are:
Observations on 12-10-18 at 11:18 am revealed, a newly installed store front door to the "Monitor Room" was equipped with a dead bolt lock only and no latching device, the room failed to provide smoke detection.

During an interview on 12-10-18 at 11:18 am, Administrative Staff A confirmed the door failed to provide latching device.

Based on observation and interview, the facility failed to ensure smoke separation doors were capable of resisting the passage of smoke. The deficient practice would allow smoke and gasses to spread. The facility had a census of 36 on the day of survey.

Findings are:
Observations on 12-10-18 at 11:43 am revealed, the smoke door equipped with self-closing devices next to Room 123 failed to close and latch within the doorframe.

During an interview on 8-30-17 at 11:43 am, Administration Staff A confirmed the smoke door failed to close.